Author
The material aid an asylum seeker is entitled to includes the right to medical care necessary to live a life in human dignity.[1] This entails all the types of health care enumerated in a list of medical interventions that are taken charge of financially by the National Institute for Health and Disability Insurance (RIZIV/INAMI). For asylum seekers, some exceptions have explicitly been made for interventions not considered to be necessary for a life in human dignity, but they are also entitled to certain interventions that are considered to be necessary for such a life albeit not enlisted in the nomenclature.[2] The reception crisis has severely limited the access to reception for single male applicants. As a result, the access to health care and the overall medical situation of destitute applicants are negatively impacted (see Constraints to the right to shelter).
In addition to the limitations foreseen in the law, Fedasil often makes other exceptions on the ground that costs are too high and/or depending on the procedural situation of the asylum seeker. For example, the latest treatment for Hepatitis C has an average cost of €90,000. It is a long treatment that loses its effects when prematurely stopped. Due to uncertainty about the decision that will be taken on the asylum application and thus if the person will be able to continue the treatment in his or her country of nationality in case of a negative decision, Fedasil often refuses to pay back these expenses even though they are on the RIZIV/INAMI list. In that case, they only pay back expenses for older, cheaper treatment. This depends on the individual medical situation, the advice of the doctors, and the asylum procedure.[3]
Asylum seekers, unlike nationals, are not required to pay a so-called “franchise patient fee” (“Remgeld / ticket moderateur”), the amount of medical costs a patient needs to pay without being reimbursed by health insurance, unless they have a professional income or receive a financial allowance.
Collective centres and individual shelters often work together with specific doctors or medical centres in the area of the centre or reception place. Asylum seekers staying in these places are generally not allowed to visit a doctor other than the one they are referred to by the social assistant, unless they ask for an exception. A doctor recruited by Fedasil is present in only 11 centres of Fedasil. This doctor may refer asylum seekers to a specialist where necessary. The other reception centres rely on the system of working with external doctors.[4] Most LRI also have agreements with local doctors and medical centres, but the costs are not refunded by Fedasil but by the federal Public Planning Service Social Integration (Programmatorische Federale Overheidsdienst Maatschappelijke Integratie). This service’s decisions are based only on the RIZIV/INAMI list, so for the costs mentioned in the Royal Decree of 2009 but not in the RIZIV/INAMI list the PCSW to which the LRI is connected has to make exceptions. Not all PCSW are familiar with the Royal Decree of 2009, however, thereby causing disparities in costs refunded for asylum seekers in LRI and those refunded in other reception places.[5]
When the asylum seeker is not staying in the reception place given to him or her or when the material reception conditions are reduced or withdrawn as a sanction measure, the right to medical aid will not be affected,[6] although accessing medical care can be difficult in practice. Asylum seekers who are not staying in a reception structure (by choice or following a sanction) have to ask for a promise of repayment through an online form (requisitorium)[7] before going to a doctor.[8] This can be a very time-consuming process. When the workload is high, it can take up to a few weeks before the medical service of Fedasil answers.[9]
Once the asylum application has been refused and the reception rights have ended, the person concerned will only be entitled to emergency medical assistance, for which he or she must refer to the local PCSW.[10]
Fedasil refunds the costs of all necessary psychological assistance for asylum seekers who fall under their responsibility, although these costs are not on the RIZIV/INAMI list. As stated above, medical care in LRI is reimbursed by another fund than the other reception facilities. This generates disparities with regard to access to private psychologists.
There are services specialised in the mental health of migrants, such as Solentra,[11] but they are not able to cope with the demand. Public centres for mental health care are open to asylum seekers and have adapted rates but mostly lack specific expertise. Additionally, there is a lack of qualified interpreters. The Reception Act allows Fedasil or reception partners to make agreements with specialised services. The Secretary of State accords funding for certain projects or activities by royal decree, but these are always short-term projects or activities, so the sector mainly lacks long-term solutions.[12]
In Wallonia, there is a specialised Red Cross reception centre (Centre d’accueil rapproché pour demandeurs d’asile en souffrance mentale, CARDA) for traumatised asylum seekers. In Flanders, there is a centre for the intensive assistance of asylum seekers with psychological and/or mild psychiatric problems (Centrum voor Intensieve Begeleiding van Asielzoekers – CIBA) in Sint-Niklaas. CIBA provides for an intensive trajectory of maximum 3 months and has 40 places, 5 of which are reserved for unaccompanied minors of 16 years old or over.[13] In CARDA, there are 35 places for adults and families and no places for unaccompanied minors here. Neither CIBA nor CARDA have a waiting list in March 2023.[14]
On 29 October 2019, the Federal Knowledge Centre for Health Care (KCE) published the results of a field survey on the provision of health care to applicants for international protection. It shows that the organisation of health care in Belgium is unequal and not efficient. This leads to a difference in treatment of asylum seekers in the exact same procedural situation, purely on the basis of their place of residence. This makes the system non-transparent and complicated for social workers but also for the service provider themselves, as they have their own administration, control mechanisms and decision-making structure, thus resulting in a lack of coordination and cooperation. Access to specialised care also appears to be difficult for all asylum seekers due to a slow and complex administration that has to grant permission first. The KCE also identified other various thresholds that hamper access to health care, such as language barriers, a lack of interpreters and limited transportation possibilities. The KCE proposes that the financing of health care for all asylum seekers should be included to a global envelope, which includes services for prevention, health promotion and support in terms of translation and/or transportation etc. The report identifies several avenues in this regard. For example, all asylum seekers could be covered by compulsory health insurance, or Fedasil could manage care centrally. The report analyses the advantages and disadvantages of these options, and the conditions for their implementation.[15] Fedasil has analysed the different options put forward by the report and decided a coverage of asylum seekers by compulsory health insurance is the best solution. A project in that sense, funded by the European Recovery Fund, is being developed. In January 2023, a trial phase of 6 months has started, after which the implementation of this system on the level of hospitals and pharmacies is envisaged. Implementation of this system with other actors of the health sector will take place in a later stage of the project.[16]
Applicants for international protection are entitled to the same access to COVID-19 vaccines and testing as Belgian nationals. For applicants residing in reception centres, Fedasil put in place vaccination campaigns, leading to a vaccination rate of 62% in the reception network in September 2021 (compared to an overall vaccination rate in Flanders of 52% at the same moment).[17] PCR tests are reimbursed by Fedasil under the same conditions as reimbursement to Belgian nationals. Persons not residing in a reception centre but entitled to medical care can obtain reimbursement via the abovementioned requisitorium.[18]
[1] Article 23 Reception Act.
[2] Article 24 Reception Act and Royal Decree of 9 April 2007 on Medical Assistance.
[3] Court of Auditors, Opvang van asielzoekers, October 2017, 57; Myria, Contact Meeting, 17 October 2018, available in Dutch at: https://bit.ly/2FNSKEW, paras 96-101.
[4] Information provided by Fedasil, March 2023.
[5] Court of Auditors, Opvang van asielzoekers, October 2017, 57-58; Information provided by VVSG, February 2018.
[6] Article 45 Reception Act.
[7] Available in Dutch, French or English: http://bit.ly/3MawuX7..
[8] Information about this process provided by Fedasil: http://bit.ly/4324cEb.
[9] Court of Auditors, Opvang van asielzoekers, October 2017, 58.
[10] Articles 57 and 57ter/1 of the Organic Law of 8 July 1976 on the PCSW.
[11] https://www.solentra.be/en/
[12] Court of Auditors, Opvang van asielzoekers, October 2017, 55-56.
[13] Brochure of the CIBA program available in Dutch via: https://bit.ly/2YilInz
[14] Information provided by Fedasil, March 2023.
[15] KCE, Asylum seekers: options for more equal access to health care. A stakeholder survey, 29 October 2019, available at: https://bit.ly/2T8Ef3G.
[16] Information provided by Fedasil, March 2023.
[17] Myria, Contact meeting September 2021, available in Dutch and French at: https://bit.ly/3kE0oD7.
[18] Medimmigrant, ‘Covid-vaccination of people in precarious stay in Brussels’, available in Dutch and French on https://bit.ly/3Kx2Lng.