F ee clinic u ilisa ion by immig an s a e he in oduc ion o a
es ic i e heal h policy in he Basque Coun y (Spain)
Au ho s and a ilia ion:
I a xe Pé ez-U diales*1
Miguel San Sebas ián1, 2
Isabel Goicolea2
1Depa men o Nu sing I, Uni e si y o he Basque Coun y (UPV/EHU), Biscay, Spain
2Depa men o Public Heal h and Clinical Medicine, Umeå Uni e si y, Umeå, Sweden
*Co esponding au ho :
I a xe Pé ez-U diales
Depa men o Nu sing I
Uni e si y o he Basque Coun y (UPV/EHU)
Ba io Sa iena S/N Biscay
Spain
Tel: +34 94 601 8338
E-mail: i a xe.pe [email protected]
This is he accep ed manusc ip o he a icle ha appea ed in inal o m in Public Heal h 163 : 9-15 (2018), which has been
published in inal o m a h ps://doi.o g/10.1016/j.puhe.2018.06.006. © 2018 Else ie unde CC BY-NC-ND license (h p://
c ea i ecommons.o g/licenses/by-nc-nd/4.0/)
Abs ac
Objec i es Policies es ic ing heal hca e access o immig an s we e applied in imes
o public money educ ion on wel a e condi ions in Spain. This s udy aimed o assess
he impac o he implemen a ion o a mo e es ic i e heal h policy in he Basque
Coun y egion, Dec ee 114/2012, on he numbe o consul a ions a ended a a ee
clinic.
S udy Design In e up ed ime se ies.
Me hods A nega i e binomial eg ession model was applied in wo phases o he
numbe o heal hca e consul a ions a ended du ing he pe iod 2007 o 2017 (n=9,272)
o es ima e he le el and end changes associa ed wi h he implemen a ion o he
policy. Da a we e analysed sepa a ely by sex and adjus ed o Biscay p o ince´s
unemploymen a e and seasonali y o he consul a ions as con ounding ac o s.
Resul s Di e en ends o a endance be ween men and women we e obse ed du ing
he whole pe iod, cons i u ing 76.94% and 23.06% o all consul a ions, espec i ely.
A e he implemen a ion o he dec ee, he numbe o consul a ions o women pe
imes e dec eased and inc eased o men by 1% al hough i was no s a is ically
signi ican in ei he o he ends.
Conclusions No clea ela ionship be ween he implemen a ion o he Basque Dec ee
114/2012 and an inc ease in he a endance o immig an s in a ee clinic du ing he
s udied pe iod was ound.
Keywo ds ee clinic; undocumen ed immig an s; heal h policy; heal hca e access;
mig an
In oduc ion
Al hough he Eu opean Social Cha e o 1996 commi s o he p o ec ion o medical
assis ance o anyone wi hou adequa e esou ces,1 he e a e no common no ms o
Eu opean Union (EU) membe s a es ega ding en i lemen o heal hca e.2 Mo eo e ,
coun ies implemen di e en legal condi ions o access o heal hca e o na ionals and
o o eign o igin popula ions, such as immig an s o asylum seeke s,3-6 some imes
lea ing esponsibili y o hei heal hca e o non-p o i ee clinics.7-10
In ecen yea s, he numbe o immig an s in he EU has consis en ly inc eased. In 2008,
he e we e 19.5 million na ionals o non EU-27 coun ies esiding wi hin he EU11 and
a 1 Janua y 2016, he numbe o people li ing in he EU-28 who had been bo n ou side
o he EU was 35.1 million.12 As i happens in o he con ex s, no o icial igu es exis
abou how many undocumen ed immig an s could be esiding in Eu ope o on each
coun y, which ep esen s a challenge o heal hca e p o ide s and policy make s.13 The
de ini ion o undocumen ed immig an gi en by he In e na ional O ganiza ion o
Mig a ion is “A non-na ional who en e s o s ays in a coun y wi hou he app op ia e
documen a ion”.14
In Spain, by Janua y 2016, 9.89% o he popula ion was ep esen ed by egis e ed
immig an s.15 Since he yea 1986, heal hca e wi hin he Na ional Heal h Sys em (NHS)
was p o ided o any pe son, ega dless o na ionali y, on condi ion o being esiding in
Spain.16 Howe e , in Ap il 2012, he Spanish go e nmen enac ed he Royal Dec ee-
Law 16/2012 o 20 Ap il on u gen measu es o ensu e he sus ainabili y o he NHS
and imp o e i s quali y and sa e y (RDL 16/2012).17
Following RDL 16/2012, a numbe o measu es we e aken. Among o he s, by Ap il
2013, he indi idual heal hca e ca ds - he documen ha en i les indi iduals o
heal hca e access h oughou he NHS18 - o a leas 873,000 undocumen ed immig an s
we e cancelled.19 The Eu opean Commi ee o Social Righ s and di e en Special
Rappo eu s om Uni ed Na ions exp essed hei conce n abou he impac o he RDL
16/2012 on mig an s´ heal h20. Full heal hca e assis ance is cu en ly ecognised o
legal esiden s in Spain and o hose who ha e an insu ed s a us, mainly ob ained as a
con ibu o o he Social Secu i y Sys em.17,21 E en hough asylum seeke s can ge ull
heal hca e assis ance, undocumen ed immig an s can no . Howe e , heal hca e
assis ance o special si ua ions was ecognised o any pe son in case o eme gency,
an ena al, deli e y and pos na al ca e, and being a mino .
Since he NHS in Spain is decen alised, meaning ha is con igu ed as a coo dina ed se
o heal h se ices om he Cen al Go e nmen Adminis a ion and i s 17 au onomous
egions, which ha e hei own public heal hca e sys em,22,23 RDL 16/2012 was applied
in di e en ways. In he au onomous egion o he Basque Coun y, Dec ee 114/2012 o
26 June was launched o egula e access o he Basque public heal hca e sys em o
hose people excluded om heal hca e assis ance in he Spanish NHS.24 Howe e , i
was judicially e ained un il Decembe 2012, when he Cons i u ional Cou ga e pa ial
legal pe mission o apply i .25
E en i he Basque Dec ee was mo e pe missi e han he RDL 16/2012 in e ms o
undocumen ed immig an s´ access o he public heal hca e sys em, i was mo e
es ic i e o bo h documen ed and undocumen ed han he p e ious legisla ion, as he
main equi emen o access changed om h ee mon hs o one yea o consecu i e
municipali y egis a ion.24 In addi ion o heal hca e assis ance o special si ua ions
s a ed in RDL 16/2012, o he go e nmen al ins uc ions we e launched o ex end
assis ance o any pe son in he case o se ious ch onic and men al illnesses and
in ec ious diseases ha may become a public heal h h ea i le un ea ed.26
The indings in he li e a u e abou immig an s´ u ilisa ion o heal hca e in Spain a ies,
based on immig an o igin and he ype o heal h se ice.27 Fo ins ance, a ecen e iew
showed ha , in gene al, he immig an popula ion uses he eme gency se ices mo e
han Spanish-bo n esiden s and specialised ca e less. Howe e , he esul s we e di e se
ega ding he use o p ima y ca e se ices, depending on he coun y o o igin, gende
and he au onomous egion in which i was measu ed.28
The inancial c isis which has ecen ly a ec ed he indus ialized coun ies has
nega i ely in luenced he heal h o local and immig an popula ion.7,29,30 In addi ion,
immig an popula ions ace di e se ba ie s o accessing heal hca e, mos ly ela ed o
he policy a ena, he heal hca e sys em bu eauc acy, p o essionals´ beha iou and
cha ac e is ics o he immig an s hemsel es.30,31 Because o social ulne abili y and
poo e li ing condi ions o undocumen ed immig an s, o he ba ie s as lack o
awa eness abou en i lemen o heal h ca e, ea o being epo ed o he police and poo
language skills a ec hem mo e.32 The e o e, immig an s wi hou access o public
heal hca e se ices use di e en heal h-seeking s a egies, such as sel -medica ion,
bo owing insu ance ca ds, delaying he use o heal hca e un il hey eel e y sick and
use o al e na i e heal h se ices.3,33,34
To compensa e he disad an aged heal hca e si ua ion o undocumen ed immig an s, in
many Eu opean coun ies, he e a e ee clinics whe e heal hca e p o essionals a Non-
Go e nmen al O ganisa ions (NGOs) p o ide heal hca e.8-10,33,34 A ee heal h clinic is
de ined as “a p i a e, non- o -p o i , communi y-based o ganiza ion ha o e s se ices
such as p ima y and seconda y medical and den al ca e [...] These se ices a e o e ed
o no cos o a small ee o low income, uninsu ed, o unde insu ed people”.10 F ee
clinics play a p ima y ole in he ul ilmen o he igh o he highes a ainable s anda d
o heal h o hose people excluded om public heal hca e sys ems.33
Based on he hypo hesis ha mo e di icul y in accessing he public heal hca e sys em
means mo e use o he a ailable non-p o i ee clinics, he objec i e o his s udy was
o assess he impac o he applica ion o he Basque Dec ee 114/2012 on he numbe o
consul a ions a ended a a ee clinic using ins i u ion-based e ospec i e da a.
Se ing
Regis e ed immig an s ep esen ed 8.6% o he whole popula ion o he Basque Coun y
by Janua y 2016, o which 48.61% esided in he p o ince o Biscay.35 A non-p o i ee
clinic, called CASSIN (Cen e o Social and Heal h A en ion o Immig an s), s a ed
in 1997 in he ci y wi h he highes numbe o immig an s in he au onomous egion,
Bilbao. I is managed by he NGO, Médicos del Mundo-Euskadi (Doc o s o he Wo ld-
Basque Coun y).
As o ee clinics, he pu pose o CASSIN is “ensu ing access o heal h ca e by
p o iding a sa e y ne o unde se ed popula ions wi h he aim o ul ima ely dec easing
heal h dispa i ies among people o di e en socioeconomic s a uses”,10 p o iding no-
cos p ima y heal hca e and social se ices. The c i e ia o a end CASSIN a e lack o
legal access o he public heal hca e sys em and being mo e han 18 yea s old. E en i
mos o he pa ien s a he ee clinic a e undocumen ed, i is no an indispensable
equi emen o ecei e a en ion.
A CASSIN, be ween 700 and 1,000 heal hca e consul a ions a e a ended pe yea .
Heal hca e is p o ided by hi een olun a y doc o s and se en olun a y nu ses wo
days pe week, wo and a hal hou s pe day. Heal hca e se ices include disease
moni o ing, blood es s, p esc ip ions, HIV es s, wound- ea ing, and a en ion o acu e
and ch onic heal h p oblems. Legal in o ma ion and ad ice ela ed o access o he
public heal hca e sys em is p o ided by social wo ke s du ing he same hou s as he
heal h consul a ions. They also ga he and epo igh o heal h iola ions o he
compe en ins i u ions, using hem as ools o in luence poli ically ega ding he igh o
heal h o immig an popula ions.
Me hods
Da a collec ion
A CASSIN, pa ien s´ pe sonal and medical da a a e eco ded on pape egis a ion
o ms du ing he heal h consul a ion and hen ans e ed in o he da abase e e y mon h.
The numbe o heal hca e consul a ions pe imes e a ended om 1 Janua y 2007 o
30 June 2017 was di ec ly coun ed om egis a ion shee s and compa ed wi h he da a
in he da abase. Whe e di e ences in numbe s exis ed, he igu e ex ac ed om he
manual coun ing was aken in o accoun o he analysis.
Da a analysis
Da a on he numbe o heal h consul a ions a ended du ing he pe iod 2007 o 2017 was
ex ac ed in o an Excel sp eadshee on a qua e ly basis and expo ed o S a a so wa e
o analysis. F equencies o o al and new pa ien consul a ions, coun y o o igin and
diagnosis we e conside ed, s a i ied by sex.
The pe iod was subdi ided in o wo phases. The p e-in e en ion phase ep esen ed he
pe iod o he p e ious law uling ega ding access o immig an s o public heal hca e
se ices (Janua y 2007 o Decembe 2012) and he pos -in e en ion phase included he
pe iod o applica ion o Dec ee 114/2012 (Janua y 2013 o June 2017). The in e en ion
pe iod was de ined as he ime in which Dec ee 114/2012 was launched and applied
(Janua y 2013 o Ma ch 2013).
The da a was adjus ed o Biscay p o ince´s unemploymen a e and o seasonali y.
The unemploymen a e was applied o ep esen he possible in luence o he inancial
c isis on he numbe o immig an s a i ing o he ee clinic. The seasonali y cap u ed
he summe holiday pe iod (3 d imes e ), when he numbe o consul a ion days
clea ly dec ease. The seasonali y ac o was codi ied as 1 o he hi d imes e o each
yea o cap u e he summe holiday pe iod, when he numbe o consul a ion days
dec ease, and as 0 o he es o he yea imes e s.
Da a was analysed using nega i e binomial eg ession, which can be ep esen ed as he
equa ion: Y = ß0+ ß1 p e-in e en ion+ ß2 in e en ion+ ß3 pos -in e en ion + Ԑ Y ep esen s he ou come
a iable (numbe o heal h consul a ions); ß0 is he baseline le el o he ou come a he
beginning o he pe iod; ß1 es ima es he s uc u al end in he ou come be o e he
in e en ion; ß2 es ima es he immedia e impac o he in e en ion h ough he change
in le el o he ou come jus a e he in e en ion and ß3 e lec s he change in he end
o he ou come a e he in e en ion.
The in e en ion a iable was coded as 0 o he p e-in e en ion ime and he beginning
o he implemen a ion pe iod ( i s imes e o 2013) and as 1 onwa ds. The pos -
in e en ion a iable was coded as 0 up o he las poin o he p e-in e en ion and
coded as 1 onwa ds sequen ially a e he in e en ion s a ed.
Since he ou come was a coun and did no ollow no mali y assump ions, a Poisson
eg ession model was i s ca ied ou . Ini ial analysis sugges ed ha he model did no
i well he da a, so a mo e lexible nega i e binomial model was used o all analyses.
Robus s anda d e o s o he pa ame e s o con ol o mild iola ions o unde lying
assump ions we e calcula ed. Ra e a ios (RR) and he 95% con idence in e als (95%
CI) we e ob ained using he S a a 13.0 so wa e.
Resul s
A o al o 9,272 heal h consul a ions we e a ended in he whole pe iod, 76.94%
co esponding o men and 23.06% o women. Mo e women (49.58%) a ended he clinic
o he i s ime du ing he whole pe iod compa ed o men (40.03%). In he da abase,
age and na ionali y da a was only p o ided o new pa ien s and hose pa ien s who
we e a ollow-up, ep esen ing a o al o 4,707 people.
Age dis ibu ion changed depending on he sex o he pa ien s: o men, 28.98% we e
18 o 24 yea s old, 70.24% om 25 o 64 and 0.78% we e 65 o mo e, while o women
hese igu es we e 15.11%, 81.36% and 3.53%, espec i ely (Table 1). By egions o
o igin, impo an di e ences be ween men and women we e ound: 54.34% o men and
18.06% o women we e o iginally om No h A ica, while mos women (56.55%) and
ew men (7.04%) came om La in Ame ica (Table 1).
Among men, he mos p e alen diagnoses we e ela ed o he espi a o y sys em,
ollowed by diges i e, musculoskele al and egumen a y sys ems. Among women, he
mos equen diagnoses we e ela ed o he geni ou ina y sys em, ollowed in a simila
p opo ion by he espi a o y, diges i e and musculoskele al sys ems (Table 1).
T ends in a endance o men
The o al numbe o men a ending in he whole pe iod was 7,134. The da a showed a
p onounced ise in male use s om he beginning o he pe iod o he second semes e
o 2011, when a sha p dec ease occu ed un il he beginning o 2013. Howe e , he e
was a ise in he numbe o men a ending, emaining cons an a e he in e en ion and
un il he end o he pe iod (Figu e 1).
The baseline le el on he numbe o consul a ions was 193.23 a he beginning o he
pe iod among men. Adjus ed o seasonali y and unemploymen a e, he e was a no a
signi ican change in he end o consul a ions om one imes e o he nex du ing he
p e-in e en ion pe iod (RR=0.99; 95% CI=0.98, 1.02). The le el o he numbe o
consul a ions dec eased signi ican ly by 33% pe imes e in he immedia e
in e en ion pe iod, bu he end o consul a ions expe ienced an insigni ican inc ease
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Tables and igu es
Table 1. Cha ac e is ics and diagnoses o he pa ien s a CASSIN om Janua y 2007 o June
2017
Men
Women
Pa ien s
To al
7134 (76.94%)
2138 (23.06%)
A ending i s ime
40.03%
49.58%
Regions
La in-Ame ica
7.04%
56.55%
No h A ica
54.34%
18.06%
Eas e n Eu ope
3.22%
7.32%
Asia
2.65%
0.57%
Res o he wo ld
1.67%
0.49%
Diagnoses
Respi a o y sys em
18.43%
10.10%
Diges i e sys em
14.31%
10.16%
Tegumen a y sys em
13.08%
6. 57%
Musculoskele al sys em
14.68%
10.53%
Geni ou ina y sys em
2.90%
14.73%
O he s
36.60%
47.90%
Table 2. Segmen ed nega i e binomial eg ession esul s exp essed as a e a ios (95% CI in
b acke s) o he numbe o consul a ions a CASSIN by sex om Janua y 2007 o June 2017
Baseline le el
P e-in e en ion
In e en ion
Pos -
in e en ion
Men
193.23 (147.58, 253.01)
0.99 (0.98, 1.02)
0.65 (0.46, 0.91)
1.01 (0.99, 1.02)
205.15 (130.37, 322.87)a
1.02 (0.99, 1.04) a
0.60 (0.42, 0.84) a
1.01 (0.99, 1.03) a
Women
44.92 (34.35, 58.74)
0.98 (0.96, 1.00)
2.64 (1.78, 3.91)
1.00 (0.99, 1.02)
56.99 (30.18, 107.64)a
0.98 (0.95, 1.01) a
2.87 (1.80, 4.58) a
0.99 (0.96, 1.04) a
a adjus ed o unemploymen and seasonali y
