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Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia María-Luisa Vázquez a,∗ , Ingrid Vargas a , Daniel López Jaramillo b , Victoria Porthé a , Luis Andrés López-Fernández b , Hernán Vargas a,d , Lola Bosch c , Silvia S-Hernández b , Ainhoa Ruiz Azarola b a Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo, 21, 08022 Barcelona, Spain b Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio, 4, 18011 Granada, Spain c Serveis de Salut Integrats Baix Empordà, Carrer Hospital 17-19, 17230 Palamós, Spain d Agència de Salut Pública de Barcelona, Plac¸a Lesseps, 1, 08023 Barcelona, Spain

a r t i c l e

i n f o

Article history: Received 9 October 2015 Received in revised form 7 January 2016 Accepted 8 January 2016 Keywords: Immigrants Health personnel Access to healthcare Health services accessibility

a b s t r a c t Until April 2012, all Spanish citizens were entitled to health care and policies had been developed at national and regional level to remove potential barriers of access, however, evidence suggested problems of access for immigrants. In order to identify factors affecting immigrants’ access to health care, we conducted a qualitative study based on individual interviews with healthcare managers (n = 27) and professionals (n = 65) in Catalonia and Andalusia, before the policy change that restricted access for some groups. A thematic analysis was carried out. Health professionals considered access to health care “easy” for immigrants and similar to access for autochthons in both regions. Clear barriers were identified to enter the health system (in obtaining the health card) and in using services, indicating a mismatch between the characteristics of services and those of immigrants. Results did not differ among regions, except for in Catalonia, where access to care was considered harder for users without a health card, due to the fees charged, and in general, because of the distance to primary health care in rural areas. In conclusion, despite the universal coverage granted by the Spanish healthcare system and developed health policies, a number of barriers in access emerged that would require implementing the existing policies. However, the measures taken in the context of the economic crisis are pointing in the opposite direction, towards maintaining or increasing barriers. © 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction In 2013, Spain had the second greatest foreign-born population in the European Union after Germany – with 5.1 million people – and ahead of the United Kingdom [1]. A decade of rapid and concentrated immigration,

∗ Corresponding author. Tel.: +34 932531820; fax: +34 932111428. E-mail address: [email protected] (M.-L. Vázquez).

particularly in some regions – Catalonia, Madrid, Valencia and Andalusia [2] – changed the social make-up and presented a challenge for public services, including health services, which had to meet the needs of a more diverse population. Research in countries with historically high levels of immigration has revealed immigrants’ greater risk of exclusion from healthcare services [3,4]. Existing evidence from different European countries highlights inequalities in immigrants’ access to health services [5,6]. However, research identifying the factors

http://dx.doi.org/10.1016/j.healthpol.2016.01.011 0168-8510/© 2016 Elsevier Ireland Ltd. All rights reserved.

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that influence access to health care seems to be limited and there is even less research focusing on the perspectives of health workers themselves. Available studies analyse their difficulties in providing care to immigrants [7–9]. Regarding access, the research available to date has tended to focus on undocumented immigrants [10–12] and, only recently, some descriptive studies have included documented immigrants as well, with a focus on their perspectives [13–15]. Only one study has been identified that is based on a questionnaire survey amongst health personnel in Portugal [16]. These studies mention some potential barriers to access including service characteristics, but mainly focus on characteristics of the immigrants: low socio-economic status [16], limited knowledge of the local language and of healthcare entitlements. In Spain, policies and laws evolved in tandem with the increase in immigration, and affected different aspects of foreigners’ lives, including their rights to health care and access to health services. Until 2012, when this was restricted, Spain’s national health system guaranteed universal access to health care for all residents, regardless of their administrative status. In order for immigrants to exercise their right to health in the same conditions as that of the autochthonous, the only request was that they register at the city council. Those not registered were guaranteed only emergency care, with the exception of pregnant women and minors under the age of eighteen [17]. However, some studies have revealed inequalities in health between the autochthonous and immigrant populations that are not dependent on socio-economic status [18–20] and point to differences in accessing health care related to specific barriers, indicating that policies developed to address these barriers have not been fully implemented [21]. Moreover, access to health care might also differ by region: although entitlements to health care and social integration policies are defined by the central government, the national healthcare system is decentralized into 17 regional services. In this sense, differences in regional policy between Catalonia and Andalusia–where Non-Governmental Organizations (NGOs) directly provide immigrants with the healthcare card and there is reinforcement in program contracts – could translate into different results in immigrants’ access to health care [21,22]. Recent reviews [23,24] of immigrants’ access to health care in Spain reveal no clear patterns in the use of healthcare services and existing research has mainly explored trends in immigrants’ use of these services in comparison to autochthons. Studies analyzing the determinants of health services utilization are scarce and focus on individual factors (age, sex, level of education). The perspective of healthcare professionals has been captured through opinion surveys [25,26] and qualitative studies [27–29], but these did not focus on immigrants’ access to health care, rather on health workers’ needs when providing care to immigrants. In summary, there is limited empirical research available in Europe and particularly in Spain that analyzes immigrants’ access to health services and still less research has been conducted from the point of view of the healthcare professional. The objective of this article – which presents the partial results of a wider study [21], is to identify

factors influencing immigrants’ access to health care from the perspective of health personnel in two Spanish regions. 2. Methods 2.1. Study design A qualitative, descriptive and phenomenological study was conducted. The study population was health personnel that might have an opinion or influence on immigrants’ access to health care in Catalonia and Andalusia. Field work was carried out from April 2011 to March 2012, before the application of the new healthcare Act [30] which limited undocumented immigrants’ right to health care. The analysis is guided by Aday and Andersen’s [31] theoretical framework of access that takes into account various characteristics of the health services (volume and distribution of resources, organization of services) and of the population (predisposing and enabling factors, and healthcare needs), as well as the policies that influence them. The study area encompassed three counties in Catalonia (Baix Empordà, Barcelona and Montsià) and three provinces of Andalusia (Seville, Almeria and Granada), chosen because they have a proportion of immigrants that is slightly above average and they encompass both rural and urban areas. 2.2. Sampling Through a two-stage process in each region, a theoretical or criterion sample was selected. In other words, defined criteria were used to ensure that contexts and profiles that could provide information which is different and relevant to the study’s objectives are included [32,33]. In the first stage, the contexts, primary care centres with the greatest proportion of immigrants and their referral hospitals, were selected. In the second stage, informants were selected according to the following criteria in order to ensure a variety in discourses: a) primary and secondary healthcare personnel with different job profiles; and b) health managers. The final sample size was reached by saturation (Table 1). 2.3. Data collection Individual, semi-structured interviews were carried out using a topic guide, which addressed two main topics: access to and quality of care. With regard to access, it addressed the concepts of access to health care and opinions on immigrants’ access to health care in general and to primary and secondary care in particular, as well as the different factors that might influence, facilitate or hinder it, through general questions. ‘What facilitates (or hinders) access to health care?’, ‘Why?’ and ‘How could it be improved?’ were used as probing questions. All themes were addressed as they came up during the interview. In addition, all emerging themes relevant to the study objectives were followed up during the interview. Only if necessary, probing questions on specific topics were used, such as the individual health card, services, professionals or migrants’ characteristics. Interviews were conducted in

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Table 1 Characteristics of the final sample in Catalonia and Andalusia. Segmentation criteria

Variation criteria

Interviews carried out

Managers

Primary care Secondary care

Centre coordinator Hospital manager Chief of emergency care Service director Chief of Gynaecology and Obstetrics

5 3 3 3 0

5 0 2 3 3

Healthcare professionals

Primary care

Family doctor Paediatrician Nurse Patient service personnel Social worker Emergency care doctor Gynaecologist Nurse Paediatrician Tropical medicine specialist Social worker Mediator

4 3 5 6 0 3 3 3 2 0 0 0

6 6 5 0 6 4 0 4 2 1 1 1

43

49

Catalonia

Secondary care

Total

the health facilities. They lasted around 1 h (between 33 and 100 min) and were audio-recorded and verbatim transcribed.

Andalusia

3. Results 3.1. Easy access to health care for immigrants in the National Health System (NHS)

2.4. Data analysis and quality of the information A thematic analysis of the interviews was carried out with the support of the Atlas-ti software. The data was segmented by regions (Catalonia and Andalusia) and by type of informants. Categories of analysis were generated through a mix of the topic guide and those emerging from the data. Themes were identified, coded, re-coded and classified in order to identify common patterns by looking at regularities, convergences and divergences in data through constant comparisons, going back and forth between the data and the conceptual framework. Data quality was ensured through triangulation, by comparing different regions and groups of informants, as well as different sources (informants, technical and scientific literature). In addition, five analysts who worked in two teams, one per region, participated in the analysis. The analysis was developed in close collaboration. Divergences between analysts and/or teams were discussed and solved by going back to the data. In the results, to identify the type of informant producing the verbatim three set of abbreviations are used that indicate a) area: urban (ur) or rural (ru), b) healthcare level: primary care (PC) or secondary care (SC), and c) region: Catalonia (CAT) or Andalusia (AND). 2.5. Ethical considerations This study was approved by the Ethical Committee for Clinical Research (CEIC) of the Municipal Health Institute of Barcelona and by the Research Committee of the Andalusian School of Public Health (EASP). Oral and written consent was obtained from every participant prior to interview. Confidentiality and anonymity were guaranteed.

The dominant opinion among all groups of informants from both regions was that access to health care was “easy” and “quick” for immigrants and equal in conditions to autochthons: they had equal access to the healthcare system “but. . .I don’t think it can be any harder for them [to access the health system]. I mean, they are given the same options, opportunities and. . .and in that sense. . .I don’t think there’s any problem” (Professional Ru,SC,CAT), access to the same services and also to the same quality of care “The same (care) that we give to Spanish-born people. (. . .) So, I think it’s easy” (Professional Ur,SC,CAT). According to interviewees, the reasons that access to health care was so simple included (a) requirements were limited and easy to fulfill in order to receive an individual healthcare card (IHC); (b) health care was free at the point of delivery and (c) there were no requirements for receiving emergency care. Moreover, in Andalusia, a minority of informants believed that immigrants had easier access to services than autochthons. A recurring opinion, especially among primary care professionals, was that good accessibility led immigrants – in particular those who had recently arrived – to “overuse” the health services. Among the attributed causes of this, three factors stand out. Firstly, that little value is given to a healthcare system that is free at the point of delivery “When things are free they are not valued (. . .) You go to a place where they give you things and people say: “Look, even if I don’t really need it. . .” (Professional Ru,PC,CAT). Secondly, there is a wide offer of emergency services available; and thirdly, because of the possible differences between this healthcare system and those in their countries of origin (limited or mainly private). “Sometimes I think there is abuse. They move from perhaps not having any health care in their countries to here, where they have it and it is free” (Professional Ur,SC,AND).

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Only one manager highlighted that misuse of services was also widespread amongst the autochthons. The managers’ and professionals’ discourses, however, also revealed some difficulties, both when it comes to entering the system, and when it comes to the use of healthcare services, with some differences noted between the two regions. 3.2. Obtaining the individual healthcare card (IHC): the key to entering the health system Managers and professionals in both regions identified the possession of the IHC as the key factor in accessing care, since it guaranteed immediate entry to the entire health system. Despite their limited knowledge, they considered the process of obtaining it to be simple and fast, if the requirements were fulfilled; “The IHC is so easy to obtain that it is possible to get care at a health facility as soon as one arrives in the country” (Professional Ur,SC,CAT). However, some difficulties were also revealed, though with differences between regions. In Andalusia, health professionals highlighted the role played by local health authorities and NGOs in helping immigrants to obtain the IHC. Difficulties in fulfilling the requirements for obtaining an IHC (registration at the city council) were only identified in the professionals’ descriptions of strategies used by immigrants to get around the need to provide a postal address–using a fake address or paying to use someone else’s. In Catalonia, informants considered that the procedures to obtain an IHC was well-publicised through a variety of means, but that it did not reach immigrants on time; and that it was more difficult with the information and application forms in the local language, though they felt these hurdles were overcome if immigrants were accompanied. In Andalusia, similarly, information is mainly disseminated via social workers at the health centres: “Well essentially by going to the health centre and asking the social workers there for help, they can perfectly well explain to them their. . .[rights] and . . . their obligations”(Manager Ru,SC,AND), as dissemination of information has decreased in recent years, with no specific campaigns and limited use of media. In both regions, social networks emerged as the main source of information and it was considered, in some cases, to make the process more difficult as it was sometimes “erroneous” or “biased” information. In addition, other difficulties in registering for an IHC at health centres were identified: in Catalonia, opening hours coincide with the immigrants’ working hours, even in those centres with more personnel; in Andalusia, health centres are far away and there are long waiting times for receiving the IHC after filling in the application. Being charged for the services as a consequence of not having the IHC was the most notable difference between both regions: in Andalusia this did not emerge. In Catalonia, according to informants, immigrants without an IHC are requested to pay a fee for service, though some considered that this happened infrequently; others stated that immigrants do pay, even when their IHC application is ongoing. The request to pay is considered, however, inconsistent and dependent on the healthcare personnel: “In theory, when you are undocumented, you have to pay for the medical visit. In general this does not happen (. . .). There are specific cases

when you see that some have a lot of nerve and you say, I will make you pay or I won’t give you care” (Manager Ru,SC,CAT). Informants, however, did not consider the fee represented a barrier to access because there is always someone from their social network who can pay on their behalf. Nonetheless, they signal that immigrants without an IHC pay fewer visits to the health services and only go for severe health problems. However, according to informants in both regions, the most common consequence of not having an IHC was that immigrants go to the emergency services, directly or referred on from health centres. The use of another person’s IHC was considered a less frequent and easily detectable practice. 3.3. Factors influencing the use of health services In both regions, informants considered that all health services available for the autochthons were also available for immigrants and under the same conditions. They considered the (geographical, organizational and economic) characteristics of the services to be adequate and where those were limited; they considered that the case for both autochthons and immigrants. Limitations in these areas emerged as relevant barriers when they interacted with the specific characteristics of immigrants (low socioeconomic status, precarious working conditions and language difficulties), but in general it was considered, particularly in Catalonia, to be the immigrants’ responsibility to overcome these difficulties (Table 2 and Table 4). 3.4. Geographical distance to the health services Informants in Catalonia and Andalusia considered that in urban areas healthcare services are close to the entire population, within walking distance for primary care and by public transportation for specialized care. Differences were highlighted when it came to rural areas: in Catalonia, the distance to primary and secondary care emerged as a barrier to access due to insufficient public transport and limited financial means to pay for private transportation. In contrast, in Andalusia, this difficulty was described only in relation to secondary care. The consequences of these problems were similar in both regions, frequent late arrivals or missed appointments that upset the health personnel (Table 3a). In addition, according to a manager, these barriers lead to fewer visits for preventive and follow-up care as well as delays in visiting a doctor until more serious health problems appear. 3.5. Organization of healthcare provision The majority opinion is that the opening hours for both primary and secondary care are wide but not adapted to the precarious working conditions of immigrants. Difficulty also compounded by gender issues, such as the need for some immigrant women to come accompanied by their husbands or sons, who may be at work or school. According to some informants, services are organized around autochthons’ needs and it is the immigrants’ responsibility to adapt to the opening hours. As a consequence,

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Table 2 Services factors influencing the use of health care in Catalonia and Andalusia. Catalonia

Andalusia

Subcategories

Subcategories

− All services are available to all users without exception

– All services are available to all users without exception

Urban Areas

− Short distances to primary care and secondary care − Appropriate distribution of services throughout the area – Public transport is available

− Short distances to primary care and secondary care – Appropriate distribution of services throughout the area

Rural Areas

– Greater distances to primary care and secondary care – Insufficient public transport and difficulties in paying for it

– Greater distances in access to secondary care – Primary care is accessible – Difficulties in paying for public transport

Categories

Volume and distribution of services Availability of services

Geographical distance to health services

Consequences – Delays and lack of attendance – Fewer follow-up and preventive visits – More severe or developed pathologies Organization of healthcare provision Opening hours are incompatible with working hours

Communication mechanisms

Waiting Times

– Opening hours are generous but incompatible

– Opening hours are generous but incompatible

Consequences – Use of emergency care – Delays in seeking care – Lack of attendance to scheduled visits and test

Consequences – Use of emergency care

– Communications systems with patients are inadequate (phone or postal services)

– Interpreters available

Consequences – Lack of attendance to scheduled visits and tests – Interruption of treatment and follow up

Consequences – Easier access to preventive care

– Similar to autochthons – High in emergency room

– Similar to autochthons – Within the regulated waiting times – High in emergency room

– Difficulties in continuing the prescribed treatment (lack of means)

– Difficulties in continuing the prescribed treatment (lack of means)

Consequences – Incomplete treatment

Consequences – Incomplete treatment

Co-payments for treatments Payment for medication

immigrants use emergency services or delay consultation until the appearance of serious health problems (Table 3b). In Catalonia, the inadequacy of the mechanisms used to inform patients of their appointments by post or phone call – due to the frequent changes of address and phone number of immigrants – was also identified. This may additionally be compounded by a language barrier. As a consequence, patients do not receive information and they miss scheduled appointments or tests, which might lead to interruptions in treatments and follow-up. In Andalusia, mediators were identified as facilitators when it came to access to preventive activities. “It is easier to access [health care] when you have inter-cultural mediators(. . .) we are lucky to have [name of mediator]” (Manager Ru,SC,AND). In both regions, waiting times for immigrants were described as the same as for autochthons and, according to Andalusian informants, even though waiting periods are long they are still within regulations (Table 3c).

3.6. Co-payments for treatment In both regions, the need to pay for prescribed medication emerged as a barrier due to the low socio-economic status of immigrants, which prevents them from purchasing it. As a consequence, the prescribed treatment can be left incomplete, thus having important consequences on their health (Table 3d). 3.7. Limited knowledge of the local language In both regions, limited language skills to permit fluid communication with health workers comes up repeatedly: either because there are challenges in (re)scheduling appointments and tests by telephone or mail, that may result in missed visits or test results; or because patients need to reschedule when there are no interpreters available (Table 5a). Some differences emerged depending on the

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Table 3 Examples of quotes on service factors influencing the use of health care in Catalonia and Andalusia. Subcategories

Catalonia

Andalusia

“(. . .) sometimes they live in places where access by bus is difficult. And not all of them are surrounded by family members or friends from the countries they came from. So I don’t know what percentage of the population has difficulties in accessing health care” (Professional Ru,SC,CAT)

“Yes, from a geographical point of view, yes, but sometimes, there are barriers to access that are not physical in terms of accessibility and that limit your ability to obtain health care. For example, cases in which the person has no money to pay for public transport.” (Manager Ru,SC,AND)

Availability of services Geographical distance to health services (a)

“Many times they arrive late on the bus and we get annoyed, right? But it’s logical, the bus does not arrive on time” (Professional, Ru,SC,CAT)

“Here I think this is a problem, because there are so many towns in the surrounding area that access is difficult for a person who does not have. . .who does not have a car. Above all, late at night or during public holidays” (Professional Ur,SC,AND)

Organization of the healthcare provision Opening hours are incompatible with working hours (b)

“What we [health personnel] cannot do is adapt to the working hours of groups in semi-slavery”(Manager Ur,SC,CAT) “(. . .)they come much later in the evening, during the late shifts, because, because I guess for them it’s harder to be able to come in the mornings, because of their work, they are more tied down, more penalized (. . .) it must be harder to miss time off work.” (Manager Ur,PC,CAT)

Waiting times (c)

“No, the waiting times are bad for everyone. Whether they are from here or from there, everyone suffers. Everyone is always in a rush.”(Professional Ur,SC,CAT) “The majority know perfectly well that coming to the emergency services will solve the problem. . .and on top of it they grumble if they have to wait two or three hours.” (Professional Ur,SC,CAT)

“(. . .) they come at two in the morning, three in the morning, because they’ve been working and since they know it’s open 24 hours, well they come straight here because they know that we will treat them and that there is no problem no matter what time they arrive. . .” (Professional Ur,SC,AND) “Many immigrants, above all women [those who work in the domestic sector] obviously need to schedule an appointment with the doctor on their day off; there is no possibility to do this, and this is a barrier.” (Manager Ur,PC,AND) “(. . .) We don’t have important problems. I think that the current waiting times are pretty well managed right now. Maybe it’s worse in the emergency room because sometimes, every now and then, it gets beyond capacity.” (Manager Ru,SC,AND) “In terms of the attention provided, the majority of it is established by decree and the waiting times are quite reasonable.” (Manager Ru,SC,AND)

Co-payments for treatments Payment for medication (d)

“Yes, definitely sometimes they don’t buy it. Maybe you’re writing the prescription for nothing. . .and who knows. (. . .) if at some point they were unable to purchase the medicine because they were under economic strain, but hey, that could happen to anyone.” (Professional Ru,SC,CAT)

country of origin. On the one hand, Maghrebi and Pakistani women were identified as potentially facing greater language barriers, since their cultural norms restrict their learning process, and thus they need to be accompanied either by their husband or children (Table 5b). On the other hand, Latin Americans were identified as having easier access to health care thanks to their fluency in Spanish. The social support networks also emerged as a facilitating factor. In Andalusia, interviewees pointed out that immigrants from low-to-middle income countries make a greater effort to learn the local language when compared to immigrants from wealthy countries (Table 5b). They consider that the longer the time of residence in the host country (Spain), the better the knowledge of the health system and the language skills become (Table 5e).

“Here the only thing that could be an obstacle is the economic factor, especially when it comes to paying for medication, don’t you think? That maybe they don’t have the resources to continue the treatment. We try to get them access to resources through the local council, Cáritas (NGO) or other associations (. . .) but that’s the case in all sectors of society, eh. . .not only. . .in the immigrant population it might be more common because they are possibly worse-off.” (Professional Ur,PC,AND)

3.8. Precarious labour conditions and lower socio-economic status Informants from Catalonia and Andalusia highlight immigrants’ precarious employment conditions – long working hours, job insecurity and lack of formal contracts – as barriers to accessing health care when combined with factors such as geographical distance, incompatible opening hours and healthcare fees. Precariousness emerges as a barrier preventing immigrants from seeking health care, as requesting sick leave or taking time off work may jeopardize their job (Table 5c). Most interviewees also perceive that immigrants had fewer resources than autochthons. However, in Catalonia, some informants consider it to be a problem immigrants have to deal with themselves because they are responsible

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Table 4 Immigrants factors influencing their use of health care in Catalonia and Andalusia. Catalonia

Andalusia

Subcategories

Subcategories

Limited knowledge of the language

− Makes scheduling less efficient – Requires appointments to be rescheduled (if patients go alone and don’t speak the language)

− Language barriers when information is provided at healthcare centres – Dependence on an aide to facilitate communication

Differences between immigrants of different origin

−Fluid communication with those that speak the language (Latin Americans) − It is more of a challenge to communicate with Maghrebi and Pakistani women

− Fluid communication with those that speak the language (Latin Americans) − Maghrebi women don’t learn the language because they have fewer opportunities to socialise − Relations with foreigners from developed countries tend to be more conflictive (British, Germans)

Consequences: – Dependence on husbands, children or someone accompanying to visit healthcare centres (Maghrebi/Pakistani)

Consequences: – Maghrebi/Pakistanis: Dependence on husbands, children or someone accompanying to visit healthcare centres

− Precarious employments, without contracts and with long working hours, and low salaries − Fear of losing the job

− Precarious employment, without contracts and with long working hours, and low salaries − Fear of losing their jobs

Consequences: − Use of emergency services – Lack of attendance to scheduled visits and tests

Consequences: − Use of emergency services – Lack of attendance to scheduled visits and tests

− Fewer resources than autochthons − The immigrants are responsible for their own socio-economic status: autochthons have economic difficulties too

– Limited resources

Consequences: − Delays in seeking appointments − Difficulties in covering costs associated to treatment – Problems in accessing healthcare centres (in rural areas)

Consequences: − Delays in seeking appointments − Difficulties in covering costs associated to treatment

− Improves knowledge of the healthcare system − Improves language skills − Improved identification of urgent pathologies

− Improves knowledge of the healthcare system − Improves language skills − Improved identification of urgent pathologies

Consequences: – Improved use of healthcare services

Consequences: – Improved use of healthcare services

Categories

Language skills

Socio-economic situation Precarious working conditions

Low socio-economic status

Time of residence Length of residence in Spain

for their own situation. This results in greater use of emergency services, delays in visiting health services, missed appointments and test results (Table 5d). 4. Discussion This study provides a systematic and comparative analysis regarding immigrants’ access to health care and the factors that influence it based on the perspective of healthcare professionals and managers in two Spanish regions. The study was conducted during the economic crisis, but before changes in the right to health care (entitlements) and the considerable reduction in public health expenditure had taken place. Access to health care in the national health system was generally considered easy for migrants and similar to access for autochthons in both regions. However, specific barriers to accessing health care were identified when it came to administrative procedures for entering the system, i.e. getting the IHC, and to using health

services, though this was mostly attributed to the immigrants’ characteristics. Results did not differ by type of informant or region, with two exceptions: in Catalonia, access to health care was harder for users without an IHC due to the fees charged, and in general to primary health care in rural areas, due to the long distances and limited public transportation. 4.1. Not having an IHC does not impede the use of the NHS services . . . but you may be asked to pay for it Even though, at the time this study was conducted, Spain had a national health system that granted universal access, free at the point of delivery and with very few restrictions; our results revealed that in Catalonia, payment for services was being requested from those that did not possess an IHC or who were still in the process of receiving it. This meant that people who had the right (were entitled) to health care could be denied it, be charged for

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Table 5 Quotes on immigrants factors influencing the use of health care in Catalonia and Andalusia. Subcategories

Catalonia

Andalusia

“Some of them don’t even know the language (. . .) They come here. . . and it’s complicated. To examine them and assess what’s the problem” (Professional Ru,SC,CAT)

“The main thing is the language. That’s the biggest. . .umm. . ..there are others that are cultural(. . .)So basically it’s those two things, but the language barriers are the most important” (Professional Ru,PC,AND) “The main component of this lack of knowledge is, above all, the language barrier. That’s essential (Professional Ur,SC,AND)

Language skills Limited knowledge of the language (a)

“Well, I think that as foreigners they must find it difficult with the language barriers, and I guess that makes it harder to access everything (. . .). It’s definitely a barrier”(Professional Ru,SC,CAT) Differences between immigrants of different origin (b)

“Naturally Latin Americans don’t have a problem, and of those that do have language issues, for example, Maghrebis don’t have so much of a problem because they have a large network of Maghrebis and so they tend to come accompanied.” (Manager Ru,SC,CAT) “One of the only things that can make everything more difficult is basically the language barrier. In the case of Romanians this is not so difficult, because in Romania they speak a Latin language, like ours (. . .) with Maghrebis it is much harder.” (Professional Ru,PC,CAT)”

“I think it depends on the type of. . .where they come from(. . .) these women do not have the freedom to go out, and they have to wait for their husbands in order to go to the health services, right? I think this is the main reason. I also think it is because they have many limitations when it comes to the language” (Professional Ru,SC,AND). “Immigrants with the lowest purchasing power(. . .)Maghrebi or Slovak origin seem to try harder to understand our language, they break through language barriers more than foreigners with a higher purchasing power, who think that we should speak their language” (Manager Ru,SC,AND)

Socio-economic status Precarious working conditions (c)

“Especially those groups that are in a more precarious conditions, in general (. . .). If they are working for somebody, they won’t quit, no matter what happens.” (Manager Ru,SC,CAT)” “Especially because their working conditions are difficult, so of course, to use (. . .) people that have a regular job, they come after they finish work.” (Professional Ru,SC,CAT)

Low socio-economic status (d)

“They have very low wages and older people have very low pensions. What happens is clear; people here do not send money abroad. They use it to survive, to live – in poor conditions, right?” (Professional Ru,SC,CAT) “Well maybe the immigrant population is more, its a group that must have fewer economic opportunities, for sure (. . .).” (Manager Ru,PC,CAT)

“A lot of them don’t have a job contract. . .they aren’t going to say to their bosses “look I’m going to go to the doctor because my throat hurts a lot”. They basically don’t come or they try to hold on and then if they can they go to the emergency room.” (Professional Ru,PC,AND) “Most of them have precarious contracts, temporary contracts (. . .) and on top of that you’re supposed to tell your boss that you’re skipping work to go to the doctor? They’ll say: OK, you can miss work, but don’t bother coming tomorrow.” (Professional Ru,SC,AND) “The costs of paying for public transport to get to the health centre. And factors that are not directly related but at least indirectly related with their spending, their subsistence” (Professional Ru,PC,AND) “There were immigrants that didn’t come because they had to pay for transport or because they simply forgot; because sometimes they are less attentive to health issues (. . .) they’d rather keep eating than get treatment for an infected tooth.” (Professional Ru,SC, AND)

Time of residence Length of residence in Spain (e)

“Who’ve been here longer, and because their neighbours explain how things work and here we also explain it to them, and so they start to learn how to better use the health services (. . .) no, but just like locals, their patterns of use then change.” (Manager Ru,SC,CAT)

it or be referred on to emergency services, even if this was not necessary. This mirrors the findings of a qualitative study conducted among immigrants which revealed requests for payment for basic, legally guaranteed, care (such as midwifery or paediatric attention) [34]. In April 2012, new legislation modified the conditions for accessing public health care [30], linking it to social security affiliation status, meaning, inter alia, that undocumented immigrants are excluded from regular health care. Our results seem to indicate that before 2012, conditions for accessing health

“I think that things change according to how long somebody has been here. Health education policies should take this into account” (Manager Ru,SC,AND)

care were becoming more restrictive, exposing the most vulnerable population to social inequalities in access to health care. Research in other contexts has highlighted that legal loopholes or a lack of clarity means that professionals are forced to take decisions on their own [9,10]. In our study, this seemed to be the case when payment for services was required. Further research is needed to measure the actual extent of this phenomenon, which is expected to increase following the amendments of 2012, as recent studies have

Please cite this article in press as: Vázquez M-L, et al. Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.01.011

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begun to point out [35,36]. Our results also highlight the need for policies and regulations to be strengthened to avoid misinterpretations of the rights and responsibilities of all actors involved and hence inequities in its application. 4.2. Interaction between the characteristics of the healthcare services and of individuals Our results show how access to health care is affected by the complex interaction between characteristics of the healthcare services, influenced by regulating policies, and of individuals, in line with previous studies [5,13,34]. While informants considered that administrative requirements to get the IHC were easy to fulfil and the services were generally adequate, they also highlighted that when combined with immigrants’ vulnerability, these became barriers to care. These results, in keeping with previous studies [4,28,37,38], indicate that policies designed to reduce entry barriers have been insufficiently implemented [21]. This interaction is reflected in the difficulties faced by immigrants in meeting the criteria to obtain an IHC–registering at the city council. This demonstrates that barriers may emerge when exercising the right to health (entitlement to health care) is linked to an administrative procedure at local level (registration with the local council), particularly for those with poor living conditions [34]. The interaction is also evident when it comes to the structural and organizational characteristics of healthcare services: opening hours clash with working hours, the distance to services in rural areas makes access dependent on suitable transportation and adequate resources, plus there are costs for medication, etc. Consistent with previous studies [39], this analysis reveals that incompatible working hours together with low salaries and fears of being fired act as barriers for those seeking health care. Similar barriers were described in other contexts in Europe, but mostly related to undocumented immigrants with no or limited entitlements to health care [7,9,12]. These results indicate an area for further research – unmet needs arising from barriers in access to health care in the population entitled to it – an issue that has received little attention to date, since studies are mainly based on the use of health services. Once again, in this study, language, which is the focus of many policies, is identified as a factor that affects different phases of the healthcare process for immigrants that do not speak the local language: they face difficulties in accessing information on how to obtain the IHC, in scheduling visits or in actually attending them [4,5,34]. However, these difficulties are mitigated when immigrants are resident for a long time, as their language skills improve.

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care. Another recurrent argument was that easy access to health care permits immigrants to “overuse” the health services, particularly emergency services, a perception not supported by evidence [40]. This discourse might be reflecting a negative attitude towards immigrants, which could contribute to an increase in the disparities in access to health care [41], if immigrants perceive health workers’ prejudices and, as a result, delay or avoid treatment [42]. Finally, a possible limitation of this study is that it analyses the opinion of health personnel working in areas that have a higher proportion of immigrants, and so their experiences may differ from personnel working in other regions. The experiences and opinions of the migrants themselves might differ from them and also between regions. In a second stage, migrants’ views will be analysed. Another limitation is that attitudes are difficult to assess as interviewees might not openly speak about them, and may attempt to hide their prejudices and attitudes towards immigrants. This can potentially lead to a misrepresentation of problems related to the stigmatization of immigrant populations. In addition, the qualitative approach adopted has allowed us to analyse what is happening from the point of view of the health personnel and whether or not there are differences between regions, but it does not allow us to establish the magnitude of the problems or differences. 5. Conclusion This study provides evidence that health personnel do identify barriers in access to health care, related to both the health services and to immigrants’ characteristics. Structural barriers were identified which must be addressed by specific policies, and they affect all users, both autochthons and immigrants, highlighting chronic deficiencies of the health system. However, these limitations of the healthcare system tend to affect the immigrant population more severely, due to their specific characteristics and often greater vulnerability. Overcoming these barriers requires effort on the part of both, the health services and immigrants; among others, improving the implementation of existing migrant health policies. In addition, policies should focus on improving the deficiencies of the health system and on other social determinants of health to avoid exposing vulnerable populations to health inequalities. However, the measures taken in the context of the economic crisis (reduction in public health and social expenditure, exclusion of population groups from universal health coverage and/or an increase in the requirements to get the IHC, reduction in labour rights, etc.) are pointing in the opposite direction, towards maintaining or increasing barriers. Conflicts of interest

4.3. The attitudes of health personnel towards immigrants Recurrent arguments used by interviewees were that potential barriers to access could be easily overcome by immigrants, or that it was their “responsibility” or that barriers were due to cultural characteristics, instead of focusing on the need to adapt healthcare services to the diverse characteristics of the population entitled to

The authors declare that they do not have any conflict of interests. Acknowledgements To the Institut Català de la Salut, Serveis de Salut Integrats Baix Empordà, Hospital Parc de Salut Mar, Hospital d’Amposta i Verge de la Cinta de Tortosa and all the

Please cite this article in press as: Vázquez M-L, et al. Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.01.011

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people who facilitated and made the field work possible. To the professionals who shared their time and opinions. To Rebeca Terraza, who conducted the fieldwork and initial analysis and to Emily Felt, Pamela and Kate Bartlett for the English version of the paper. This research was partially financed the Instituto de Salud Carlos III and the European Regional Development Fund (FEDER), PI09/02642.

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Please cite this article in press as: Vázquez M-L, et al. Was access to health care easy for immigrants in Spain? The perspectives of health personnel in Catalonia and Andalusia. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.01.011