France

France’s Institute of Health Surveillance conducted a study in 2011 on access to health care for sex workers. 251 people participated in the social health component the study and 78 participated in the medical component. Sixty-six percent of the study participants were women and of those, 78% were foreign-born women.  Most respondents reported living in precarious conditions including their social environment, housing conditions and access to health care. More than half of the respondents reported that they were in average, poor or very bad health. Respondents reported low oral contraceptive use and high use of abortion. Forty-four percent of transgender respondents in the study were HIV positive. In addition to reporting mental health issues, study respondents were exposed to physical and psychological violence.

France has a long history of migration. The number of migrants to France has grown from 1.1 million at the start of the 20th century to 7.8 million, or 12% of France’s population in 2015. In 2012, 43% of migrants, or 2.5 million people, were born in Africa. In 2012, there were an estimated 400,000 undocumented migrants in France mainly from Asia, Central Africa, West Africa, Algeria, Morocco, Turkey, and Chechnya.

Studies show that while migrants’ health status was generally better than non-migrants during the 1990s and 2000s, it has been on the decline since. The “healthy migrant effect”, which is largely a result of selective factors for immigration so that mostly healthy migrants immigrate, disappears as the duration of residence increases. Health status for first-generation and female migrants appears to be worse now than it was in the early 2000s.

Migrants in France experience lower use of medical services compared to non-migrants. This inequality can largely be explained by disadvantaged social and economic conditions that migrants in France face. Migration can include a loss of social network and may increase social isolation which may generate obstacles to accessing health care services. Language difficulties among migrants in France has resulted in misunderstanding of health information related to preventive care, to treatment or more broadly to access to healthcare. Discriminatory practices have resulted in one third of beneficiaries from the State Medical Assistance to be refused care form a health professional. Additionally, high levels of unemployment, poverty, low social status and social inequalities act as barriers to migrants receiving HIV specific services in France.

France introduced universal medical coverage for all residents in 2000. Residents in France receive coverage for healthcare services through their employer, as a benefit (for those who are unemployed) or through being a student or retired person. France covers health care costs for those who fall outside the groups who are covered for health care (these are typically undocumented migrants which comprise 0.4% of the population). Health care services covered include primary care, specialist care, hospital care, some dental care and pharmaceutical care (a co-pay is required for most services).

Although the French health care system is generally considered to be of high quality, there are persistent issues with regard to access to care for some. Economically insecure people in France, of which migrants are a key population, experience access issues to primary care. This is likely due to the co-pay that is required to be paid for all health care services. This often results in lack of uptake for treatment for various illnesses.

Over 20% of migrants do not have the optional health insurance that covers the co-pay for health care services. The state generally covers 70% and the health care user is expected to pay the remaining amount. Most employed people, unemployed people, students, and retired people receive additional coverage as a result of their status and therefore are not required to pay the co-pay.

There is a distinction between documented and undocumented migrants when it comes to health care coverage. Documented migrants can claim common law benefits whereas undocumented migrants are only eligible for a specific health care benefit called the State Medical Assistance (SMA). When universal health coverage was introduced for all residents of France in 2000, the SMA was created as health protection for undocumented migrants. The SMA has been the object of intense debate due to claims of perceived fraud and the legitimacy of providing social protection to undocumented migrants. As a result, the SMA has introduced conditions of residence (an undocumented migrant must prove residency for at least 3 months) and some financial contribution to address the criticisms of the program. IF a migrant cannot justify minimum residency, a contingency measure exists where emergency care is covered and treatment to avoid the spread of disease is also covered.

Undocumented migrants can apply for the SMA at various health and social service centres, hospital and non-governmental organizations. Undocumented migrants must provide identification document (e.g., passport, birth certificate, or expired residency permit), an address, evidence of in-country residence for at least three months, and proof that household income is under the threshold (€631/ month as of 2009). The SMA current covers all medical treatment resulting from illness or childbirth within. All healthcare professionals in France are obliged to accept SMA beneficiaries (undocumented migrants). The period of SMA entitlement is one renewable year.

An estimated 180,000 undocumented migrants receive SMA coverage. Undocumented migrants who do not meet SMA eligibility requirements are entitled to: care in life-threatening situations; treatment of contagious diseases, but not other chronic diseases; all types of health care for children; maternity care; and abortion for medical reasons.

Even with the SMA, undocumented migrants face many difficulties in accessing care. Thousands of undocumented migrants do not have SMA, though they appear to be entitled. Main reasons include uneven interpretation and implementation of the law across agencies and cities, lack of awareness of the program, and lack of acceptable identification documents or adequate evidence regarding residency requirements. Additionally, some doctors and pharmacies reportedly refuse to serve people with SMA coverage.

Ethnic minorities and migrants in France experience barriers in accessing HIV services because of high levels of unemployment, poverty, low social status and inequalities. Low socio-economic status among persons from sub-Saharan Africa may often interplay with HIV service-seeking behaviour. Data has shown that women living with HIV who were born in sub-Saharan Africa receive minimal HIV education, with a significant number also confronted with homelessness.

In 2013, France adopted a new national HIV policy where all people living with HIV are offered anti-retroviral therapy and the promotion of a “combined prevention” which links behavioral measures, testing strategies and antiretroviral therapy. Although access to HIV treatment is universal, barriers to access may still exist. These include difficulty in navigating the health care system and being denied care and treatment as a result of discrimination. France also has a higher proportion of delayed HIV diagnosis in migrants, which are likely the result of barriers to accessing health care including stigma, lack of community support, isolation, racism and double discrimination for being an HIV-positive migrant.

Although France has a universal health care system with pharmacare coverage, documented and undocumented migrants still experience barriers to accessing health care services as a result of discrimination, stigma, isolation and difficulty in navigating the health care system. Undocumented migrants face difficulty in accessing the state’s publicly funded health care services as identification documents (e.g., passport, birth certificate, or expired residency permit), an address, evidence of in-country residence for at least three months, and proof that household income is under the threshold for receiving state sponsored benefits must be provided. For homeless migrants this would be difficult to do. Additionally, undocumented migrants and HIV-positive migrants may be fearful of presenting themselves at government agencies to register for heath care coverage for fear of deportation.

Given that France provides health care coverage to all residents, irrespective of status, removing the need for providing identification and evidence of in-country residence would remove obstacles for undocumented migrants to access France’s health care system.

France’s labour market can be difficult for new migrants to secure safe and fair employment. Restrictions on foreign nationals working in the public sector and stringent requirements for some jobs can exclude migrants from jobs. New migrants can be excluded from getting jobs in the public sector for example due to restrictions on foreign national. Migrants who arrived in France in 2000 and onwards tended to fare badly in the first few years after arrival. After 9 years in France, most migrants’ labour market performance is similar to that of French nationals. However, unemployment rates for the same group of migrants was 10% lower than native workers in 2011, pointing to persistent structural obstacles to labour market access for migrants.

Migrants’ region of origin, level of education, reason for migration and gender are all factors that are related to how successful they might be at securing safe fair employment. Newly arrived migrants from North Africa and sub-Saharan Africa tend to cluster in low skilled jobs across most sectors of employment. This group tended to have higher credentials than were required for the jobs they were performing.

France has larger proportions of family-driven migration than labour migration. Since some migrants have not been selected on the basis of their skills, they can be at a higher risk of being unemployed due to low educational attainment. Unemployment has ripple effects which include poorer health outcomes (higher depression, anxiety and self-esteem), precarious housing situations and less social networks.

Given that migrants mainly migrate for economic opportunities, policies that are integrated across the heath, labour and migration sphere should be developed to provide migrants with the opportunity to thrive.