The Swedish Agency for Public Management

Care for undocumented migrants. Final report of the commission to monitor the act concerning healthcare for people residing in Sweden without permission (2016:11)

Since 1 July 2013, county councils are obliged to offer undocumented migrants over 18 health and medical and dental care that cannot be deferred. The costs­ of this healthcare and the medicine prescribed in connection with healthcare are subsidised. Children under the age of 18 are to be offered healthcare on the same terms as those who are residents. (Refer to The Act (2013:407) on healthcare for certain foreigners residing in Sweden without the required permit.)

Statskontoret's commission

The Swedish Government has tasked Statskontoret (the Agency for Public Management) with analysing how the act on healthcare for undocumented migrants has been implemented and applied. The commission has included mapping

  • the extent to which undocumented migrants have been offered healthcare,
  • which steps have been taken to ensure that healthcare staff are aware of the regulations,
  • how government agencies and county councils have worked to develop the regulations, guidelines and procedures that make it easier for the healthcare services to ­comply with the legislation.
  • if the confidentiality regulations for the healthcare services and police work in searching for undocumented migrants have affected their ability to obtain healthcare
  • what impact the regulations have on migration to Sweden.

The majority of undocumented migrants are offered care in accordance with the law

The overall conclusion of Statskontoret is that most undocumented migrants who seek treatment are provided with healthcare, dental care and medicine in accordance with the law. However, monitoring carried out by the agency shows that there are some barriers and shortcomings in the care of undocumented migrants. The greatest risk for undocumented migrants not being offered healthcare in accordance with the law is that healthcare­ staff are not familiar with the law.

The interviews that Statskontoret has carried out with voluntary organisations, county councils and government agencies show that, together with the rest of our work, the application of the law essentially works well. In 2015 there were almost 30,000 cases of undocumented migrants using healthcare. In comparison with 2014, this is an increase of 56%. Even if healthcare to undocumented migrants is a small part of the total care, Statskontoret notes that county councils offer undocumented migrants­ a considerable amount of healthcare. Six county councils offer complete healthcare to undocumented migrants, i.e. more than the law requires.

Information initiatives for better compliance with the law

Statskontoret considers that the knowledge of the relevant law needs to be improved. Our questionnaire given to general practitioners in primary healthcare indicates that they have limited awareness and knowledge of the law. Seven out of ten doctors say that they have heard of the law, but do not know it very well. Experience indicates that knowledge of the law among voluntary­ organisations­ can be improved in the entire healthcare chain, from staff at receptions to nurses and doctors.

Statskontoret assesses that county councils and the state can do more to improve compliance with the law. Above all, we need more knowledge about which persons are covered by the law, what is meant by the term "healthcare that cannot be postponed" and procedures for the prescription of medicine. Statskontoret recommends that­ county councils organise courses and further develop their guidelines­ and advisory activities. Statskontoret also recommends that the National Board of Health and Welfare, as a complement to the initiatives of the county councils, produces a handbook with tips for different groups of staff describing what is important to keep in mind when undocumented migrants seek healthcare.

The law needs to be clearer about when EU citizens can be given healthcare as undocumented migrants

After the law was introduced, the number of so-called vulnerable EU citizens residing in Sweden has increased significantly. Statskontoret notes that county councils vary in how they interpret their obligation to provide healthcare for undocumented migrants. Some county councils offer vulnerable EU citizens subsidised care, while others have a policy of charging a fee for the entire cost of healthcare. Statskontoret considers that it is an important issue of principle whether EU ­ citizens should have access to subsidised healthcare in Sweden. According to the National Board of Health and Welfare,­ ­there is no basis in preparatory work for the law that gives clear guidance on how the law should be interpreted. Statskontoret therefore proposes that the government clarify what is meant by the description in the preparatory work that it "… is not ruled out that [the law] in individual cases may also be applicable to citizens of the Union.". The ambiguities which now exist in this area constitute a risk that those seeking healthcare are wrongly refused or are wrongly provided with subsidised care.

Government grants cover the county councils' costs

County councils have so far been overcompensated for their commitment to provide healthcare to undocumented migrants. In 2015, the county councils' healthcare costs accounted for half of the government grants of SEK 300 million which county councils receive. The costs have increased since the law was introduced. Between 2014 and 2015 the county councils' costs increased ­from SEK 100 million to SEK 150 million. Statskontoret estimates that the costs will continue to increase over the coming years. The main reason for this increase is that 180,000 people are registered in the Migration Agency's reception system, and that some of them who have their asylum applications rejected will stay in Sweden as undocumented migrants. In the light of this situation, Statskontoret considers that the government should not reduce the level of the government grant.

Statskontoret estimates that the costs will increase primarily in county councils in large cities, where it is easier to live clandestinely. In 2015 the Stockholm County Council accounted for 56% of total costs. Stockholm ­was also the only county council in that year which was not given full financial compensation­ from the government. Statskontoret proposes that the government change the method used to distribute the government grant between county councils so that it covers the county councils' actual costs better. The grant is currently allocated solely on the basis of the number of residents in each county council area.

Low risk of being discovered by the police in healthcare

Statskontoret considers that the work of the police in searching for undocumented migrants does not constitute a major obstacle their seeking healthcare. A follow-up here shows that the police rarely search for undocumented migrants in healthcare. It is not considered to be efficient and is perceived as delicate. Statskontoret has not received any indication that it is common for healthcare staff to breach confidentiality by giving information to the police about undocumented migrants seeking healthcare. Statskontoret cannot assess the extent to which undocumented migrants refrain from seeking healthcare because they are afraid of being detected by the police. The fact that there were more than 30,000 visits to the healthcare services in 2015 indicates that many undocumented migrants consider that it is safe for them to seek treatment.

The law has no significant impact on migration

In the opinion of Statskontoret, the law has no significant impact on migration to Sweden. For those who come to Sweden to live as undocumented migrants, it is most likely that access to some form of network that can organise work, income and housing determines their choice of country. Access­­ to subsidised care may in some individual cases attract those who­ need ­healthcare to move to Sweden. Statskontoret considers that the risk of the law being misused in this area is greatest in the case of people who can come to Sweden legally or move freely within the EU.

Statskontoret considers that the law is of marginal importance for how long undocumented migrants remain in Sweden. Life as an undocumented migrant is hard for most, and the decision to remain in Sweden is influenced mainly by conditions in the person's home country. For a minority who become seriously ill in Sweden, access to healthcare may be one reason for a longer stay in Sweden.

Proposals and recommendations by Statskontoret

Proposal to the Government

  • Clarify what is meant by "not excluded that the law in individual cases may be applicable to EU citizens".
  • Change the method used to compensate county councils for their costs in providing care for undocumented migrants so that the government grant is allocated in a way that better corresponds to the county councils' actual costs.
  • Give the National Board of Health and Welfare the commission to examine whether coordination numbers can also be used to register healthcare given to undocumented migrants who have had their asylum applications rejected, provided that this is introduced for asylum seekers.
  • Consider changing legislation so that consumables ­required in healthcare are subsidised under the same conditions as medicines.

Recommendations to the National Board of Health and Welfare

  • Produce a handbook with tips for healthcare professionals describing what is important to keep in mind when undocumented migrants seek healthcare
  • Produce an online course for healthcare staff and also information to undocumented migrants specifically adapted for social media.
  • Develop procedures for registering healthcare using reserve numbers.
  • Give staff training and information about the law on healthcare for undocumented migrants and how it should be applied.

Recommendations to county councils

  • Develop guidelines and advice about what applies when undocumented migrants seek healthcare.
  • Improve opportunities for healthcare staff to obtain support from their colleagues about applying the concept of "care that cannot be postponed".
  • Use voluntary organisations' contacts with undocumented migrants to spread­ information about the possibility of obtaining healthcare.

Recommendation to Swedish municipalities and county councils

Monitor how county councils' costs for providing healthcare for undocumented migrants develops­­ in the future. This could be coordinated with the follow-up that the Swedish Association of Local Authorities and County Councils is currently making on the county councils' costs for providing healthcare for asylum seekers.