Switzerland: Providing medical care to the hidden uninsured

These are mainly economic migrants, asylum seekers whose applications for asylum have been refused but who choose to remain in Switzerland and people who have lost their legal resident status due to divorce or unemployment. Switzerland's health care system requires legal residents to purchase health insurance from one of the country's many private health insurers. According to national recommendations, migrants without legal status still have the right to purchase health insurance. However, several factors make this difficult to do. To begin, Switzerland is a federal state, and not all of the cantons (member states) apply the federal recommendations in the same way. For the time being, only a few cantons require insurers to accept migrants lacking legal status. Insurance is also too expensive. It costs approximately US$100-250 a person per month while most migrants without legal status earn an average of US$1,100 each month. Many migrants lacking legal status are often unaware that they can buy this insurance. Others hesitate to engage in this process for fear of declaring themselves to the authorities who - although it is illegal - could alert the police. Thus, the vast majority of migrants without legal status remain uninsured and have very limited access to health care services, except for emergencies. Health structures offering services rarely approach this population proactively. According to an MSF evaluation, nearly 50 percent of the people in this group never consult a medical doctor. Those that do, often wait until they suffer from an advanced stage of disease. Seeking out Fribourg's uninsured Since November 2003, MSF has run a pilot medical project in the canton Fribourg. Under the name Fri-Santé, we run a medical facility staffed by one nurse who acts as a "gatekeeper" and reference point. Consultations at the facility are free of charge. A network of voluntary health professionals (general practitioners and specialist doctors, dentists and a psychologist) and pharmacies has been established to support the program's work. Depending on their financial capacity and the availability of drugs in the program's reference pharmacies, patients may be asked to contribute towards the cost of their medicines and/or treatment. In March 2004, the facility saw 33 patients during 49 consultations and referred 18 of them for medical problems. The number of consultations is growing, which reflects the experience of comparable institutions in Geneva and Lausanne, suggesting that it takes some time to build confidence in such programs' services. The canton's authorities already contribute financially to the project. In the second half of 2004, it is likely that operational responsibility can gradually be handed over to a new, local association. MSF is now exploring the need to replicate the Fri-Santé approach in other parts of the country. To start, an exploratory mission is currently underway in Zurich.