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 that fall under the responsibility of the Ministry of Home Affairs.[4] The latter can however cooperate with public entities and/or private non-profit organisations in the framework of a MoU 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] Additionally, the 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 due to the limited number of such decisions to date (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 applicable legal provisions. However, persisting challenges have an impact on the quality of health care. According to previous research,[21] and 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 translation hotline); difficult access to diagnosis procedures and medication paid by the SNS due to bureaucratic constraints; or very limited access to mental health care and other categories of specialised medical care (e.g. dentists)[22] in the SNS. The difficulties in accessing specialised care in the SNS, including dentists, also came out as the main concerns in consultations conducted by CPR in October 2017 in the framework of the relocation programme.
In August 2020, the National Association of Pharmacies informed its associates of new procedures regarding prescriptions of applicants for international protection.[23] According to the experience of CPR’s CAR, since then, access to medication paid by the SNS has been adequately ensured. In practice, applicants only have to pay for medication that is not (fully or partially) co-paid by the SNS. Nevertheless, the experience of CPR’s CACR reveals that there are still discrepancies in the procedures adopted by different health units for the issuance of prescriptions. This led to the need to pay for the medication of unaccompanied asylum-seeking children under the care of this facility on most 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 as well as COVID-19 vaccination among applicants. Additionally, the unit provides routine support to assisted medication, pregnant women, new-borns, as well as persons with other health-related vulnerabilities. Within the context of the coronavirus pandemic, the team also supported testing whenever necessary.
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. Unaccompanied children residing at CPR’s CACR have also been able to access dental care in SOL, a clinic managed by SCML that provides specialised care in the field for children living or studying in Lisbon.[24]
Within the context of the pandemic, CACR faced challenges in liaising with the geographically responsible healthcare unit, including for registration (a necessary requirement for subsequent medical follow-up, vaccination, Covid testing…). Access has been ensured with the support of other healthcare units.
The National Vaccination Plan (COVID-19) was approved by Ministerial Decree no.298-B/2020, of 23 December 2020.[25] The Ministerial Order determines that the national vaccination plan is grounded on the principles of universality, acceptability, and feasibility and is free of charge.
Priority groups for the COVID-19 vaccination were defined based on a combination of factors such as age and pre-existing conditions (in addition to essential workers).[26] Asylum seekers and refugees living in communal facilities are considered a group with an increased risk of infection and outbreaks (e.g., similarly to elderly homes) and, as such, are prioritised. Vaccination at CPR’s Reception Centres occurred throughout 2021. According to the experience of CPR’s Integration Department, while access to COVID-19 vaccination was not problematic, some asylum seekers faced challenges in accessing their vaccination certificate due to the lack of a SNS number. The lack of such a number also posed some challenges in the scheduling of tests and issuance of prophylactic isolation certificates when necessary.
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.[27]
In 2021, DGS launched an awareness-raising campaign targeting the general population and healthcare practitioners focusing on the promotion of human rights and prevention of violence and discrimination towards migrants and refugees.[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 the 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] Italian Council for Refugees et al., Time for Needs: Listening, Healing, Protecting, October 2017.
[22] In this regard, DGS noted in the past that such difficulties are similar to those faced by Portuguese citizens.
[23] Following what was prescribed in the handbook governing the relationship between Pharmacies and the SNS, available at https://bit.ly/3sapk7K.
[24] For more information see: https://bit.ly/2x2l8Ak.
[25] Ministerial Decree 298-B/2020 of 23 December 2020, available at: https://bit.ly/3fU70NC.
[26] Plano de Vacinação COVID-19, 3 December 2020, available at: https://bit.ly/2PPD5eF.
[27] Sandra Roberto, Carla Moleiro, ed. Observatório das Migrações, De menor a maior: acolhimento e autonomia de vida em menores não acompanhados, April 2021, pp. 44 et seq, available at: https://bit.ly/3fqMKBK.
[28] For more information see: https://bit.ly/3JuehPe.