South to South migration and access to health care: The case of bordering country immigrants in Argentina

1. South to South migration and access to health care:The case of bordering country immigrants in Argentina Nina Zamberlin CEDES Buenos Aires, Argentina Séminaire “Migrations et Développement” Plate-forme pour la Population et le Développement Bruxelles, 13 Mars 2006

2. Migration and health Dimensions for analysis • Disease transmission or acquisition as a consequence of migration • Health problems that arise from the migrating process (stress, lower defenses, life style change) • Differences in patterns of morbidity between native and migrant populations • Health issues as a part of the decision to migrate • Immigrants’ access to health care • Institutional responses to immigrants’ health care needs

3. Sources for this presentation • Argentine National Censuses and household surveys • Bibliography: Novick (2004); Cerrutti (2004); Caccopardo & Maguid (2001); Cenicacelaya (2003); Jachimowicz (2003). • E. Jelin, A. Grimson, M. Cerrutti, and N. Zamberlin; “Regional Migration and health in Argentina: Citizenship, discrimination and intercultural communication” (2005) Analysis of the conditions affecting access to health care by bordering country immigrants in Argentina, as well as the intercultural situations that take place during. health care provision.

5. ARGENTINA • Population: 36 million • Urban population under poverty line: 38,5% • Urban population in extreme poverty: 13,6% • Unemployment: 10,1% • Underemployment: 11,9% • Growing social inequities in the 1990s • Between 1998 and 2003 the poverty incidence increased from 26% to 47.8% • 2001: economic collapse and social and institutional crisis. • Sanitary emergency

6. Argentina: Health care system • Three sub-sectors: public, private and social insurance funds (“obras sociales”) • Public sector provides free medical care • Increase of demand in public health care system (lower class and former middle class currently unemployed) • Nearly half of the population has only public health coverage • Crisis of the public health care system

7. ARGENTINA • International migration has been key for economic development • European immigrants (late 19th and early 20th century) • 8.5 million immigrants from Spain and Italy arrived between 1870 and 1950 • Immigrants from neighboring countries (20th century) • Between 1955 and 1985 1.5 million immigrants from neighboring countries settled in Argentina

8. EMIGRATION Skilled young professionals who leave due to economic crisis and high unemployment Mostly to Europe and US 300.000 left to Spain and Italy in past 5 years 1.05 million Argentines are were living abroad as of March 2005. IMMIGRATION From neighbouring countries with weaker economies whose natives seek employment and higher wages Unskilled, low wage mostly in the informal sector (agriculture, construction and domestic work). MERCOSUR ARGENTINA End of the 20th century: changes in immigration flow. Co-existence of two different trends.

9. Immigrant population 1895-2001 Source: Novick, S. “Evolución reciente de la política migratoria Argentina”, 2005.

10. Immigrant population in Argentina (1869- 2001) INDEC, Argentine National Censuses

11. Bordering country immigrants in national censuses (1869-2001) Source: INDEC, Argentine National Censuses

12. Immigrants in Argentina • 70% of the immigrant population from bordering countries is between ages 25-64 • 25.4% of immigrant population from bordering countries never attended school or did not complete primary school • Men: Construction work. Women: domestic work, textile industry (sweatshops) • Concentrate in marginal urban areas. Precarious living conditions • Low income (exploitation, illegal status, no benefits or health insurance) • Many returned after the 2001 economic crisis (devaluation)

13. Top eight source countries of immigration as a % of the total foreign-born population Foreign-born population: 1,531,940 (5% of the total) 66% are immigrants from neighbouring countries Migration rate: 0.4/1,000 population The country is host to over half of South America's migrant population.

14. Bordering country (and Peru) immigrants in Argentina (2002)

15. Reasons for migrating • Better economic opportunities (Differences in per capita income) • Family • Age • Health status (great disparities in access to health care; differences in morbidity and mortality patterns) • Argentina: greater availability of services, quality, professional competence, technology. • Solid public health care system (per capita health expenditure) • 14% of users of the public health care system are NC migrants

16. Socioeconomic and health indicators

17. Immigration legislation “Videla Law” (1981-2003) • Issued by the military dictatorship • Based on repressive and discriminatory conceptions (“Selective” immigration) • Immigrants considered a threat to national security and public order • Emphasis on control and deportation • No respect for fundamental rights guaranteed by the Constitution • Any public official (including teachers and doctors) who had contact with an undocumented foreigner had the obligation to report him/her to the immigration control authorities.

18. Immigration legislation New immigration law (2003) • Significant progress in the recognition of immigrants’ rights. • Objective: Promote the integration in Argentine society of those who have been admitted as permanent residents • State must guarantee immigrants “equal access to the protection and rights that Argentine born citizens are entitled to, particularly access to social services, health, education, justice, employment and social security”. • “In no case should access to the right to health, social assistance or sanitary care, be denied or restricted to any foreigner who requires it regardless of his/her immigration status”. • “the authorities of health care institutions must offer orientation and information about the necessary steps to solve the irregular immigration status”.

19. Immigration legislation Mercosur Free Movement and Residence Agreement (2002) • Signed also by Bolivia and Chile • Similar to the EU model of open borders. Grants Mercosur citizens an automatic visa and freedom to work and live in the country. • The intention of this agreement was to regularize illegal immigrants

20. Immigration legislation Health Law of the City of Buenos Aires (1999) • Seeks to “guarantee the right to integral health”. • Its dispositions are valid “within the city’s territory and reach all persons without exception, regardless of whether they are residents or non-residents of the City of Buenos Aires”. • The rights “for all people with regards to their relationship with the health care system and services” include “the inexistence of economic, cultural, social, religious, racial, sexual, ideological, political, ... or any other type of discrimination”. • Law 664 (2001) states that “access to public health care services, education, justice, and social services provided by the City of Buenos Aires are of non-restrictive character. No limitation to their practice could be based on reasons of origin, nationality, race, language, religion, or immigration or social status”.

21. Immigration legislation • Contrary to global trends, recent migration policy developments in Argentina are intended to create a more open immigration regime. • Legal framework provides sufficient legal protection to ensure that immigrant’s rights are not violated • However the existence of laws regulating rights and obligations of individuals and the State does not necessarily imply that they are enforced and respected. • There are provincial and institutional norms that contradict the national law • Public officials and population are unaware of the policy changes

22. What is really happening? • Discrimination • Medical care denied to undocumented immigrants • Request of national ID card to provide care • Charge for medical provision in public health care system • AIDS medication denied • No admission into health programs

23. What is really happening? • Variations among institutions (access, type of care provided, waiting time) • Differences between hospitals and primary care centers • Crisis of health care system affects both natives and immigrants • Paradox Limited access to health care Excessive use of health care system by immigrants

24. Immigrants and health care:Providers’ views Two types of immigrants • Those who reside in the country. Considered to have the same rights as natives. • Those who migrate exclusively to use the health care system (“health charters”). Seen as a deliberate “abuse” of scarce public resources. According to this logic, providing health care to a foreigner indefectibly implies that the same type of provision is delayed or denied to an Argentine citizen. Is it really possible for health care providers to make this distinction???

25. Immigrants and health care:Providers’ views • Administrative problems arise when undocumented people receive health care • Providing care to immigrants is considered a waste of money • Embassies from bordering counties do not respond the request of payment for services provided to their citizens • Hospital staff adopt the role of “border protectors” (filter out immigrants) • Act to prevent the health care system from being swindled by foreigners • Overwhelming demand • Sometimes there are more restrictions for locals than for foreigners • Racist and xenophobic attitudes (fueled by right wing sectors) • Critical health condition in which many foreigners arrive that must be solved in a context of excessive workload and frequently adverse working conditions.

26. “If it wasn’t that we request ID and they do not have it –because most of them are here illegally- we wouldn’t be providing services to Argentines and this would be a hospital for foreigners. We proposed the director to make two different lines and a system of quotas where we could give priority to Argentines. The director liked the idea but the social workers began to say that it would be discriminating and so forth... Nonsense!! We are not saying that foreigners shouldn’t receive health care; we just want to set priorities. The reality is that they come to this hospital, maybe they stay in the country for one of two months, and then they leave. Meanwhile, the people who live here have to wait three or four months to be seen by a doctor. So for not discriminating foreigners we end up neglecting our own people” (Administrative employee who assigns appointments at a public hospital in the City of Buenos Aires)

27. Immigrants and health care • Health professionals who become personally involved and try to help vulnerable immigrants • Flexible with bureaucratic norms that could restrain immigrants’ access • “Friendly” institutions known in the immigrant community • Private clinics specifically for immigrants

28. Paraguayan & Peruvian women More educated Adapt easily Demanding Aware of their rights Confront medical staff “Astute” Bolivian women Lower education Communication problems Submissive, quiet Enduring Greater tolerance to pain Domestic violence Male domination Stereotyped images of immigrant women

29. Cultural differences and medical careBolivian women in Argentina • Communication barrier (language, terms, ability to express themselves) • Difficulties to describe symptoms (“value of anamnesis is lost”; “veterinary medicine”) • Difficulties in interpreting and following medical instructions • Demand more time and patience • Exhausting, annoying and frustrating for providers • Mutual lack of trust

30. Cultural differences and medical careBolivian women in Argentina • Position for giving birth • Breastfeeding • Refuse C-sections • Refuse blood extractions • Machismo. Women do not make decisions • Clothing. Don’t like to undress to be examined • Personal hygiene habits / possibilities

31. Immigration Progress in legislation • Recognition of immigrant’s rights within a framework of human rights • New paradigm: multicultural, inclusive, integrated society. However changes are not reflected in practice yet • Discriminatory practices persist • Need to change attitudes and practices Challenge: TO TRANSLATE THE LAW INTO ACTIONS • Must define the specific policies and procedures which will make possible the concretization of the contents of the law.