Author
Asylum seekers under the regular procedure, like any other third-country nationals below a certain income level, have access to healthcare thanks to the Universal Health Protection Scheme (PUMA).[1] Since January 2020, the 3-month residence requirement applies to all adult asylum seekers without exception.[2] During the first three months, they only have access to emergency health coverage (Dispositif Soins Urgents et Vitaux). Children have access to health care coverage upon arrival. After this 3-month period, asylum seekers benefit from the PUMA.
The request to benefit from the PUMA is made to the social security services (CPAM) of the place of residence or domiciliation. The asylum seeker must submit documentary evidence of the 3-month residence requirement, the legality of their stay in France, their marital status and the level of their resources. As a result, during this 3-month period asylum seekers cannot see a doctor for free, except in hospitals in case of emergency, which means a postponement of treatment. Similarly, because of the 3-month residence requirement, the compulsory examination upon entry into the accommodation centres cannot be set up, psychological care is not accessible and vulnerability assessments are rendered more complicated. These 3 months without proper coverage impacts asylum seekers that also need to request a permit for medical reasons, as they are supposed to apply for that permit within exactly three months[3] (if they apply later without new circumstances, the application can be denied purely based on tardiness): during this period they must provide information on their medical situation and therefore consult a health professional for this, which is very complicated without health insurance.
Persons who have no right to remain on the territory, including rejected asylum seekers, benefit from the PUMA for six months after the end of validity of the asylum claim certificate. Before 2020, the time period was one year. After this period, State Medical Aid (AME) enables them to receive free treatments in hospitals as well as in any doctors’ offices.[4]
Individuals with low income and still awaiting health insurance and needing healthcare quickly can turn to the Open and free centres for Access to Health Care (PASS) at their nearest public hospital. This is therefore also a possibility for asylum seekers under the accelerated and Dublin procedures. There, they will receive care and, if necessary, the medical letter needed to speed up the processing of their application for public health insurance. According to the law, all public hospitals are required to offer PASS services
As a general rule, difficulties and delays for effective access to health care vary from one city to another in France.
The period of validity of PUMA is one year. At the end of this period it only be renewed if the person has a valid asylum claim certificate.
Finally, some of the problems with regard to medical care are not specific to asylum seekers. Some doctors are reluctant to receive and treat patients who benefit from the AME or PUMA and tend to refuse booking appointments with them[5] even though these refusals of care can in theory be punished.[6]
Lastly, asylum seekers are affected by general shortcomings of the healthcare system, with “social and regional inequalities”,[7] and saturation of emergency medical services.[8]
Mental health
In a study published in July 2023, the French NGO France terre d’asile reported that there are multiple factors at the origin of the significant psychological distress of exiled persons, and many care needs are noted by both the exiles themselves and the socio-educational teams who support them. However, in parallel they face many barriers in accessing mental health services, such as the lack of knowledge of their rights and the available services, the lack of adaptation of the health’s system organisation, the language barrier, etc. There is generally difficulty in accessing the public system, as well as an unequal associative offer in level of care and geographically (urban vs rural area). The virtual absence of care provision for children is also noted.[9]
National legislation does not provide any specific guarantee for access to care related to mental health issues. Asylum seekers can theoretically benefit from psychiatric or psychological counselling thanks to their health care coverage (AME or PUMA). However, access remains difficult in practice because many professionals refuse to receive non-French speaking patients as they lack the tools to communicate non-verbally and / or the funds to work with interpreters.
Victims of torture or traumatised asylum seekers can be counselled in a few NGO structures that specifically take care of these traumas. This adapted counselling is provided, for instance, at the Primo LeviCentre and Comede in Paris as well as the Comede and Osiris centres in Marseille, Mana in Bordeaux, Forum réfugiés – Cosi Essor Centre in Lyon and Clermont Ferrand, Parole Sans Frontière à Strasbourg, Comede in the Loire departement and lastly in Guyane, in overseas France. These specialised centres are however too few in France, unevenly distributed across the country and cannot meet the growing demand for treatment. The difficulties are aggravated by the geographical locations of some reception centres where accessing mental health specialists would entail several hours of travel.
The general health system cannot currently cope with this adapted care for victims of torture and political violence. Regular structures lack time for consultations, funds for interpreters and training for professionals.
Health care access systems are available in detention centre and transit zones, for all people in these places (including asylum seekers). It is thus possible to ask for a medical examination and to see a doctor. Access is effective in practice.
[1] Article L. 380-1 Social Security Code.
[2] Decree No. 2019-1531 of 30 December 2019 relating to the residence requirement applicable to asylum seekers for covering their health expenses, available in French at: https://bit.ly/2tcEvoe.
[3] Article D.431-7 Ceseda.
[4] Sercice public, ‘What is state medical assistance (AME)?’, verified 1 April 2024, available at: https://bit.ly/3xwJv7Z.
[5] Slate, ‘Pour obtenir un rendez-vous médical, mieux vaut ne pas être bénéficiaire d’une aide à la santé’, 2 November 2022, available in French at: https://bit.ly/40J4v5i.
[6] Circular DSS n. 2001-81, 12 February 2001 on the care refusal for beneficiaries of the CMU.
[7] CNCDH, ‘Contribution to the 4th cycle of the universal periodic review of France’, January 2023, available at: https://bit.ly/3ITaJIs.
[8] France Inter, ‘Urgences : une saturation mortelle ?, 26 February 2024, available in French at: https://bit.ly/3IV4YKs.
[9] France terre d’asile, ‘Répondre aux besoins en santé mentale des demandeurs d’asile : une étude qualitative’, July 2023, available in French at: https://bit.ly/3vqtwI7.