“Economic migrants will anyway be deported soon”. Negotiating access and deservingness of refugees

Abstract

Abstract Background Conflicting rationales permeate the European discourse on refugee migration: inclusiveness and human rights clash with xenophobia and aims to protect territory and wealth. Against this backdrop, health care access for newly arrived refugees in many European countries is restricted. The legal frame in Germany allows for extended restrictions as well as inclusive health care. While vague legal formulations create uncertainties regarding entitlements, they allow for discretionary decisions by a plethora of health care and government actors. Methods An ethnographic field study in two German refugee outpatient clinics including participant observation and interviews with 29 members of health care, administrative, social work and interpreting staff was conducted. By means of a qualitative content analysis we explored prioritisation criteria and negotiations about service provision to refugees by street-level decision-makers. Results Medical decision makers adopted government criteria to increase the chances of success of requests for reimbursement. We could identify various non-medical criteria, like asylum status and logistics impacting on access to care. Political and societal discourses seeped into discussions on granting or denying medical services: Medical and government decision-makers reflected on prospects of staying associated with the countries of origin of asylum seekers and illegitimate motives for flight, such as poverty, while negotiating what services should be provided to whom. Conclusions The vagueness of legal concepts allows for the implementation of restrictions based on non-medical grounds in practice, that would contradict international conventions if included in the legal norm unambiguously. In the face of contradictory imperatives, the state has chosen to leave policymaking to practitioners. They are in danger of being instrumentalized as agents of migration control, exclusion and deterrence, which raises practical and ethical questions. Key messages • Legal uncertainty leads to inconsistent medical care practices, that can exacerbate health inequities. • Health professionals have to be made aware of their responsibility as gate keepers to the medical system for refugees, so they cannot be politically instrumentalized as agents of migration control.