“I was trying to speak to them to their human side.” Moral understandings of undocumented migrants regarding access to healthcare in urban settings in Belgium.

Problem

Belgium’s law on ‘Urgent Medical Aid’ provides with a legal framework about who should account for medical services provided to undocumented migrants. However, epidemiological findings show that this legislation is inadequately implemented in practice: compared to the Belgian population, both the utilization rate and the per capita expenditure are far lower. Language barriers, as well as a climate of fear are well-known factors that hinder undocumented migrants’ access to healthcare. Yet, the way meanings and micro-level social interactions, and more specifically the moral positions of undocumented migrants themselves impact on the access to healthcare for undocumented migrants has so far been largely under investigated.

Approach

We performed focused ethnography and in-depth interviews with undocumented migrants living in Brussels to understand patient decision making around accessing health care services. Thematic analysis was conducted in conjunction with the theoretical framework of ‘moral understandings’ (Walker, 2007). This theoretical framework was used as a tool to explore undocumented migrants’ moral self-description and their ideas about what both individual primary care workers and the collective entity of the ‘medical world’ are supposed to do, expect, and understand.

Findings

Three themes emerged out of the thematic analysis. The motivation for utilisation of healthcare services by undocumented migrants is influenced by (1) contrasting views about one’s own agency, as well as perceptions about (2) permeability of the health services, and (3) the quality of care. First, participants expressed contrasting views about agency and autonomy: they mentioned the importance of local actors to navigate through the health care system, simultaneously they expressed the presence of choice between different institutions and humanitarian actors. Secondly, participants made assessments about inclusiveness and the likelihood to be refused. Thereby they presupposed the conditionality of the assistance: they claimed not to have a right to everything and valued self-control and avoidance of conflict. They balanced this with the obligation in the medical world to offer life-saving care and the use of strategic discursive tools in response to situations of crises. Thirdly in the evaluation about the quality of care they valued a direct, personal approach over bureaucratic procedures. Further, the care was compared to the country of origin, instead of stressing the importance of equal treatment to Belgian residents.

Consequences

This research provides new insights in the factors that affect the health service usage of undocumented migrants. These are important factors to take into account in the design of health policies aimed at undocumented migrants.