To the doctor without fear

Not everyone can simply go to the doctor when they have a complaint - not even in this country. This is especially true for people without papers. Even small steps such as the "anonymous sick bill" can provide a bit of normality.

By Christine Höpfner

When the Lower Saxony Integration Prize was awarded in June 2014, the Medical Refugee Counseling Service in Hanover and the one in Göttingen were among the winners: The two non-governmental organizations (NGOs) are part of the MediNetze or MediBüros, which provide anonymous and free medical help for migrants without health insurance in many German cities, mostly on a voluntary basis.

"In the event of illness, people without papers are particularly reliant on doctors who treat them for free," says Maren Mylius, a doctor in advanced training in psychiatry at a clinic in Hanover and a volunteer at the medical refugee advice center. "In purely formal terms, you are entitled to medical benefits under the Asylum Seekers' Benefits Act even without legal residence status," she explains. "But doctors' surgeries, outpatient clinics and hospitals have to contact the social welfare office for reimbursement, which has to pass the patient data on to the relevant immigration authority. To avoid being discovered and risking deportation, the necessary medical help is often not sought at all or is sought far too late."

Maren Mylius has been concerned aboutthe precarious situation of undocumented migrants for years. Even as a research assistant at the Department of Ethics at the University of Erlangen/Nuremberg, she dealt with the question of how to ensure appropriate care for these people. And like Mylius, the other MediNetz helpers - doctors, psychotherapists, nurses, medical students and interpreters - bring a wealth of professional experience to their work.

Anonymous and free treatment in the pilot project

The state parliament of Lower Saxony also relied on the good local networking of these NGOs and their qualified staff when it approved the "anonymous sick bill" pilot project at the end of 2014. This was preceded by a motion for a resolution in which the SPD and Greens called for an anonymous sickness certificate for people without a defined residence status in addition to the health card for refugees in the asylum process. According to the motion, this should be introduced "in cooperation with the Association of Statutory Health Insurance Physicians and the Medical Refugee Aid in Göttingen and Hanover" and "enable this group of people to access medical care without having to fear negative consequences".

The three-year pilot project was launched in December 2015, with a "contact and referral office for the placement of paperless people in medical care" being set up in both cities, each with half a staff position for medical management.

In Hanover, the allocation office is located in the Linden leisure center, which provides integration and educational work and sees itself as a place for multinational encounters. Work began there on March 11, 2016. It is open on Mondays, Tuesdays and Fridays from 9 a.m. to 11 a.m. and Thursdays from 1 p.m. to 4 p.m. The staff clarify the health problem and social situation of those seeking help, then give them an anonymous health certificate (AK) if required and refer them to doctors' surgeries or hospitals - and, on request, also to offices that provide advice on residence law.

"With the anonymous sickness certificate, people without papers can go to any registered doctor and be treated free of charge," says Maren Mylius. "The treatment costs are settled anonymously via a fund set up by the Ministry of Social Affairs. Doctors thus avoid the risk of being stuck with the costs and clients don't have to worry about personal data being passed on to the authorities."

The project has been specifically advertised, for example at advice centres for migrants, in collective accommodation or at aid organizations for people without papers. The clientele consists of refugees who have not applied for asylum because it would not be granted anyway, people whose regular residence permit has expired or who have entered the country with a temporary visa and stayed.

"Most of the patients are children"

"From March to the end of May, 50 consultations were held in Hanover and 40 anonymous sick bills were issued: to pregnant women, patients with pain, for children with nutritional problems - to people with a wide variety of complaints," says Maren Mylius. "The age range extends from babies to over 50-year-olds, but most of the patients are children."

The pilot project receives 500,000 euros per year from the state of Lower Saxony for personnel and material costs and medical care. This means that each location has to make do with 250,000 euros a year - so it's important to budget well, especially as the number of people seeking help is now gradually increasing. "Most of the budget goes towards medical care," emphasizes Maren Mylius. "The money is tight, but we hope that we can enable as many people as possible to receive treatment."

With the AK, you are entitled to medical services as provided for in Section 4 AsylbLG. "This means treatment for acute illnesses that require treatment and for pain, which also includes dental services as well as pre- and post-pregnancy care," explains Mylius. "However, long-term therapies, which are necessary for chronic illnesses such as HIV infection, are not included. Whether an asylum seeker's HIV infection is in need of treatment and therefore requires long-term treatment is therefore interpreted very differently by the social welfare offices."

For HIV cases in the pilot project, an advisory board made up of medical ethicists, doctors, representatives of the contractual partners and the public health service decides whether antiretroviral therapy is indicated. "So far, however, we have only had a few HIV patients - the project has only been running since March 2016," says Maren Mylius. "There is still hardly any experience with HIV and other chronic diseases in the pilot project. In a few months, we will be able to better assess what is going well and where there are problems."

The AK is not accessible to everyone who needs it

The doctor considers it right that the project is aimed solely at those without paperwork. Nevertheless, she regrets that others who would also need it cannot benefit from it. For example, more and more clients are coming to the contact point who are legally resident in Germany but do not have health insurance, such as migrants from Eastern European EU countries like Romania or Bulgaria, for whose medical care there is no cost bearer. "We then have to see which other aid organization we can send them to."

Asylum seekers are also excluded. According to the law, they are entitled to basic medical care. However, given the overcrowded initial reception facilities, the authorities are overwhelmed and can barely keep up with processing asylum applications and issuing treatment certificates. Without this certificate, however, it is not possible to see a doctor and the local authorities do not cover the costs.

Even if the project cannot solve all the problems: Maren Mylius is nonetheless pleased about it, as the anonymous medical certificate is one of MediNetze's very own concerns, enabling paperless people to receive medical help from doctors of their choice. "We see this as at least a step towards making the right to healthcare more effective."

Hope for a nationwide adoption of the model

After many years of political battles, the AK was considered almost unattainable. So far, similar models have only been implemented in Hamburg and Düsseldorf: There, so-called clearing houses are used to clarify whether clients can be integrated into the standard care systems; where this is not possible, an emergency fund bears the costs of medical treatment. Whether the anonymous sick bill has a future will depend on the evaluation of the pilot project at the end of its term. Maren Mylius therefore hopes that the red-green state government will be confirmed in office at the next state elections in 2018: "Then there is a better chance that it will be adopted nationwide."

Göttingen and Hanover show that the AK for paperless people can be put into practice despite all the formal and legal hurdles. In Bremen, Hamburg, Berlin and Schleswig-Holstein, on the other hand, asylum seekers receive a health card with which they can go directly to a doctor of their choice without having to go through the social welfare office - this also ensures a degree of normality. However, it is difficult to adopt such models in the larger states, and nationwide solutions such as lifting the restrictions of the AsylbLG or abolishing Section 87 of the Residence Act are currently not in sight.

Together with Doctors of the World, MediNetz Berlin and Aktionsbündnis gegen Aids, Deutsche AIDS-Hilfe wants to draw attention to the fact that the problem is urgent and that decisive political action is required with an action in front of the Federal Ministry of Health on July 18 - at the same time as the International AIDS Conference, which will take place from July 18 to 22 in Durban/South Africa under the motto "Access Equity rights now".