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Refusal to provide health care to sub-Saharan African migrants in France

Abstract : In France, the public health insurance system has a principle of universality.1 However, refusal to provide care by health-care professionals has recently emerged as an issue.2 People living with HIV and vulnerable populations have an increased risk of being denied care. The ANRS-PARCOURS study5 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.4, 6 The reasons identified for denying care to these patients were mainly about delays in payments and minimal payments,4, 6 discriminatory reasons and fear of contracting HIV have also been reported.7 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.
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Submitted on : Thursday, December 13, 2018 - 2:52:25 PM
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Nicolas Vignier, Rosemary Dray Spira, Olivier Bouchaud, Annabel Desgrées Du Loû, Pierre Chauvin. Refusal to provide health care to sub-Saharan African migrants in France. Lancet Public Health, Elsevier, 2018, 3 (1), pp.e12. ⟨hal-01954137⟩

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