Counteracting Bordering Practices: Non-State Healthcare Provision for Migrants with Precarious Legal Status in Berlin

Counteracting Bordering Practices: Non-State Healthcare Provision for Migrants with Precarious Legal Status in Berlin Authors: Sofia Lehmann & Elisa Mannes A chapter from: Schmiz, A., & Lehmann, S. (Eds.) (2025). Geographies of the European Border Regime. How borders shape the everyday lives of refugees and asylum-seekers. Berlin Geographical Papers, 56. https://doi.org/10.17169/refubium-48773 Institute of Geographical Sciences Freie Universität Berlin 2025 Contact Freie Universität Berlin Department of Earth Sciences Working Group 'Society, Space and Gender' Malteserstr. 74-100 D-12249 Berlin https://www.geo.fu-berlin.de/geog/fachrichtungen/anthrogeog/index.html This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. DOI: hUps://doi.org/10.5281/zenodo.17466367 Citation suggestion: Lehmann, S., & Mannes, E. (2025). Counteracting Bordering Practices: Non-State Healthcare Provision for Migrants with Precarious Legal Status in Berlin. Berlin Geographical Papers, 56, 14–26. https://doi.org/10.5281/zenodo.17466367 Published in: Schmiz, A., & Lehmann, S. (Eds.) (2025). Geographies of the European Border Regime. How borders shape the everyday lives of refugees and asylum-seekers. Berlin Geographical Papers, 56. https://doi.org/10.17169/refubium-48773 14 Sofia Lehmann & Elisa Mannes Counteracting Bordering Practices: Non-State Healthcare Provision for Migrants with Precarious Legal Status in Berlin Abstract: This paper explores how non-state actors in Berlin counteract exclusionary healthcare practices that are conceptualised as urban bordering practices of the European border regime. Focusing on neighbourhood-based organisations offering healthcare to migrants with precarious legal status, we examine how these actors navigate the tension between immediate service provision and the broader goal of systemic reform. Drawing on five semi-structured interviews and a qualitative content analysis, we focus on two guiding themes: the neoliberal shift of care responsibilities away from the state, and the ideological reimagining of healthcare as a holistic, inclusive practice. Our findings highlight how these organisations operate under significant financial and structural constraints while striving to remain politically critical and innovative. Despite limited funding and challenging working conditions, strategies such as building networks, reducing barriers in accessibility and maintaining anonymity are used to expand the reach and effectiveness of their services. However, this dual role – providing care and pushing for change – reveals contradictions that place pressure on organisations’ ideals and operational capacity. We conclude that while these non-state efforts offer inspiring models of inclusive healthcare, sustainable change will require political recognition, financial support, and structural reform at the state level. 1 Introduction The right to health, and the appropriate care and services needed to access and maintain a healthy life, is one of the central human rights as defined by the World Health Organisation (WHO 2023). Accordingly, the International Covenant on Economic, Social and Cultural Rights in 1976 demanded that access to this basic human right must be ensured and protected for all people, including individuals on the move, migrants with and without certain documents and refugees (UNHCR n.d.; International Covenant on Economic, Social and Cultural Rights 1976). Under German law, refugees and asylum-seekers do not have legal access to the general healthcare system but are instead afforded limited medical services under the Asylum Seekers Benefits Act (AsylbLG) (Integrationsbeauftragte n.d.). People not registered within the asylum-seeking process or those who have not been granted refugee status, whose living status is irregularised and illegalised (De Genova 2012) as ‘undocumented’ or ‘illegal’ migrants, cannot access even these limited services. This is enforced primarily as social service offices responsible for the negotiation of forms of access to healthcare in Germany are legally obligated to report people without a residence permit to local authorities, in accordance with the reporting obligation (Meldepflicht) laid out by the German Residence Act (§ 87 AufenthG). While medical personnel, bound by patient confidentiality, are exempt from this reporting 15 obligation, the legal situation of the social welfare system fails to ensure the confidentiality and protect the privacy and safety of migrants with precarious legal status1 in accessing healthcare (Stingl/Wieland 2017, pp. 16-17). Such legal and bureaucratic hurdles are conceptualised as bordering practices (ibid., 16), as nation-state boundaries and borders are established and upheld through exclusionary practices that extend beyond the physical nation-state border to interact with urban scales (Fauser 2017). In the case of Germany and its specific legal and social welfare system regulations, bureaucratic mechanisms such as the reporting obligation are identified as especially restrictive practices of bordering in comparison to other European states (ibid.), granting access to this basic human right to certain groups while refusing and marginalising others. We identify a central problem in this current absence of safe, sufficient and accessible healthcare for all people in Germany, regardless of insurance or residence status. Shifting from the scale of national and supranational (EU) policies, we emphasise that cities and municipalities can exercise their urban capabilities in implementing practices of the European border regime more restrictively or more inclusively on the local scale (Kreichauf/Mayer 2021). In the city-state of Berlin, efforts to move against such exclusionary bordering practices by providing healthcare to individuals without health insurance, as pertaining to migrants with precarious legal status, are taken on by non-state organisations (Kreichauf/Mayer 2021; Stingl/Wieland 2017). This small-scale student research project explores the work of such non-state actors in counteracting bordering practices of the German healthcare system. We understand such counteraction both in physical or structural terms, as providing direct care to those for whom access is otherwise denied, as well as in ideological or political terms, as challenging hegemonial understandings of healthcare systems and nation-state’s responsibilities of care. Seeking to understand how bordering practices in the city of Berlin, in the form of unequal(ised)2 access to healthcare, are counteracted in this dualistic sense, we ask the following questions: In what ways does the shifting of duties of healthcare away from states’ responsibility in current neoliberal realities create specific challenges for the work of non-state organisations in the healthcare sector? What strategies are employed by healthcare organisations in response to these challenges? 1 We employ the term ‘migrants with precarious legal status’ here to refer specifically to individuals with experiences of mobility and migra<on who do not possess legal status as refugees or asylum-seekers, and who are not in possession of a limited tolera<on (Duldung). 2 We use the phrasing of ‘unequal(ised)’ access here to highlight the purposeful nature of such inequali<es, so as not to fall into the trap of trea<ng these as objec<ve or natural. Throughout our project, we seek to con<nually emphasise the responsibili<es and accountabili<es of hegemonial sociopoli<cal and ideological power structures and their associated discourses which deliberately perpetuate and seek to normalise states of inequality. We reference here exis<ng analyses on the power of language and discourse that produce and uphold hegemonial inequali<es (see also: Hall 1992) 16 What role does a re-imagining of healthcare and/or the interrogation of current hegemonial understandings of healthcare systems have for organisations providing healthcare to migrants with precarious legal status? We begin by introducing our broader research context and the theoretical frameworks that inform our study. Subsequently, we outline our methodological approach, accompanied by a critical reflection on our positionality. This is followed by an overview of our key findings, which we then situate and discuss in relation to existing bodies of research and theory. To conclude, we summarise our main insights and offer a critical reflection on the limitations of our study, alongside suggestions for future research. 2 Healthcare as a political field in bordering processes 2.1 Locating the border: Healthcare and (urban) belonging A growing body of research connects bordering practices and the negotiation of the European border regime on urban scales to exclusionary and discriminatory conditions of unequal(ised) access to healthcare (Di Stefano 2024; Fauser 2017; Johnson et al. 2011; Lebuhn 2013). Di Stefano (2024) understands healthcare as a central migration control field while Fauser (2017) describes the salient role of healthcare policies as a control mechanism of states used to govern migration and migrants. Research on urban bordering practices in this context emphasises how cities and municipalities make use of their ‘urban capabilities’ in reacting autonomously to local place-specific contexts (Kreichauf/Mayer 2021, 985). In so doing, cities and municipalities determine how the European border regime is put into practice and experienced locally. While some cities use these capabilities to implement border regimes more rigorously and exclusively, other municipal governments follow a more inclusive practice by offering broader services and access than national governments require (Kreichauf/Mayer 2021; Kuge 2019). The work of non-state actors in response to or in contact with such practices of urban bordering is well-researched, especially within the framework of sanctuary or solidarity cities that aim to enact uniquely local forms of inclusion and belonging (Fauser 2017; Özdemir/Pisarevskaya 2024). Bauder (2016; 2017) and Kreichauf/Mayer (2021), among others, conceptualise such activist or alternative action in establishing more inclusive access to healthcare as a ‘remaking’ or ‘reimagining’ of cities and their role in healthcare provision. While we find ample academic knowledge on urban citizenship and urban belonging in this context (Bauder 2016; 2017; García Agustín/Jørgensen 2021; Kron/Lebuhn,2020), we identify a gap in knowledge focused more specifically on actors and organisations working on the scale of the neighbourhood within the spatial context of Berlin. Especially in Berlin, the scale of neighbourhood, or ‘Kiez’ in Berlin vernacular, represents a uniquely important category of scale that encompasses not only a specific territory, but also a sense of belonging and community (Hochmuth 2017). Therefore, we aim to focus our analytical lens on organisations in Berlin who are active especially on a neighbourhood scale, who identify with a specific neighbourhood or who have a historical, logistical, strategic/political or other unique connection to the neighbourhood in which they are spatially located. 17 Returning to our dualistic understanding of ‘counteracting’ bordering practices, which acknowledges both a structural and an ideological interpretation of the verb, we formulate two guiding concepts to organise the theoretical frameworks that inform our research process and our analysis of results. The first guiding concept focuses on the structural politics that contextualise the shifting of healthcare responsibilities to non-state organisations; our second guiding concept addresses important theories and knowledge related to ideological and discursive underpinnings that inform hegemonial definitions of healthcare. 2.2 Guiding concept (1): Shifting responsibilities in neoliberal realities As already indicated in chapter one, in many German cities, including Berlin, care duties of the state in providing healthcare to all people are taken on by non-state or civil society organisations (Kreichauf/Mayer, 2021, 987). This phenomenon can be readily connected to broader known mechanisms of a neoliberal state and its view on healthcare and welfare politics. For example, van Dyk/Miesbach (2016) explore the effects of neoliberal policies on volunteer work with refugees, while Haubner and van Dyk (2023) describe this shift of healthcare responsibilities to non-state actors as a ‘civil-society-ification’ of social care duties, highlighting the salient role of non-state actors’ work to fill in where states take a step back in this context. Known problems connected to this kind of outsourcing from state to non-state capacities include that qualifications of service providers may be lacking and that services cannot be provided in the comprehensive, all-encompassing manner in which they are needed (Kreichauf/Mayer 2021, 989). Furthermore, non-state organisations filling in gaps in healthcare provision may result in state governments not adjusting their policies and budgets to more adequately take on these responsibilities (ibid.). We draw on this critical perspective to account for the active role of the neoliberal state and its capitalist tendencies in investigating the shifting of healthcare responsibilities to non-state organisations. This is reflected in our first research focus: In what ways does this shifting of duties of care away from states’ responsibility create specific challenges for the work of non-state organisations? What strategies are employed by organisations in response to these challenges? 2.3 Guiding concept (2): Rethinking healthcare Connected to literature on healthcare provision and its politicised function in current states and societies is a key body of theory on the concept of care itself. Conceptualising ‘care’ in this sense goes beyond providing medical services to understanding health and care also as supporting other necessities of human life, such as social inclusion and communal activity (Saltiel 2021). Saltiel/Strüver (2022) build on Joan Tronto’s ideas on critical feminist care ethics in redirecting the focus of understanding inequalities in healthcare settings to underlying social structures, linking care provision to broader questions of social injustices. Literature on care in this context demonstrates how healthcare and social services are offered or made accessible to some, as a practice of caring, while being actively denied to other groups in a community or society, as actively uncaring (Gabauer et al. 2021). Uncaring in practice interacts with legal and discursive categorisations that marginalise and exclude, as pertaining also to those categorised and criminalised as undocumented migrant(s) (Saltiel 2021). Such 18 differential practices of inclusion and service provision that uphold un/caring mechanisms can be conceptualised in terms of care as an act of inequality (ibid.). This emphasises how care in this context is a deliberate action, and therefore neither neutral nor naturally occurring nor objective. Imaginations of deservingness in healthcare contexts run parallel to and interact with binary conceptualisations of identity/other or belonging/not-belonging which are inherent in upholding border regimes (Gabauer et al. 2021; Korteweg/Yurdakul 2024; Saltiel 2021). This is also identified in Foroutan’s (2019) postmigrant perspective on constructions of a ‘nativemigrant binary’ as a discursive mechanism of differentiation in German popular discourse. These arguments suggest that counteracting bordering practices in the form of unequal(ised) access to healthcare requires rethinking the systemics of healthcare provision itself in two ways: first, by inviting to reimagine and re-define healthcare as caring in its broader, more holistic sense, which includes a multitude of life aspects; and second, by directing specific focus to the discursive and ideological underpinnings of care provision as an act. Recalling our second research focus, we ask: What role does a re-imagining of healthcare and/or the interrogation of current hegemonial understandings of healthcare systems have for organisations providing healthcare to migrants with precarious legal status? 3 Methods and process This student research project draws on qualitative research methods, centring around five semi-structured interviews conducted in October and November 2024. These interviews were conducted with three organisations in Berlin who, according to their online presence, provide healthcare services to individuals without regularised access to healthcare in three neighbourhoods, namely: open-med in Steglitz-Zehlendorf, open.med in Lichtenberg and Gesundheitskollektiv (Geko) in Neukölln. These conversations with a project assistant (I#1), a project manager (I#2), a practicing physician (I#3) and a doctor in further training (I#4) enabled us to gain a broader and more nuanced perspective on our research topic. For the interviews at open.med in Lichtenberg and Geko in Neukölln, which were conducted in person at their respective locations, additional experience logs (L#A; L#B) were drafted to document our own observations and impressions of the spaces. Additionally, we interviewed a researcher and activist (I#5) familiar with our research focus and with extensive expertise in this field. To create meaningful and relevant prompts for our semi-structured interviews, we conducted a preliminary literature review as well as basic research on the organisations of our interviewees. We adopted a semi-structured approach in the form of an ‘interview guide’ as opposed to the more structured ‘interview schedule’ (Dunn 2021, 151), with the aim to more fully benefit from and respectfully acknowledge the expertise of our interview partners. Interview topics related to the work of the organisations in providing healthcare services – including their goals, challenges they encounter and strategies they employ – as well as their visions or suggestions for a more adequate or inclusive healthcare system. 19 All interviews were analysed after transcription using the computer-based software MAXQDA and employing a qualitative content analysis according to Kuckartz (2018). Our research method utilised a deductive-inductive approach, beginning with deductively defined main categories that corresponded to the central themes of our interview guide as informed by our research questions. This was followed by several cycles of open inductive and in-vivo coding to identify relevant subcategories, which represent important aspects and key arguments emerging directly from the data collected. The structure and content of resulting subcategories and subcodes, as well as relations between these, constitute our empirical research findings, which are presented in the following chapter. An essential aspect of our considerations on research ethics is recognising and reflecting on our own positionality and privileges as well as potential power imbalances inherent in our research setting. We as student researchers and authors of this paper possess both German citizenship as well as general health insurance, which represents a form of power in spaces in which our research was conducted. We aimed to remain continuously aware and critical of our own implicit bias and subjectivities when formulating research questions, entering the spaces of the organisations we spoke with, interacting with staff and users of these spaces and throughout our coding process and qualitative analysis. 4 Findings 4.1 Navigating contending objectives Our findings highlight a challenge faced by healthcare providers who navigate contending objectives as they establish on-the-ground healthcare structures while simultaneously advocating for necessary systemic change in healthcare provision overall. As one interviewee noted, organisations ‘are taking on social welfare responsibilities’ even as this is identified clearly as the state’s ‘duty as a welfare state’ (I#5). Another interviewee stated: ‘We [opened] with the slogan, “too bad, but we’re opening” … because actually we’re not supposed to exist; the responsibility is supposed to lie somewhere else entirely’ (I#1). This critical viewpoint on the necessity for taking on healthcare provision despite it being the responsibility of the state was consistently expressed throughout all interviews, indicating the importance of this dynamic for organisations and providers of healthcare in this context. Interviewees described that while taking on this acute responsibility of care, they remain at the same time committed to advocating for systemic change through political work, ultimately aiming to render themselves obsolete (I#2; I#4). Navigating these two intentions is described as no easy task: ‘That you provide concrete assistance and at the same time [organise] political campaigns … that is really exhausting’ (I#5). Conversations with I#1 and I#4 describe a unique approach to this dilemma which seeks to establish an alternative way of providing healthcare centred around servicing all residents in the organisations’ neighbourhood or Kiez, regardless of socioeconomic factors such as legal or insurance status, or experiences of migration and mobility. Instead, this approach emphasises a sense of belonging to a neighbourhood community and shared living space, as opposed to a definition of belonging rooted in 26 International Covenant on Economic, Social and Cultural Rights - Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966 (1976). https://www.ohchr.org/en/instrumentsmechanisms/instruments/international-covenant-economic-social-and-cultural-rights Johnson, C., Jones, R., Paasi, A., Amoore, L., Mountz, A., Salter, M., & Rumford, C. (2011). Interventions on Rethinking ‘The Border’ in Border Studies. Political Geography - POLIT GEOGR, 30, 61–69. https://doi.org/10.1016/j.polgeo.2011.01.002 Korteweg, A., & and Yurdakul, G. (2024). Non-Belonging: borders, boundaries, and bodies at the interface of migration and citizenship studies. Journal of Ethnic and Migration Studies, 50(2), 293–316. https://doi.org/10.1080/1369183X.2024.2289704 Kreichauf, R., & Mayer, M. (2021). Negotiating urban solidarities: multiple agencies and contested meanings in the making of solidarity cities. Urban Geography, 42(7), 979– 1002. https://doi.org/10.1080/02723638.2021.1890953 Kron, S., & Lebuhn, H. (2020). Building Solidarity Cities: From Protest to Policy. In F, Baban & K. Rygiel (Eds.), Fosterung Pluralism through Solidarity Activism in Europe (pp. 81– 105). https://doi.org/10.1007/978-3-030-56894-8_4 Kuckartz, U. (2018). Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung. 4. Auflage. Beltz Juventa. Kuge, J. (2019). Uncovering Sanctuary Cities: Between Policy, Practice, and Politics. In J. Darling & H. Bauder (Eds.), Sanctuary cities and urban struggles: rescaling migration, citizenship, and rights (pp. 50–76). Manchester University Press. Lebuhn, H. (2013). Local border practices and urban citizenship in Europe. City, 17(1), 37–51. https://doi.org/10.1080/13604813.2012.734072 Özdemir, G. Ş., & and Pisarevskaya, A. (2024). Why do some cities support irregular migrants? Qualitative comparative analysis of municipal activism for irregular migrants in 13 European global cities. Journal of Ethnic and Migration Studies, 50(20), 4966–4986. https://doi.org/10.1080/1369183X.2024.2363873 Saltiel, R. (2021). Care as an Act of Inequality? In Complex Social Relations Within the Refugee Camp in Brussels' Maximilian Park (pp. 204–214). Routledge. https://doi.org/10.4324/9781003031536-24 Saltiel, R., & Strüver, A. (2022). Just care! Rethinking the uneven geographies of care. ERDKUNDE, 76(3), 161–170. https://doi.org/10.3112/erdkunde.2022.03.01 Stingl, I., & Wieland, S. A. (2017). Die Governance von Rechten irregulärer Migrant_innen in der Stadt: eine Analyse am Beispiel der medizinischen Versorgung in Berlin. Humboldt-Universität zu Berlin. UNHCR (n.d.). Access to healthcare. Retrieved 14.07.2024 from https://www.unhcr.org/what-we-do/protect-human-rights/public-health/accesshealthcare van Dyk, S., & Misbach, E. (2016). Zur politischen Ökonomie des Helfens: Flüchtlingspolitik und Engagement im flexiblen Kapitalismus. PROKLA. Zeitschrift für kritische Sozialwissenschaft, 46(183), 205–227. https://doi.org/10.32387/prokla.v46i183.109 WHO (2023). Human rights. Retrieved 14.07.2024 from https://www.who.int/newsroom/fact-sheets/detail/human-rights-and-health