Availability and access to health care for irregular migrants in Greece:
a study about changes between 2010 and 2020
Teona Gusterman
Supervised by Daniel Strand, PhD
Masters in Humanitarian Action and Conflict Department of Theology, Uppsala University
Master Thesis 15 ECT May 2020
This thesis is submitted for obtaining the Master’s Degree in International Humanitarian Action and Conflict. By submitting the thesis, the author certifies that the text is from
his/her hand, does not include the work of someone else unless clearly indicated, and that the thesis has been produced in accordance with proper academic practices.
2 Abstract
There are millions of irregular migrants in the world. This group lives outside the law, registrations, and any statistics. They are often not covered by insurance and, in some countries, do not even have the right to seek health care. Nevertheless, migrants are at high risk of medical problems.
Greece is the first entry to Europe for many migrants. In 2015 alone, 800 000 migrants entered the country. Even before that, Greece had been in the list of top 10 European countries with the highest number of unauthorized migrants. In 2011, 90% of the irregular migrants who arrived to Europe entered through Greece.
This thesis aims to explore and compare the availability and access to the public health care sector for irregular migrants in Greece during the period 2010-2020. Previous research regarding this subject is limited. By using secondary material such as reports from international organizations, scholarly articles, and newspaper articles, this study analyzes how availability and access have changed from 2010 to 2020. Structural violence theory by Johan Galtung is used for interpreting and understanding the results.
The results show that the availability of health care services provided by the Greek government for irregular migrants had many limitations during the first part of the decade.
While subsequent legal changes improved the health care situation for irregular migrants, the access to healthcare became once again somewhat limited towards the end of the decade. The results also demonstrate that irregular migrants have faced many barriers to accessing health care, like not being allowed to seek health care and being obliged to pay high economic fees. However, the overall situation in Greece also played a significant role. The financial crisis in the country and the increasing number of migrants in 2015 affected the migrants’ access to health care. The application of structural violence theory shows that both availability and access to healthcare have been characterized by social injustice, unfairness between different social groups and a failure to fulfil basic human needs.
Keywords: Irregular migrants, Greece, Availability, Access, Health care.
3
Table of content
1.0 Introduction ... 5
1.1 Aim ... 6
1.2 Research questions ... 6
1.3 Concepts ... 7
1.4 Theory ... 8
1.5 Methodology ... 9
1.6 Selection of sources and empirical material ... 10
1.7 Previous research ... 12
1.8 Disposition ... 14
2.0 Analysis ... 15
2.1 Time period 2010-2015 ... 15
2.2 Time period 2016-2018 ... 17
2.3 Time period 2019-2020 ... 20
2.4 Comparative discussion ... 22
3.0 Conclusion ... 28
4.0 Bibliography ... 30
4 List of abbreviations
WHO World Health organization UN United Nations
FRA European Union Agency for Fundamental Rights IOM International Organization for Migration
EU European Union
MSF Médecins Sans Frontières / Doctors Without Borders AIDA Asylum Information Database
NGOs Non-Governmental Organizations
5 1.0 Introduction
The estimated number of irregular migrants in the world is 58 million (IOM Global Migration Indicators 2018, p. 30). People migrate illegally for reasons such as no security or opportunity, no stable home or income, no access to basic services, and reunification with loved ones (Yayboke and Garcia Gallego 2019, p.7). This group is vulnerable because they lack legal status and live in the shadows. Besides, irregular migrants are often victims of forced labor, trafficking, and violence (Yayboke and Garcia Gallego 2019, p.15). Also, migrants overall are at high risk of getting medical problems. Problems might be hypothermia, gastrointestinal illnesses, cardiovascular events, diabetes, alcoholism, and nutrition disorders (WHO Regional Office for Europe, Migration and Health: Key Issues 2020). Despite this, migrants sometimes delay seeking health care because they face racism, corruption, and legal barriers, such as deportation (IOM World Migration Report 2020, p.210). What kind of health care services irregular migrants can access, both what they are entitled to and what they need, varies from country to country and time to time.
One of the European countries affected most by the increasing number of migrants is Greece.
Greece is a member of the European Union, with a population of just over 10 million.
For many migrants who come to Europe, Greece is the first country of arrival. In 2011, the European Court of Justice reported that 90% of irregular migrants in Europe entered through Greek borders (International Organization for Migration 2020). As of 2019, there are over 1 million migrants in Greece (Migration Data Portal 2020). The country has been on the list of top 10 European countries with the highest number of unauthorized migrants between 2008-2014 (European Policy Analysis 2016, p.6).
In 2005 Greece introduced a migration law which gave hospital staff the right to not contact the police in case irregular migrants sought medical care (Björngren Cuadra 2010, p.13). Since then, the law of the availability of health care services in Greece has been modified several times.
Greece is an interesting country to study because of several major factors that happened and affected the country for the past ten years. Firstly, during the 2015 migration crisis, when over 1 million migrants entered Europe, within that number, 800,000 entered Greece (BBC News 2015). Secondly, the country has had an economic crisis for many
6 years, including 2015. That year, Greece missed the payment of 1,6 billion Euros to the
International Monetary Fund, the first time in history that a country missed payment to the IMF (Investopedia 2020). Having irregular migrants is costly for countries, for example, in a matter of access to publicly provided services (European Policy Analysis 2016 p.2).
Both these factors above contribute to how Greece has dealt with the situation of irregular migrants.
1.1 Aim
This study aims to analyze the changes in the availability of health care services offered by the Greek government to irregular migrants in the country during the period 2010- 2020. This period is chosen because the law of available medical care in Greece changed several times during these years.
Moreover, the aim is to study how the changes in availability of health care services for irregular migrants affected access to health care services. Based on the changes in availability during the time period 2010-2020, the thesis is divided into three parts: time period 2010-2015, time period 2016-2018, and time period 2019-2020. The thesis will analyze differences and similarities of availability and access during these three time periods.
1.2 Research questions This thesis has three questions.
The first question aims to find how health care services available for irregular migrants in Greece have changed during the time period 2010-2020:
● How has the availability of health care services for irregular migrants changed in Greece between 2010 and 2020?
The second question focuses on understanding what effects these changes have had on access:
● How have changes in availability affected access to health care services for irregular migrants in Greece between 2010 and 2020?
7 The third question analyzes and compares the results of time periods regarding changes:
● What are the similarities and differences in availability and access to health care services for irregular migrants in Greece during different periods of 2010-2020?
1.3 Concepts
There are three main concepts this thesis draws on: irregular migrants, availability, and access.
European Commission defines “irregular migrants” in the context of the European Union as following:
“A third-country national present on the territory of a Schengen State who does not fulfil, or no longer fulfils, the conditions of entry as set out in the Regulation (EU) 2016/399 (Schengen Borders Code) or other conditions for entry, stay or residence in that EU Member State.”1 (European Commission 2020)
“Irregular” is often used interchangeably to “undocumented” and “unauthorized”
(Migration Data Portal 2020). Being an irregular migrant means not existing in any registry and not having a legal status. Irregular migrants have an unclear position in relation to the Universal Declaration of Human Rights (UN 1948), which gives every person the same fundamental rights, including the right to medical care and necessary social services. This brings us to the second concept: availability.
Availability is a broad concept and can be described differently depending on the context.
For example, if we are talking about the availability of a web service, it can be described as the following:
“Any service-oriented system that relies on the function provided by some Web service must see the function of the Web service highly available despite any hardware or software failures of its tentative service providers.” (Liang, Lee and Hung 2012, p.48)
1 The European Commission defines “irregular migrants” within two contexts: EU and global. Because this thesis is about an European country, I chose to use the definition within the EU context.
8 Furthermore, World Health Organization writes about the availability of health care
workforce:
“The sufficient supply and appropriate stock of health workers, with the competencies and skill‐mix to match the health needs of the population.” (WHO 2020)
In the first example, we see that the definition underlines the importance of high availability of service despite the receiver. The second example is more about matching the needs to the system.
In this thesis, health care availability refers to the health care services that are offered to irregular migrants by the government.
Lastly, the concept of access. Penchansky and Thomas (1981) define access as the fit between the patient and the healthcare system. Additionally, they write about five dimensions of the concept:
• Availability – the relationship between the volumes of the services and the clients.
• Accessibility – the relationship between location of the services and the clients.
• Accommodation – the relationship between the organization of services and the client needs.
• Affordability – the relationship between price and what clients can pay.
• Acceptability – the relationship between the client’s personal preferences and the provider’s actual delivery.
In this thesis, the concept of access explores all the five dimensions mentioned above.2 Additionally, it focuses on if the irregular migrants access and get the health care they need. This includes if the group has enough information regarding what they are entitled to and if they feel safe to visit medical services, given their illegal status.
1.4 Theory
The theory applied in this study is structural violence by Johan Galtung.
Johan Galtung is a Norwegian professor of Peace and Conflict Studies who developed a three-layered understanding of violence: direct violence, structural violence, and cultural
2 In this thesis, a different definition of the concept “availability” is used. Nevertheless, the definition of the concept “availability” according to Penchansky and Thomas is relevant for reflecting on “access”.
9 violence. Direct violence is intended, visible and can be traced back to a specific person
(Galtung 1969, p.170). Structural violence is unintended, indirect and causes deficits of basic human needs (Galtung and Fischer 2013, p.35). In this case, the violence is built into the structure and does not necessarily need to be performed by an individual (Galtung 1969, p.171). Cultural violence, finally, is used to make direct and structural violence feel normal (Galtung and Fischer 2013, p.35).
Galtung describes structural violence as social injustice and inequality in power and life chances (Galtung 1969, p.171). Institutions and social practices have a significant part in the theory of structural violence. The theory explores their role in preventing people from fulfilling their basic needs. Structural violence also includes the unfairness in society when some groups do not get to exercise their full potential. The resources, such as income, education, and medical care, are unevenly distributed (Galtung 1969, p.171).
Structural violence is a pattern in society. Galtung describes structural violence as marginalization and exploitation (Banerjee et al. 2012, p.391). He writes:
“When one husband beats his wife there is a clear case of personal violence, but when one million husbands keep one million wives in ignorance there is structural violence.”
(Galtung 1969, p.171)
Structural violence theory is suitable for this study because it shows problems with social systems and injustice for different groups. Furthermore, this theory is based on patterns in society and does not necessarily focus on individuals. Structural violence theory will be used for interpreting and understanding the data analyzed in this thesis.
1.5 Methodology
A qualitative methodological approach was used when producing this thesis. This method was chosen to show and describe irregular migrants’ experiences when seeking health care in Greece. It was most suitable because the qualitative method reflects on and gives contextual real-life knowledge about social structures and practices of specific groups (Scribbr 2020). There was an ethical consideration not to reveal personal information while talking about the experiences of individuals. Even if the articles and reports this thesis refers to had gone into details with personal information of the migrants, it was still an ethical dilemma for me, and I chose not to do it. Taking into consideration that the
10 qualitative method is more interpretative than quantitative, throughout the research and
writing process, I tried to the highest possible degree to stay neutral and not influence the study with my views.
The analysis was made by studying secondary sources. It was most effective to analyze secondary sources because the study was done in Sweden without any direct connection to Greece or the possibility of contacting irregular migrants. Furthermore, this method gives a better understanding of irregular migrants’ experiences as a group rather than individuals. Analyzing secondary material gives this study more data to rely on, making the results more applicable to a group. The material for analyzes was collected on the internet, the majority from the library of Uppsala University.
Producing this study, thematic analysis was performed. Found research materials were divided into different themes and patterns. An inductive and semantic approach was involved, meaning the gathered data determined the themes.
The study was carried out with the awareness of the lack of statistics regarding irregular migrants. The irregular migrants are not part of any registrations, and they live outside the law. Nonetheless, during research, reports and articles based on collected data with direct contact with irregular migrants were analyzed.
1.6 Selection of sources and empirical material
Based on the aim of the study, the material used in this study reflects on the health care services provided by the government of Greece between 2010 and 2020. All the material about the medical services provided by Non-Governmental Organizations (NGOs) and humanitarian organizations in Greece is used to underline the case of medical services provided by the public sector. Health care services provided by NGOs and humanitarian organizations during this time in Greece and how irregular migrants had access to them, were not the focus of the analysis.
The study is limited to a specific time period: 2010-2020, and because of that, the materials used in the study are from this decade. Since the study is done during the spring of 2020, the material included in this study from the year 2020 is published on the latest 6th of May.
11 There sources were limited, especially material about the availability of health care
services offered by the government of Greek. The research material could not include Greek language materials due to the fact that I do not read Greek. There was only English material used for this study. Valid sources were chosen in English, which clarified information regarding the health care system in Greece.
The study is based on different types of material: scholarly articles, reports from international organizations, information from EU and news articles.
For background, materials used are mainly reports and other documents produced by the United Nations (UN), World Health Organization (WHO), International Organization for Migration (IOM), and the European Union (EU) as well as scholarly articles.
The availability of health care services provided by the government of Greece is based on information provided by reports and research articles referring to the laws of the country.
Policies on Health Care for Undocumented Migrants in EU27, written in 2010 by Carin Björngren Cuadra, a professor from Malmö University, is one of the reports used in the study.
Alexander Krämer and Florian Fischer from the Department of Public Health Medicine at Bielefeld University in Germany, edited the book Refugee Migration and Health in 2019. In this book, there is a part by Irini Tagiadou and Ioannis Baskozos which talks about the Greek law regarding health care for irregular migrants. This study is referring to that information.
To describe availability of healthcare, I have used two reports published by the medical humanitarian organization Médecins Sans Frontières (MSF): “Overcrowded, dangerous and insufficient access to healthcare in Moria” from 2018, and “Greece denies health care to severely sick refugee children” from 2020. I have also used Amnesty International’s
“Greece: Grant Asylum-seekers and Migrant Children Healthcare” from 2020 as well as news article from The New Humanitarian “Briefing: How will Greece’s new asylum law affect refugees?”.
The analysis of the access to health care is grounded on scholarly articles and reports about the study subject.
12 One of the sources used in the analysis is Migrants in an irregular situation: access to
healthcare in 10 European Union Member States published by the European Union Agency for Fundamental Rights (FRA) in 2011. FRA is the EU’s independent center of fundamental human rights expertise. This article shows the law and practice of access to healthcare for irregular migrants in 10 EU member states.
Another report used in the analysis is the international human rights organization Doctors of the World’s Access to healthcare in Europe in times of crisis and rising xenophobia explains issue of availability of health care services to irregular migrants and the access published in 2013. This report is based on materials from 14 cities in seven countries and discusses social health determinants and health care systems. This and the previously mentioned report are also used when describing availability.
“Health and health needs of migrants in detention in Greece: shedding light to an unknown reality” by Souliotis et al. from 2018 is also a source for the analysis.
“Impact of the Refugee Crisis on the Greek Healthcare System: A Long Road to Ithaca”
was written by Kotsiou et al. and was published in 2018. This paper explores the health care problems of migrants in Greece.
In the analysis, there are also references to information from the humanitarian organization MSF, the NGO Amnesty International and the database Asylum Information Database (AIDA) managed by the European Council on Refugees and Exiles.
Furthermore, the news articles “Briefing: How will Greece’s new asylum law affect refugees?” in The New Humanitarian, “Coronavirus: Urgent appeal for evacuation of Greek refugee camps” in Deutsche Welle, “Migrants arriving in Greece say they have no protection against coronavirus” in Euronews, and “Help for refugees and undocumented migrants in Greece” in InfoMigrants are also used in the analysis.
1.7 Previous research
Collecting the data for this study was challenging because there are not many reports and articles regarding the subject to be analyzed. From an academic standpoint, there is a need to deepen the research and knowledge about the irregular migrants in Greece.
13 There are some reports and scholarly articles that explored health care services to irregular
migrants in Europe and other counties than Greece or talked about precise health care issues of irregular migrants in Greece as well as views of specific groups.
The report Out of the Shadows Shining a Light on Irregular Migration by Yayboke and Garcia Gallego published in 2019 discusses the lives of irregular migrants. This report explores experiences from Mexico, Eritrea, and Ghana and focuses on why migrants leave their countries, how their journey is, and how they live in the shadows.
There is a study called “Health and access to care for undocumented migrants living in the European Union: a scoping review” from 2014 by Woodward et al. The authors did a review of existing research to find what is known about the subject, the gaps, and potential future steps regarding the health care of irregular migrants in Europe.
The articles “Healthcare access for refugees in Greece: Challenges and opportunities” by Gunst et al. and “Supporting access to healthcare for refugees and migrants in European countries under particular migratory pressure” by Chiarenza et al. both underline the situation of irregular migrants in Europe after the high number of arrivals in 2015. The first article talks about the different challenges of health response for refugees in Greece, for example, integrating the migrants in the health care system. The second article aims to provide information on how to improve health care access for migrants in Europe.
Numerous articles describe the mental health issues of irregular migrants in Greece.
However, besides that, there is also “Reporting mental health problems of undocumented migrants in Greece: A qualitative exploration” by Teunissen et al. from 2015. This article talks about the barriers that irregular migrants with mental health issues face, one of them being unable to access health care. Another article, “Migrant screening: Lessons learned from the migrant holding level at the Greek–Turkish borders” by Eonomopoulou et al., aims to find common symptoms, the communicable disease profile, and vaccination patterns irregular migrants at the border of Greece.
There are also research articles that show the health care system from the perspective of health care providers: “Health care for irregular migrants: pragmatism across Europe. A qualitative study” by Dauvrin et al. and “Challenges in the provision of healthcare services for migrants: a systematic review through providers’ lens” by Suphanchaimat et al. The first study is based on semi-structured interviews with medical staff from 16 EU countries and three medical care departments: primary care services, mental health
14 services and 48 Accident & Emergency departments. The second study aims to discover
health care providers’ challenges and barriers in their practice with irregular migrants as patients.
1.8 Disposition
The remaining thesis is divided into two chapters. Chapter 2 analyzes the availability of and access to health care services for irregular migrants in Greece during the period 2010 to 2020. The chapter contains four subchapters: time period 2010-2015, time period 2016- 2018 and time period 2019-2020, and a comparative discussion. The time periods are divided based on changes in the availability of health care services to irregular migrants in Greece provided by the government. Chapter 3 summarizes the results of the thesis.
15 2.0 Analysis
2.1 Time period 2010-2015
During this period, according to Greek law, health care services for irregular migrants in Greece were only available in cases of emergency or if the patient was underage (Björngren Cuadra 2010, p.11). It was the doctor who decided if the patient was in a life- threatening situation and was entitled to seek medical care or not (Doctors of the world 2013, p.42). There were several different cases included in “emergency”:
• HIV and other serious infectious diseases were included in the emergency (Doctors of the world 2013, p.42).
• Irregular migrants could also use medical services in case of pregnancy.
• Emergency case was also an immediate need to see a psychiatrist (FRA 2011, p.30).
In all the other cases, the provision of any type of health care service in the public sector was prohibited for irregular migrants (Björngren Cuadra 2010, p.11).
During this period, there were no free health care services for irregular migrants provided by the Greek government. Unlike Greek citizens, irregular migrants paid full cost for health care appointments and lab tests. They also paid full price in case of further needed treatment in outpatient units or secondary health care services. Those services were free for everyone else in the country (Björngren Cuadra 2010, p.12).
Continuing with the analysis of access to health care services, during the time period 2010-2015, the irregular migrants faced several barriers. The restricted availability to health care services, costly care, and the effects of the financial crisis in Greece were some of the aspects why irregular migrants could not access the medical care they needed.
Costly medical services in Greece was one of the hinders why irregular migrants could not access the health care services they needed. This is highly discussed in the 2011 report Migrants in an irregular situation: access to healthcare in 10 European Union Member States published by the European Union Agency for Fundamental Rights. The report shows that without the guarantee of payment, the necessary medical care was not received (FRA, 2011:42). Additionally, in some cases, the patients checked out earlier than necessary to keep the fee down, or they ran away before the treatment was finished. For
16 example, there have been cases when women after giving birth have run away with their
newborns during the night (FRA 2011, p.37).
Furthermore, the report shows that irregular migrants could not access health care because of the unawareness of their rights. They did not have information regarding how the system worked. Thus, they did not know what to do or where to go (FRA 2011, p.43).
As mentioned above, children of migrants in an irregular situation had the right to seek health care in Greece. Nevertheless, the report Migrants in an irregular situation shows that they did not always get what they were entitled to. For example, hospitals could not provide basic vaccinations. This was due to the budget cuts and affected not only migrants, but everyone (FRA, 2011 p.28). In cases like this, hospitals tried to send the migrants to NGOs which provided cost-free vaccines. Sometimes even in other cases, the health care staff sent patients to NGOs. Since irregular migrants had to pay for prescriptions themselves, where possible, NGOs provided cost-free medication (FRA 2011, p.31).
The FRA report also mentions that there were times when Greeks themselves had problems with accessing health care because they were not insured (FRA 2011, p.38) because of ongoing financial crisis in the country during that time. Even though this is beyond the scope for the thesis, it is an important part of the context for the situation in the country.
In 2013, Doctors of the World published the report Access to healthcare in Europe in times of crisis and rising xenophobia explains issue of availability of health care services to irregular migrants and the access. This report brings up several aspects of why the law for health care services for irregular migrants was problematic in Greece. Firstly, the treatment for infectious diseases was only available to patients until they were
“stabilized”, but there was no explanation of what the “stabilization” exactly meant (Doctors of the world 2013, p.42). It was up to the doctors from case to case to define this state. Secondly, even though the law gave irregular migrants the possibility to access health care in case of infectious diseases, they could be detained because of having an infectious disease. This has been used as a reason for deportation because the patient was considered as a risk for public health (Doctors of the world 2013, p.42).
Some studies show other issues with the Greek health care system during this time period.
For example, while seeking care for mental health, irregular migrants faced cultural and
17 language barriers. Medical staff lacked training and tools to work in a cross-cultural
environment. There was also the shortage of interpreter services, which added to the language and cultural barriers. Finally, medical staff have also stressed the irregular migrants’ financial issues, which made them feel powerless (Soulitos et al. 2018, p.1).
To sum up, during the time period 2010-2015, the availability of health care services for irregular migrants was very limited and included no cost-free care. This caused restricted access to needed medical services. As the analysis has shown, the irregular migrants did not have the information regarding what health care services they were entitled to. The law was not very clear either. It was up for interpretation by individual medical staff.
Additionally, in several cases the irregular migrants did not have the money to seek care.
The medical staff of public health care relied on medical NGOs in Greek to assist the irregular migrants. This, for example, for free medication or the necessary treatments that were not provided by the public sector due to the financial restrictions from the government. Irregular migrants and medical staff also faced cultural and language barriers.
Structural violence theory can be applied on this time period because the violence, which in this case was barely allowing irregular migrants to seek health care, was built in the structure of society. It was social injustice and disbalance in power because some groups got to do it but not others. Additionally, it also denied basic human needs, which is getting medical treatment.
2.2 Time period 2016-2018
In 2016, the Greek Parliament passed the law 4368/2016, which aimed to provide free access to the public health system. It also made access to medical care and treatments easier at free or near-zero costs. This law applied to everyone living in Greece, including irregular migrants.
Dr Ioannis Baskozos, Secretary General of Public Health in Greece and Irini Tagiadou, Associate of Secretary General of Public Health, have said following about the change in the law:
“This law is based on the principles of equality, non-discrimination, fairness and solidarity.” (Tagiadou and Baskozos 2019, p.150)
18 Furthermore, those with medical referrals got all the medical services and prescriptions
for free. This was the case for what the law called the “vulnerable groups”. These groups needed to have a Social Security Number (AMKA), or in case they did not fulfill the requirement for AMKA, a special Foreigner´s Health Care Card (K.Y.P.A) (Amnesty International 2020). In the vulnerable groups were included:
• Children under the age of 18;
• Pregnant women;
• People with disabilities;
• People with mental health issues (Tagiadou and Baskozos 2019, p.150/151).
Even though the law of health care availability changed dramatically and in theory, access to health care became easier to get, there were still several barriers that irregular migrants in Greece faced during the time period 2016-2018. Some were the same as before, and some were new. As the thesis will show below, increased migration flows to Greece and continued economic crisis had a big effect on the country’s health care services, and it opened up new challenges.
Even during this time period Greece was in the midst of an economic crisis. This had a direct impact on the health care system, and the country was not meeting health needs.
For example, there was not enough necessary medical equipment or effective coordination. The lack of medical staff and human resources in public hospitals were consequences of the economic crisis. Irregular migrants were affected by this, as was the local population (Kotsiou et al. 2018, p.7).
It was also during this period when a large number of refugees arrived in Greece, making the volume of health care services insufficient. According to a study made in a reception center at Lesbos Island, migrants were in urgent need of mental and dental care (Kotsiou et al. 2018, p.7). There were cases when refugees with mental illness were detained in jail without any necessary treatment. It was several months waiting to get an appointment to a psychiatrist. According to the study, which included experiences of over 2000 patients, only 26% had access to psychological services.
In the study from Lesbos island, it is also reported that reception centers and border- crossings faced administrative problems and local customs that hindered access to health care. There was also a barrier of lack of time at health care facilities as well as continuity
19 in care. The financial difficulty was continuing to be an issue for irregular migrants
seeking health care (Kotsiou et al. 2018, p.8).
Just as during previous years, the lack of information about the health care system in Greece and the culture and language barriers were something irregular migrants faced.
There was a lack of cultural mediators, and volunteers were used as interpreters. This was not sustainable because professional interpreters were needed for confidentiality. The language barrier was an issue for irregular migrants as well as for the medical staff because the medical history was in another language. It was reported that even with an interpreter, the language barrier was still there (Kotsiou et al. 2018, p.8).
NGOs continued to have an important role in the health care system. Around half of all the cases of irregular migrants who needed access to specialized care or treatments were done by NGOs. Nevertheless, there was inefficient coordination between the public sector and the NGOs, which sometimes caused increased load on the health sector (Kotsiou et al. 2018, p.10).
Different sources confirm the mentioned problems of irregular migrants when the latter accessed health care in Greece in this period. One of the sources is Asylum Information Database (AIDA). According to its information, the health care system was very stretched because of the shortage of staff and capacity. The public sector was not able to answer all the health care needs in the country. Furthermore, AIDA also writes that there was a lack of cultural mediators for the migrants (AIDA 2020). They refer to UNHCR, which has stated:
“Across the islands and on some camps in the mainland the low number of staff under the Ministry of Health, in particular doctors and cultural mediators, is not sufficient to help refugees with medical and psychosocial needs. The limited public mental health institutions in Greece are a particular concern.” (AIDA 2020)
Several humanitarian organizations have publicly spoken about inefficient health care services for migrants in reception camps in Greek. Médecins Sans Frontiéres (MSF) has reported that at Lesbos, 500 new people arrived every week in 2018, making the only public hospital on the island overwhelmed (MSF 2018). MSF continued to report that they had been warning the Greek government about a dramatic increase in medical care, but without any response. They also stressed the urgent need for mental health treatments due to the fact that many of their patients made suicide attempts and caused self-harm.
20 Another fact that MSF highlights is that access to health care during nighttime and
weekends was very limited, at the same time as the need of health care services, such as sexual and reproductive health care services, were doubling from month to month (MSF 2018).
In summary, during time period 2016-2018, the availability of health care services to irregular migrants in Greece developed to a more open and easily accessed system.
Everyone got an opportunity to seek the care they needed. Several services were offered for free. Even though, in theory, the changed law should have made access to health care easier, surrounding factors have a big impact on the system. The high influx of migrants and the economic crisis in Greece made the health care system in the country weak. Not only for migrants but for everyone. Much material brought up the same issues. The capacity of medical services was not enough. The public sector was understaffed, and the budget was cut. Additionally, several sources talk about a lack of mental health treatment for newly arrived migrants, which were several hundred each week during some periods.
Some barriers stayed the same from the previous period. There was a shortage of interpreters, and cultural mediators, as well as irregular migrants, had administrative and financial barriers while seeking health care. Medical NGOs continued to have a crucial role in the Greek health care system.
Structural violence can be applied on this time period because the violence was un- intended and indirect. According to the law, the government made seeking health care for irregular migrants easier. However, there were still many barriers caused by, among other things, the financial crisis and the high increase of migrants in the country.
2.3 Time period 2019-2020
In July 2019, the Greek government revoked free access to the public health care system for irregular migrants (MSF 2020). This group could no longer seek free health care, not even in emergency situations. Free health care for vulnerable groups was maintained according to the law 4368/2016 (Amnesty 2020). However, the vulnerability criteria were modified, and for example, individuals with posttraumatic stress disorder (PTSD) were no longer considered to be included in the vulnerable groups (The New Humanitarian 2020). In July 2019, the Greek Ministry of Labour also withdrew issuing social security
21 numbers (AMKA) for the members of vulnerable social groups (Amnesty International
2020).
Irregular migrants struggle to access the health care system in Greece continued even during this time period. It is important to underline that the material analyzed in this part is only from time until May 2020.
Humanitarian organizations like Amnesty International have called out the government of Greece for not taking responsibility for the health care of migrants in the country. In a report, the organization writes:
“NGOs like MSF and doctors in the public system have been doing their best to continue providing health care and make up for the State’s failure, but they are not equipped to meet the scale of existing needs and serious cases continue being reported.” (Amnesty International 2020)
Besides withdrawing the issuing of AMKA, no new alternative has been offered for groups who fall within the vulnerable category. A process for granting foreigners a health care card (K.Y.P.A) has been inactive (Amnesty International 2020). In practice, this means that vulnerable groups have been without free access to healthcare. There has been reports that children are not able to receive vaccination (The New Humanitarian 2020).
MSF has also called out the government of Greece to transport and take care of children with chronic illnesses living in the refugee camps. The organization is not equipped to do specialized treatments for children with serious diseases. For example, there was a patient, a young girl suffering from autism who needed special treatment (MSF 2020).
“Often in the middle of the night she has seizures and there is no one to help us.” Says the girl´s mother (MSF 2020).
As mentioned before, PTSD was taken away from the criteria of vulnerability. This has been criticized by doctors who work with migrants. Apostolos Veizis, director of medical operational support in Greece for MSF, have said that this will stop migrants from getting the appropriate medical and social support they need. MSF reported a 40% increase in mental health-related cases in the summer of 2019 in comparison to the summer of 2018.
Several of the patients were children, and the cases included suicide attempts and self- harm incidents (The New Humanitarian 2020).
22 At the beginning of 2020, the world was introduced to the pandemic of the Coronavirus.
In order to stop the virus from spreading, the World Health Organization (WHO) has recommended a one-meter distance between people, following good hygiene, and self- isolating even with minor symptoms (WHO 2020).
The Greek island of Lesbos has Europe’s biggest refugee camp, Moria. Twenty thousand people are living there. That is 17 000 more than the camp is designed for (Deutsche Welle 2020). Besides the overcrowding, several aspects go against the recommendations for tackling public health threats like Coronavirus. Migration expert, Gerald Knaus commented regarding the situation:
“Conditions have been terrible for a long time, but if you add that some in these hotspots will at some point catch the virus, under conditions in Lesbos where 20,000 people can't separate, can't wash their hands, and with only six intensive care beds on the island — it is obvious why we must act.” (Deutsche Welle 2020)
There are several other camps on Lesbos and other islands of eastern Aegean which have more people than the capacity (Euronews 2020).
To sum up, even during the time period 2019-2020, irregular migrants had to rely on medical NGOs for health care services. At the same time, the Coronavirus pandemic made several NGOs close down or reduce their services (Info Migrants 2020). Another issue during this time period was the lack of a process of getting health care for vulnerable groups. The mental health cases continued to rise at the same time as the availability to psychiatric care decreased. The Coronavirus pandemic hit at the beginning of 2020 and affected public health, including irregular migrants.
Structural violence can be applied on this time period because of, once again, social injustice. Social structures keep irregular migrants from seeking the necessary health care.
There is a pattern and unfairness in society when groups with different resources get different access to basic human needs.
2.4 Comparative discussion
Based on the changes in availability of health care services, the analysis has been divided into three parts: time period 2010-2015, time period 2016-2018, and time period 2019- 2020. In this subchapter, firstly, will be comparative discussion of similarities and
23 differences of availability and secondly, of access. In some cases, two of the periods are
similar to each other but different from the third, and vice versa. Because of this, the division of similarities and differences crosses each other.
There are several similarities in the availability between the three time periods:
• In all three time periods irregular migrants had the possibility to seek emergency care. This included life-threatening situations, pregnancy, mental health issues, and severe infectious diseases.
• Children under the age of 18 could seek medical care at any time period.
• Time period 2010-2015 was also very unclear based on the fact that a lot of interpretation, for example, such as the state of “emergency” or “stabilized” was put on doctors. As was the changed law from 2019. It took away the Social Security Number (AMKA), which was needed for the vulnerable groups to seek care and did not put a functioning new system instead. Another similarity between those two time periods is that no treatment was free of charge. Even though in 2019, irregular migrants could seek any health care with a fee.
There are several differences in government offered health care services to irregular migrants in Greece between the three time periods:
• During period 2010-2015, irregular migrants were prohibited from visiting public medical facilities if it was not an emergency or patient under the age of 18. This was a unique case for this time period and was changed in 2016.
• The first time period, 2010-2015, was very limited and did not allow irregular migrants to seek any health care free of charge. This is the opposite of the next time period, 2016-2018, when the law allowed everyone to seek health care. In comparison to the time period 2010-2015, the time period 2016-2018 was more generous in offered health care services.
• Not only all emergency care got free of charge in 2016, but other treatments were also available for free or near-zero costs. This was a big contract to previous time, when no treatments was without a charge. After time period 2016-2018, in the upcoming year, the law regarding the public health care system for irregular migrants in Greece changed once again. Public health care became once again costly. There were no free medical services left in the country for irregular migrants as a group.
24
• The vulnerable group was introduced in 2016, which was a significant difference from previous time periods in the aspect that the health care for vulnerable groups were free. Vulnerable groups were children under the age of 18, pregnant women, people with disabilities and people with mental health issues. Even though the criteria of what is included in the vulnerable groups changed in 2019, the vulnerable group continues to be active concept. Individuals with posttraumatic stress disorder (PTSD) were no longer part of the vulnerable group.
From the perspective of irregular migrants as a group and Greek citizens as a group, there were differences during different time periods. During 2010-2015 when irregular migrants needed to pay for emergency care, it was free of charge for Greek citizens. Later it got equal, and in 2016 everyone had the same health insurance and availability of health care services. Even though he comparison of irregular migrants to other groups is outside the scope of this thesis, it is an important part of understanding the situation in the country and how government dealt with health care system.
Structural violence theory can be applied on the system of available health care services in Greece during periods 2010-2015 and 2019-2020. However, it must be pointed out that Galtung’s theory of structural violence says that action is unintended and indirect. This is not the case for the Greek laws of health in the all the time periods. During the 2010-2015 period, the group of irregular migrants was not allowed to seek health care, and during 2019-2020 the system of services for vulnerable groups was not put in place. Both acts were intentional and direct.
Nevertheless, there are several grounds for structural violence. There was social injustice between irregular migrants and other groups, such as Greek citizens. Basic human needs, which in this case is health care, were not met. This was not only the case for one person, but for the whole group of irregular migrants. The violence was built into structural of society in the example of laws. Those laws were preventing people from meeting their basic needs. The resources were unevenly distributed, and it was unfairness in society.
Moving on to access to health care offered by the Greek government to irregular migrants in the country, there have been barriers in all three time periods. In some cases, the barriers have been similar from time period to time period and, in some cases, different.
25 Firstly, regarding similarities:
• When comparing these three time periods from the access perspective, the first note should be that all three time periods similarly had issues with irregular migrants accessing health care. The barriers of accessing health care in 2010-2015 and 2019-2020 were mostly legal and had to do with Greek law prohibiting irregular migrants to access health care.
• The financial issues were a barrier in accessing health care both during time period 2010-2015 and 2016-2018, even though these issues seem to have been bigger during the first period. This could be because public health care services got free.
During the time period 2010-2015, the financial access barrier was due to the fact that no treatment was free of charge, and irregular migrants did not have money to pay. Unclear if this continued to 2019 and forward.
• For 2016-2018, many research materials underline shortages of medical care volumes. This had continued even 2019-2020 when irregular migrants did not have the ability to protect themselves from Coronavirus.
• Another similarity between those two time periods, 2016-2018 and 2019-2020, is a shortage of mental health treatments. Previous research material talks about the lack of mental health care in those two time periods. In 2016-2018, this barrier was caused by the shortage of services. Even in the time period 2019-2020, mental health treatments were problematic to access for irregular migrants. In this case, it was one of the effects of changed availability.
• In all three time periods, the role of medical NGOs in the country has been significant. Not only the irregular migrants had to rely on the services of medical NGOs but also the government of Greece, and in some cases the country´s population. The NGOs also have been very outspoken regarding issues of medical care in the country, and they contribute with a big part of the information on the situation of migrants in Greece.
• Similarly, the available health care services had a big effect on access. An example of this was patients within the vulnerable group not getting the treatment they needed. 2020 also introduces Coronavirus, which needs several precautions to avoid. Numerous reports show that this was not accessible for irregular migrants.
Continuing to 2019-2020, change in the law to take away the Social Security Number (AMKA) led to a vulnerable group of children not getting the medical
26 services they needed. It was this time period when Post-Traumatic Stress Disorder
(PTSD) was taken away from the vulnerable group. The effect of this action was clearly shown on increased mental health related cases at the medical NGOs.
There were several differences in access between the three time periods:
• The barriers of 2016-2018 were caused by other circumstances, like the poorly functioning health care system in the country. Several previous research materials talks about the lack of volumes of medical services. Even though the available health care services has theoretically increased for irregular migrants, there still were significant barriers. The available amount of medical services was less than medical needs. This was both medical staff and equipment.
• There have been reports that there was not enough information regarding available health care services for irregular migrants in time period 2010-2015. This information has not come back in research of other time periods.
• Furthermore, specifically for 2010-2015, several medical treatments were not available for irregular migrants, which caused no access for irregular migrants to all needed health care treatments besides emergency and patients under the age of 18.
As shown above, the availability of health care services affected access. Nevertheless, there have also been two significant influences that have put their marks on the situation.
The first is the financial crisis of Greece, which has led to a lack of medical equipment and staff members. This problem has not only affected irregular migrants, but everyone living in the country. The second factor is that Greece was not prepared for the number of migrants that arrived in 2015. This can be seen on overcrowded refugee centers and overwhelmed medical facilities by the borders.
The results of access to health care can be interpreted with the help of structural violence theory by Galtung. Unlike the part of availability, the government’s actions regarding access to health care have been intended and direct as well as unintended and indirect.
Greek law gave possibility to irregular migrants in the time period 2010-2015 to seek emergency care. However, examples show that irregular migrants were not able to do it because of the financial issues. This would be unintended and indirect, but the same law also prohibited migrants from seeking any other needed health care treatments. Which indicated intended and direct action. Nevertheless, basic human needs were not met and
27 the groups of irregular migrants were marginalized. Later in 2016-2018, the law opened
up the possibility of more services but the lack of necessities in functioning health care system continued to make access to health care for irregular migrants a problem. Those aspects can also be defined as unintended and indirect. Furthermore, all the barriers of access are examples of structural violence. This because of social injustice, unfairness in society, and lack of possibility of getting basic human needs.
To repeat once again, irregular migrants do not exist in any registration and live outside the law. Thus, it is hard to have statistics or concrete data. The information I found in the empirical material I have applied to the whole group of irregular migrants. It must be noted that several of the articles only refer to irregular migrants who lived in refugee camps, not the whole group of irregular migrants who live in Greece.
28 3.0 Conclusion
In this thesis, I set out to explore how the availability of health care services provided by the Greek government to irregular migrants has changed between 2010 and 2020. I have also analyzed how those changes have affected access to health care. Finally, I have examined differences and similarities in availability and access during the time periods 2010-2015, 2016-2018 and 2019-2020. For interpreting the results, I applied structural violence theory by Johan Galtung.
In 2010, available health care services to irregular migrants in Greece was limited, and only included emergency care and patients under the age of 18. No treatments were free of charge. In 2016, the law changed to allow irregular migrants free emergency care as well as other treatments for free or near-zero cost. Additionally, the new law introduced the concept of “vulnerable groups” who got all the care for free. Vulnerable groups included children under the age of 18, pregnant women, people with disabilities, and people with mental health issues. In 2019, free public health care for irregular migrants was revoked, and processes for the vulnerable group as well as criteria were changed. The process of getting special card that entailed being part of vulnerable group and having right for free health care was taken away and not replaced by new functioning system.
Also, individuals with PTSD were no longer part of vulnerable group.
Changing availability of health care services also had consequences for the access to these services. During the time period 2010-2015 when there were no free of charge treatments, irregular migrants did not have financial ground to seek health care. When in 2019, PTSD was taken away from vulnerable groups, mental health issues raised within the migrant group. Further, changes in the processes of vulnerable groups seeking health care meant that children could not access the necessary medical care.
I would argue that the barriers to and changes in access to health care for irregular migrants in Greece were also heavily dependent on surrounding factors such as financial problems and an unexpectedly big migration in 2015. This was seen in the 2016-2018 period when irregular migrants, while they should have had an easier access to health care, did not get it. There were not enough medical treatments in the country.
When comparing the three time periods, one can discern a change in the available health care services offered to irregular migrants. Availability was first very limited and did not allow irregular migrants to receive several needed treatments. Moreover, it was also
29 costly. Later, the availability became very open and almost free. In 2019, finally all the
treatments once again became costly, even though it was still possible for irregular migrants to seek any health care they needed. I would argue that the biggest difference between the three time periods is irregular migrants were prohibited from seeking several forms of medical care during 2010-2015. Moreover, the available services were costly at that time, similar to 2019-2020, but different from 2016-2018. The biggest similarity is that irregular migrants could to seek health care during all periods in case of emergency or if they were under the age of 18.
Even though the availability changed, irregular migrants had barriers in accessing health care in all three time periods. In 2010-2015, several reports talked about the financial issues of irregular migrants while seeking health care. In 2016-2018, by contrast, the most common problem of access was the shortage of medical services. 2019-2020 brought new barriers to access, with the Coronavirus pandemic and bureaucratic problems with vulnerable groups accessing health care. Overall, I would argue that even if some barriers were similar during the three time periods, most of them were unique for the specific periods.
30 4.0 Bibliography
Amnesty International. 2020. “Greece: Grant Asylum-seekers and Migrant Children Healthcare”, January 17. https://www.amnesty.org/en/documents/eur25/1683/2020/en/
[Accessed 7 May 2020].
Asylum Information Database. 2020. “Health Care Greece”.
https://www.asylumineurope.org/reports/country/greece/reception-conditions/health- care [Accessed 7 May 2020].
Banerjee A., Daly T., Armstrong P., Szebehely M., Armstrong H. and Lafrance S.
“Structural violence in long-term, residential care for older people: Comparing Canada and Scandinavia”. Social Science and Medicine 74, 3 (2012) 390-398.
BBC News. 2015. “Migrant crisis: One million enter Europe in 2015”, December 22.
https://www.bbc.com/news/world-europe-35158769 [Accessed 7 May 2020].
Björngren Cuadra C. Policies on Health Care for Undocumented Migrants in EU27.
Malmö: Malmö university MIM/Health and Society, 2010.
Chiarenza A., Dauvrin M., Chiesa V., Baatout S. and Verrept H. “Supporting access to healthcare for refugees and migrants in European countries under particular migratory pressure”. BMC Health Services Research (2019)
Dauvrin M., Lorant V., Sandhu S., Devillé, Dia H, Dias S., Gaddini A., Ioannidis E., Jensen NK., Kluge U., Mertaniemi R., Puigpinós I., Riera R.,Sárváry A., Strabmayr C., Stankunas M., Soares JJ.,Welbel M. and Priebe S. “Health care for irregular migrants:
pragmatism across Europe. A qualitative study”. BMC Research Notes (2012).
Dw.com. 2020. “Coronavirus: Urgent appeal for evacuation of Greek refugee camps”, March 31. https://www.dw.com/en/coronavirus-urgent-appeal-for-evacuation-of-greek- refugee-camps/a-52967371 [Accessed 7 May 2020].
Doctors of the World. Access to healthcare in Europe in times of crisis and rising xenophobia. France, European Programme for Integration and Migration, 2012.
Doctors Without Borders. 2020. “Greece denies health care to severely sick refugee children”, January 23. https://www.doctorswithoutborders.org/what-we-do/news-
stories/news/greece-denies-health-care-severely-sick-refugee-children [Accessed 7 May 2020].
31 Eonomopouloua A., Pavlib A., Stasinopouloua P., Giannopoulosa L.A, and Tsiodrasc S.
“Migrant screening: Lessons learned from the migrant holding level at the Greek–
Turkish Borders”. Journal of Infection and Public Health 10, 2 (2017): 177-184.
Euronews.com. 2020. “Migrants arriving in Greece say they have no protection against coronavirus”, March 28. https://www.euronews.com/2020/03/28/migrants-arriving-in- greece-say-they-have-no-protection-against-coronavirus [Accessed 7 May 2020].
European Commission. 2020. “Irregular Migrant”. https://ec.europa.eu/home-
affairs/what-we-do/networks/european_migration_network/glossary_search/irregular- migrant_en [Accessed 7 May 2020].
European Union Agency for Fundamental Rights Migrants in an irregular situation:
access to healthcare in 10 European Union Member States. Luxemburg, Publications Office of the European Union, 2011.
Galtung J. Violence, Peace and Peace Research. Olso: Oslo Peace Research Institute, 1969.
Galtung J. and Fischer D. Johan Galtung: Pioneer of Peace Research. Berlin: Springer- Verlag Berlin Heidelberg, 2013.
Global Health Workforce Alliance. 2020. “What do we mean by availability, accessibility, acceptability and quality (AAAQ) of the health workforce?”.
https://www.who.int/workforcealliance/media/qa/04/en[Accessed 7 May 2020].
Gunsta M., Jarmanb K., Yarwoodc V., Rokadiyad S., Capsaskise L., Orcuttf M. and Abbarag A. “Healthcare access for refugees in Greece: Challenges and opportunities”.
Health Policy 123, 9 (2020): 818-824.
InfoMigrants.net. 2020. “Help for refugees and undocumented migrants in Greece”, April 8. https://www.infomigrants.net/en/post/23948/help-for-refugees-and-
undocumented-migrants-in-greece[Accessed 7 May 2020].
International Organization for Migration. 2018. “Global Migration Indicators”.
https://publications.iom.int/system/files/pdf/global_migration_indicators_2018.pdf [Accessed 7 May 2020].
International Organization for Migration. 2020. “IOM Greece”.
https://greece.iom.int/en/iom-greece [Accessed 7 May 2020].
32 International Organization for Migration. 2020. “World Migration Report 2020”.
https://www.un.org/sites/un2.un.org/files/wmr_2020.pdf [Accessed 7 May 2020].
Kotsiou O., Kotsios P., Srivastava D., Kotsios V., Gourgoulianis K. and Exadaktylos A.
“Impact of the Refugee Crisis on the Greek Healthcare System: A Long Road to Ithaca”. International Journal of Environmental Research and Public Health 15, 8 (2018).
Liang Q., Lee B. and Hung P.C.K. “A rule-based approach for availability of service by automated service substitution”. Software: Practice and Experience 44, 1 (2014): 47-76.
Migration Data Portal. 2020. “Greece”.
https://migrationdataportal.org/data?i=flows_abs_immig1&t=2013&cm49=300 [Accessed 7 May 2020].
MSF. 2018. “Overcrowded, dangerous and insufficient access to healthcare in Moria”, May 4. https://www.msf.org/greece-overcrowded-dangerous-and-insufficient-access- healthcare-moria [Accessed 7 May 2020].
Penchansky R. and Thomas J.W. “The Concept of Access, Definition and Relationship to Customer Satisfaction”. Medical Care 19, 1 (1981): 127-140.
Scribbr.com. 2019. “How to write a research methodology”, February 25.
https://www.scribbr.com/dissertation/methodology/ [Accessed 7 May 2020].
Souliotis K., Saridi M., Banou K., Golna C., Paraskevis D., Hatzakis A. and Smith A.
“Health and health needs of migrants in detention in Greece: shedding light to an unknown reality”. Globalization and Health, 15, 4, (2019).
Suphanchaimat R., Kantamaturapoj K., Putthasri W. and Prakongsai P. “Challenges in the provision of healthcare services for migrants: a systematic review through
providers’ lens”. BMC Health Services Research, 15, 390, (2015).
Teunissen E, Tsaparas A, Saridaki A, Trigoni M, van Weel-Baumgarten E, van Weel C, van den Muijsenbergh M & Lionis C. “Reporting mental health problems of
undocumented migrants in Greece: A qualitative exploration”. The European Journal of General Practice, published by Informa UK Limited, trading as Taylor & Francis Group, 22:2, (2016): 119-125.
33 Thenewhumanitarian.org. 2019. “Briefing: How will Greece’s new asylum law affect
refugees?”, November 4.
https://www.thenewhumanitarian.org/news/2019/11/04/Greece-new-asylum-law- refugees [Accessed 7 May 2020].
Tagiadou I. and Baskozos I. “The Challenge of a Comprehensive Health Response to the Refugee Crisis in Greece”. In Refugee Migration and Health: Challenges for Germany and Europe, edited by Krämer A. and Fischer F. Cham: Springer, 2019.
United Nations. 1948. “Universal Declaration of Human Rights”.
https://www.un.org/en/universal-declaration-human-rights/ [Accessed 7 May 2020].
Woodward A., Howard N. and Wolffers I. “Health and access to care for undocumented migrants living in the European Union: a scoping review”. Health Policy and Planning 29, 7 (2014): 818–830.
World Health Organization. 2020. “Migration and Health: Key Issues”.
http://www.euro.who.int/__data/assets/pdf_file/0005/293270/Migration-Health-Key- Issues-.pdf?ua=1 [Accessed 7 May 2020].
World Health Organization. 2020. “Coronavirus disease (COVID-19) advice for the public”, April 29. https://www.who.int/emergencies/diseases/novel-coronavirus- 2019/advice-for-public [Accessed 7 May 2020].
Yayboke E.K. and Garcia Gallego C. Out of the Shadows Shining a Light on Irregular Migration. Washington: Center for Strategic & International Studies 2019.
