1. Health of the former Soviet Union migrants in the Czech Republic Helena Hnilicová, PhD Charles University Prague, First Faculty of Medicine, Institute of Public Health and Medical Law Karolina Dobiášová Charles University Prague, Faculty of Social Sciences, Institute of Sociological Studies

2. Structure of presentation Background information on Migration in the Czech Republic Health status of migrants - routine statistics - research survey Accessibility of health care for migrants, barriers and obstacles Conclusion

3. Background information on migrants Background information on migrants (Source: Foreigners in the CR, Czech Statistical Office 2009) Since the 1990s, the Czech Republic has been among the countries with fast increase of immigration. In 1990 – 2006, the number of foreigners increased to nearly a tenfold. The immigrants’ inflow is caused by work migration. Total number of migrants (2008): 438 000 (4 % of population) Undocumented migrants: 50 000 – 200 000 (estimated) permanent residents 40% (173 000) - women 40 % long-term residents 60% (265 000) - men 60 % Economic activity 87 % Age structure Employees 78 % 20 – 65 77 % Self employed 22 % children and adolescents 20 % older 65 years 3 % Nationality structure Ukraine 31 % Slovakia 17 % Vietnam 13 % Russia 6 %

4. Migrants in the CR by the country of origin SOURCE: Institute of Health Information and Statistics of the CR, 2009

5. Structure of the former Soviet Union migrants by nationality Top 10 Ukraine 131 998 Russian Federation 27 467 Moldova 10 653 Belarus 4 123 Kazakhstan 3 447 Uzbekistan 2 339 Armenia 1 956 Georgia 761 Kyrgyzstan 535 Azerbaijan 369 Others (Lithuania, Turkmenistan…) 866 Total 184 514

6. Demographic characteristics former Soviet Union migrants Gender : men 58 % women 42 % SOURCE: Institute of Health Information and Statistics of the CR, 2009 Education: exact statistics are not available. - elementary + apprenticeship 44% - secondary 27% - graduated 10 - 12% Source: (Horáková 2001, Leontieva 2008) Age structure (estimated) - 20 – 65 87% - children and youth 10%, - older then 65 3%

7. Health of migrants in routine statistics Health of migrants in routine statistics Czech routine statistics do not include data on ethnic origin or nationality. Foreigners are monitored only in case of obligatory reported diseases (infections) and there are some data on hospitalization. TBC incidence: - very low and decreases gradually (6,8 TBC cases per 100 thousands inhabitants). The migrants share by 20 % HIV/AIDS prevalence: - the lowest in the EU (0,1 % in 2005) The foreigners share by 35% Sexually transmitted diseases The incidence of syphilis is relatively high among foreigners in the Czech Rep. Foreigners share 29 % Former Soviet Union migrants belong to frequently reported S OURCE: Institute of Health Information and Statistics of the CR, 2009

8. Work related injury Work related injury was found as the most common cause of migrants’ hospitalization ( 22 - 24 %) in the period 2000 – 2007 Higher rate of work injuries corresponds to the fact that foreigners are often employed in high-risk branches of industry; additionally, it is well known that the Occupational safety and health protection regulations are not always followed as needed in case of migrants; language barriers, low education and low awareness of health risks were identified as the main causes In summary: Work accidents and injuries belong to the most important health risks of migrants in the Czech Republic. S OURCE: Institute of Health Information and Statistics of the CR, 2000- 2009

9. Health of migrants in light of the research study (2004) The most valid and reliable data are available from comparative research of the perceived health, health determinants and healthcare utilization. Representative sample of former USSR migrants was compared to the sample of the Czech population (age, gender and education structure was comparable) N = 524 Migrants N = 528 Czechs Male : 57 % Females: 43 %

10. Results Both genders of the former USSR migrants indicate better subjective health, fewer chronic diseases and fewer health problems and they suffer less from pain The migrants visit general practitioners three times less frequently, and they utilize specialized outpatient care significantly less. “ Healthy Migrant Effect” ? Source: Dobiasova et al. 2005

11. Healthcare utilization Source: Dobiasova et al. 2005

12. Life style of the former Soviet Union Migrants The migrants´ life style is more risky: there are significantly more smokers and proportion of heavy smokers is also higher. The migrants indicate a higher consumption of alcohol, preferring spirits; they indicate also a large working load (10-12 hours/per day, 6 days per week). Source: Dobiasova et al. 2005

13. The Czech health system and migrants’ entitlement to health care Basic principles: Health care is guaranteed by the Czech Constitution: universal access, universal coverage. Health care is provided on the basis of mandatory public health insurance. The availability of public health insurance depends on the type of stay, the employment status, and the country of origin. Entitled groups are the following: Czech citizens, all residents with permanent stay, EU residents with long term stay (incl. dependents, children, partners). All employees of the employers (companies) registered in the CR (incl. foreigners). Some other groups e.g. – asylum seekers. Unequal access to public health insurance of migrants from third countries They can only apply for public health insurance in case they are employed. The others – the self employed and the dependents of all the third country migrants without permanent residence must apply for commercial health insurance.

14. Czech commercial health insurance Health insurance is set up as an necessary condition for visa and work permit and „Valid“ health insurance is provided only by the insurance companies registered in the CR Commercial health insurance covers basically acute healthcare in emergency situations, all other healthcare must be paid out-of-pocket It does not cover all situations when health care must be provided in any case according to health laws ( sexually transmitted diseases, HIV/Aids, acute psychiatric disorders, premature born children and some others )

15. Who are clients of commercial health insurance? Who are clients of commercial health insurance? Ukrainians, Russians, other third countries migrants (self- employed, partners, children) Overall number is estimated 100 000 – 120 000 - about 1/3 are migrants from former Soviet Union

16. Barriers resulting from commercial health insurance I Barriers resulting from commercial health insurance I To be insured in commercial system - it represents many barriers and real problems in access to needed care with serious ethical consequences It works according to market principles – it is not a pretension, risk clients might be refused; client over 70 are excluded No commercial insurance company will insure a migrant with a chronic disease or serious health problems. There is no obligation to insure all applicants.

17. Barriers resulting from commercial health insurance II The insurance contract is based on the results of medical examination ( necessary condition). All events/diseases whose cause or symptoms originated before insurance contract are excluded Other examples of uncovered care: diabetes, hemodialysis, all injury connected with alcohol and drug consumption, drug addiction, congenital defects

18. Barriers resulting from commercial health insurance III Ccommercial health insurance for the families with small children is quite expensive; it has to be paid in advance for the whole insurance period - at least for 1 year In summary: the most vulnerable groups are children, esp. prematurely born children or children born disabled or with congenital defects. No insurance company insure such children. In practice Czech physicians are obliged to provide all necessary care to such children in need under the same conditions as for the Czechs, but sometimes nobody pays for that

19. Conclusion Conclusion Elimination of existing inequalities in access to public health insurance is targeted in the Czech government migration policy agenda as one of the priorities. Czech Government Decree issued in 2007 which declaring inclusion of third country migrants into public health insurance has not been implemented yet Unequal access to health care is considered as one of the most important barriers to integration migrants into the Czech society Increased risk of infectious diseases and work injuries should be targeted in migration related Czech health policy Improvement of health related behavior of migrants needed to be addressed in specific health promotion programs: anti smoking campaign, reducing of alcohol abuse, development of alternative leisure time activities (substitution of excessive alcohol drinking …), sports, culture events offer ( European Integration Fund ) Additionally - lack of information on the Czech healthcare system (rights and obligations, service network, practicalities) was identified as another obstacle which migrants have to face using the health services, esp. migrants not speaking Czech.

20. Thank you for attention