Author
The Asylum Act enshrines the right of asylum seekers and their family members to health care provided by the National Health System (Serviço Nacional de Saúde, SNS),[1] and includes a specific provision on the right to adequate health care at the border.[2]
The primary responsibility for the provision of health care lies with the Ministry of Health,[3] except for asylum seekers detained at the border who fall under the responsibility of the Ministry of Home Affairs/Ministry in charge of migration.[4] The latter can however cooperate with public entities and/or private non-profit organisations to ensure the provision of such services.[5]
In accordance with the Asylum Act,[6] the specific rules governing access of asylum seekers and their family members to health care[7] are provided by Ministerial Order No 30/2001 and Ministerial Order No. 1042/2008,[8] according to which:
Access to health care encompasses medical care and medication, and is available from the moment the asylum seeker applies for asylum;[9]
Medical assistance and access to medicines for basic health needs and for emergency and primary health care are to be provided under the same conditions as for Portuguese citizens;[10]
Asylum seekers have access to the SNS free of charge[11] for emergency health care, including diagnosis and treatment, and for primary health care,[12] as well as assistance with medicines, to be provided by the health services of their residence area.[13]
Asylum seekers are entitled to health care until a final decision rejecting the asylum application unless required otherwise by the medical condition of the applicant.[14] Reduction or withdrawal of reception conditions cannot restrict the access of asylum seekers to emergency health care, basic treatment of illnesses and serious mental disturbances or, in the case of applicants with special reception needs, to medical care or other types of necessary assistance, including adequate psychological care where appropriate.[15] This provision remains to be tested in practice (see Reduction or Withdrawal of Reception Conditions).
The special needs of particularly vulnerable persons must be taken into consideration in the provision of health care,[16] through adequate medical care,[17] and specialised mental health care including for survivors of torture and serious violence,[18] and in detention.[19] The responsibility for special treatment required by survivors of torture and serious violence lies with ISS.[20]
In practice, asylum seekers have effective access to free health care in the SNS in line with the applicable legal provisions.[21] However, persisting challenges have an impact on the quality of health care. According to prior research,[22] and to the information available to CPR, these include:
- Language and cultural barriers (e.g., the lack of interpreters for certain languages and the reluctance of health care services to use interpretation services such as ACM’s/AIMA’s translation hotline);
- Difficult access to diagnosis procedures and medication paid by the SNS due to bureaucratic constraints.
While CPR has observed improvements in access to mental health care services and to other categories of specialised medical care (e.g., dentists)[23] in the SNS due to partnerships with relevant actors,[24] access to these services generally continues to be challenging.
Worryingly, between the end of 2023 and the beginning of 2024 CPR has received occasional reports of difficulties in accessing necessary healthcare by applicants who have been provided accommodation directly by AIMA.[25] Despite CPR’s efforts, it was not possible to obtain further information in this regard.
According to CPR’s experience, while it has been possible for unaccompanied children under its care to access mental health care support within the SNS[26] or through other resources, access to psychological support remains challenging. Similar concerns have been shared by UNICEF. Challenges are especially relevant for children that do not speak Portuguese. CPR’s CACR has observed an improvement in access to psychiatric care since 2022 due to a protocol established with Psychiatric Hospital Centre of Lisbon that allowed easier and faster access to services, medication and specialised care.
CPR’s Psychological Support Department continued to provide psychological assistance to applicants for international protection supported by CPR, and to facilitate referrals to relevant services provided by partners such as psychiatric follow-up. In the course of 2023, the Psychological Support Department provided 783 individual consultations, mediated multicultural meetings with applicants for international protection and organised other group activities, and made referrals to external services, such as psychiatric care.
According to the information provided by SCML, the team ensuring support to asylum seekers includes a psychologist. Applicants can also be referred to psychiatric care within the health care units managed by the organisation. SCML also confirms that access to mental healthcare within the SNS is often challenging, particularly due to delays, the suitability of available solutions, and language barriers. JRS also has a Mental Health Office, specialising migration-related matters.
According to CPR’s experience, unaccompanied asylum-seeking children have access to gender-specific care and family planning support. CAR has further observed that arrangements to promote patient’s comfort in medical care are ensured upon request.
In August 2020, the National Association of Pharmacies informed its associates of new procedures regarding medical prescriptions issued to applicants for international protection.[27] According to CPR’s experience, access to medication by the SNS has improved and, in general, applicants only have to pay for medication that is not (fully or partially) co-paid by the SNS. Nevertheless, there are still discrepancies in the procedures adopted by different health units for the issuance of prescriptions and flaws in the issuance of digital prescriptions. This led, for instance, to the need for CPR to pay for medication on several occasions.
CPR and the local health centres of Loures-Odivelas cooperate closely. The long-term care unit conducts medical appointments at CAR once a week and ensures the implementation of the national vaccination plan among applicants. Additionally, the unit provides routine support to persons in need of assisted medication, pregnant women, new-borns, as well as to persons with other health-related vulnerabilities.
CPR provides financial support to unaccompanied asylum-seeking children and asylum seekers in admissibility and accelerated procedures to cover the costs of diagnosis procedures and medication depending on the individual circumstances and available resources. In 2023, CACR began a partnership with the Faculty of Dental Medicine of the University of Lisbon which has led to significant improvements in the access of unaccompanied children to dental care, as well as in the continuity of such care with reduced costs.
According to a study focusing on the situation of asylum-seeking unaccompanied children and ageing out in Portugal published in 2021, the majority of participants evaluated their health condition and the relationship with doctors positively and did not feel discriminated within the context of healthcare.[28]
[1] Articles 52(1) and 56(1) Asylum Act.
[2] Article 56(2) Asylum Act. This provision should be read in conjunction with Article 146-A(3) Immigration Act that provides for the right of pre-removal detainees in CIT to emergency and basic health care.
[3] Article 61(3) Asylum Act.
[4] Article 61(1) Asylum Act. While not included in this provision, SEF should also be considered responsible for providing access to health care to asylum seekers in pre-removal detention given its managing responsibilities of CIT: Article 146-A(3)-(4) Immigration Act.
[5] Ibid.
[6] Article 52(1) in fine Asylum Act.
[7] The legal and operational background pertaining to the access of asylum seekers to health care was revisited by the ACSS and the DGS in an internal guidance note issued on 12 May 2016 in the framework of the European Agenda for Migration, available at: http://bit.ly/2jdBIFW.
[8] Ministerial Order No 1042/2008 extends Ministerial Order No 30/2001 ratione personae to applicants for subsidiary protection and their family members.
[9] Ministerial Order No 30/2001, para 2. Under Article 52(2) Asylum Act, the asylum seeker is required to present the certificate of the asylum application to be granted access to health care under these provisions. The internal guidance note issued on 12 May 2016 by the ACSS and the DGS provides for possible documents entitling the asylum seeker to access health care and includes a complete list of documents issued to the asylum seeker by SEF during the asylum procedure (e.g., renewal receipts of the certificate of the asylum application, provisional residence permit, etc.)
[10] Ibid.
[11] Article 4(1)(n) Decree-Law 113/2011.
[12] For the purposes of free access to the SNS, primary health care is to be understood as including among others: (i) Health prevention activities such as out-patient medical care, including general care, maternal care, family planning, medical care in schools and geriatric care (ii) specialist care, including mental care (iii) in-patient care that does not require specialised medical care, (iv) complementary diagnostic tests and therapies, including rehabilitation and (v) nursing assistance, including home care: Ministerial Order No 30/2001, par.6.
[13] Ministerial Order No 30/2001, par.5.
[14] Ministerial Order No 30/2001, par.8.
[15] Article 60(7) Asylum Act.
[16] Article 77(1) Asylum Act.
[17] Articles 52(5) and 56(2) Asylum Act.
[18] Articles 78(3)-(4) and 80 Asylum Act.
[19] Article 35-B(8) Asylum Act.
[20] Article 80 Asylum Act.
[21] However, UNICEF reported having observed challenges in the registration of unaccompanied asylum seeking children in certain healthcare units throughout the country mostly due to lack of awareness of the relevant services.
[22] Italian Council for Refugees et al., Time for Needs: Listening, Healing, Protecting, October 2017.
[23] In this regard, DGS noted in the past that such difficulties are similar to those faced by Portuguese citizens.
[24] Such as the Psychiatric Hospital Centre of Lisbon, the Unit for Intervention in Addiction and Dependency and the Local Healthcare Unit of Sacavém.
[25] For instance, no assistance in referrals, and being accommodated far away from the nearest hospital and not having financial conditions to pay for the necessary trip. Within the context of the right of reply of the authorities to the draft AIDA report, AIMA noted that applicants are referred to healthcare authorities. Information provided by AIMA, 25 June 2024.
[26] Particularly through programme “Aparece” (information available at: https://bit.ly/3mzqad1.
[27] Following what was prescribed in the handbook governing the relationship between Pharmacies and the SNS, available at https://bit.ly/3sapk7K.
[28] Sandra Roberto, Carla Moleiro, ed. Observatório das Migrações, De menor a maior: acolhimento e autonomia de vida em menores não acompanhados, April 2021, available at: https://bit.ly/3fqMKBK, 44 et seq.