Refusal to provide health care to sub-Saharan African migrants in France
Authors: Nicolas Vignier, Rosemary Dray Spira, Olivier Bouchaud, Annabel Desgrées du Loû, Pierre Chauvin
Journal: The Lancet Public Health (2018)

In France, the public health insurance system has a principle of universality.1Nay O Béjean S Benamouzig D Bergeron H Castel P Ventelou B Achieving universal health coverage in France: policy reforms and the challenge of inequalities.Lancet. 2016; 387: 2236-2249Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar However, refusal to provide care by health-care professionals has recently emerged as an issue.2Le défenseur des droitsLes refus de soins opposés aux bénéficiaires de la CMU-C, de l'ACS et de l'AME. Rapport au premier ministre. Le défenseur des droits, Paris2014Google Scholar People living with HIV and vulnerable populations have an increased risk of being denied care.3Douay C Toullier A Benayoun S Castro DR Chauvin P Refusal to provide health care to people with HIV in France.Lancet. 2016; 387: 1508-1509Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Després C Couralet PE Situation testing: the case of health care refusal.Rev Epidemiol Sante Publique. 2011; 59: 77-89Crossref PubMed Scopus (9) Google Scholar The ANRS-PARCOURS study5Desgrees-du-Lou A Pannetier J Ravalihasy A et al.Is hardship during migration a determinant of HIV infection? Results from the ANRS PARCOURS study of sub-Saharan African migrants in France.AIDS. 2016; 30: 645-656Crossref PubMed Scopus (52) Google Scholar analyses how health trajectories and social and migratory paths are interlaced for migrants from sub-Saharan Africa living in France. It is a life-event survey that was done in 2012–13 in health-care facilities in the Paris area, among sub-Saharan migrants recruited in primary care centres (n=760; reference group) and in HIV care centres (n=922; HIV group). A trained interviewer administered a face-to-face, standardised, life-event history questionnaire to each participant. When participants answered that they had been denied care, they were asked about the reason for the denial of care. These reasons were categorised by the investigators and then analysed. We weighted the percentage of patients to take into account the study design. When participants were asked about their experiences with refusal of health-care since their arrival in France and about the reasons underlying refusal, refusal of care was reported more often in the HIV group (119 [12%] of 922 participants) than in the reference group (59 [6%] of 760 participants, p=0·0006; appendix). Denial of care appeared to be more frequent at general practices (6·4% for the HIV group and and 3·2% for the reference group) than at hospitals (3·0% and 1·4%) and pharmacies (5·2% and 2·8%; appendix). The main reasons for refusal of care were refusal of the specific health insurance coverage for poor people and undocumented migrants (28 [40%] of 59 participants in the reference group and 36 [32%] of 119 participants in the HIV group), HIV status (33 [29%] in the HIV group), and being uninsured (16 [26%] in the reference group and 34 [25%] in the HIV group). In France, two schemes—the Universal Health Insurance Coverage and the State Medical Assistance (created in 1999)—are available for vulnerable populations and for undocumented migrants who were previously excluded from the health insurance system. These two schemes ensure free health care for these populations. Nevertheless, some health professionals deny the beneficiaries.4Després C Couralet PE Situation testing: the case of health care refusal.Rev Epidemiol Sante Publique. 2011; 59: 77-89Crossref PubMed Scopus (9) Google Scholar, 6Boisguérin B Haury B Les bénéficiaires de l'AME en contact avec le système de soins. Etudes et résultats 2008.http://www.cnle.gouv.fr/IMG/pdf/DREES_juillet_2008_Les_beneficiaires_de_l_AME_en_contact_avec_le_systeme_de_soins.pdfGoogle Scholar The reasons identified for denying care to these patients were mainly about delays in payments and minimal payments,4Després C Couralet PE Situation testing: the case of health care refusal.Rev Epidemiol Sante Publique. 2011; 59: 77-89Crossref PubMed Scopus (9) Google Scholar, 6Boisguérin B Haury B Les bénéficiaires de l'AME en contact avec le système de soins. Etudes et résultats 2008.http://www.cnle.gouv.fr/IMG/pdf/DREES_juillet_2008_Les_beneficiaires_de_l_AME_en_contact_avec_le_systeme_de_soins.pdfGoogle Scholar discriminatory reasons and fear of contracting HIV have also been reported.7Nostlinger C Rojas Castro D Platteau T Dias S Le Gall J HIV-Related discrimination in European health care settings.AIDS Patient Care STDS. 2014; 28: 155-161Crossref PubMed Scopus (37) Google Scholar As our survey suggests, refusals to provide health care are too frequent. For migrants who have often encountered many bureaucratic obstacles to benefit from French health insurance dedicated to the poor or the undocumented, being denied access to care by health-care professionals or services is unlawful and should not be tolerated. Refusal of care for migrants with and without HIV needs to be addressed to improve equity in health-care systems. Policymakers, insurance bodies, and health councils must act. We declare no competing interests. We thank the French National Agency for Research on AIDS and Viral Hepatitis for funding. Download .pdf (.14 MB) Help with pdf files Supplementary appendix Protecting migrant womenEurope is facing massive movements of refugees and migrants—women, girls, men, and boys of all ages. The journey to Europe is perilous; migrants often face high levels of violence, extortion, and exploitation along the way, reaching a paroxysm with recent reports of slave auctions in Libya. Full-Text PDF Open Access