B Explanatory memorandum
by Ms Pelin Yılık, rapporteurNote
1 Introduction
1. People migrate for many reasons:
to escape violence and war, as well as in response to demographic changes,
human rights concerns, poverty and climate change. These factors
drive forced global mobility, exposing individuals to new environments
and, inter alia, to significant
health challenges. Migration may therefore constitute an independent
risk factor for ill health, often exacerbating pre-existing conditions
or creating new ones.
2. The motion for a resolution I tabled on 3 February 2025 on “Migrants’
and refugees’ access to healthcare” (
Doc. 16112) underlined the importance of ensuring effective access
to healthcare, including mental health services, in order to give
full effect to the right to health enshrined in international human
rights law.
3. Migrants’ and refugees’ health problems may arise before,
during and after their journey to Europe, reflecting the various
dangers, injuries and trauma they encounter. They are frequently
victims of violence, ill-treatment, beatings, loss or confiscation
of belongings and pushbacks. Many travel by sea in small boats and face
risks such as hypothermia in winter, dehydration and heatstroke
in summer, as well as burns and inhalation of toxic fumes from engines.
Even after arrival, significant physical and psychological health problems
often persist. Such conditions may pose serious risks and can prove
fatal if left untreated.
4. Forced migration and exposure to violence also produce lasting
psychological harm. Although many arrive in Europe with hope, they
frequently experience culture shock and disillusionment, leading
to depression, post-traumatic stress disorder, anxiety and related
conditions.
5. These risks are exacerbated upon arrival by inadequate nutrition,
poor infrastructure, limited access to medical care, unhygienic
living conditions, and adverse socio-economic circumstances. Additional
barriers further undermine health and hinder access to treatment,
including shortages of facilities and personnel, financial hardship,
language and transport difficulties, lack of health insurance, restrictive
migration laws, insufficient awareness of rights and available services,
harmful traditional practices, overcrowded housing, unsafe water
supplies, poor sanitation, and the absence of childcare services
for working mothers.
6. Member States must take into account both formal and informal
living situations when assessing migrants’ and refugees’ access
to healthcare, including that of undocumented migrants.
Note Formal situations are more readily
defined, as migrants are accommodated through official structures
such as reception centres or hotspots. Informal settings – such
as makeshift settlements, camps, squats, or street situations –
pose additional challenges for public authorities. Nevertheless,
for humanitarian reasons and in the interests of public health,
such situations cannot be ignored. Access to healthcare is therefore
essential not only for the individuals concerned but also for the
well-being of host societies.
7. In formal contexts, addressing health needs begins at points
of first arrival, particularly disembarkation areas, through medical
screening, rapid diagnosis and initial treatment. Longer-term care
is generally provided within national reception systems, often through
dedicated health centres. However, not all member States – particularly
those facing high numbers of first arrivals or congestion at borders
areas – are able to meet such demands fully.
8. Migrants and refugees remain particularly vulnerable, whether
within formal systems or outside them, and public authorities, together
with non-governmental organisations, are not always able to guarantee effective
access to healthcare, including mental healthcare, despite considerable
efforts.
Note Those living entirely outside official
structures face even greater risks, including acute shortages of
basic necessities, constant threats to health and safety, and significant
legal or administrative barriers.
9. The above-mentioned motion recalls
Resolution 2504 (2023) “Health and social protection of undocumented workers
or those in an irregular situation”, as well as
Recommendation
CM/Rec(2011)13 of the Committee of Ministers on mobility, migration
and access to healthcare. Both underscore the responsibilities of
national and local authorities and the key role of organisations
working to maintain and restore health.
10. The Assembly and, in particular, its Committee on Migration,
International Protection and Economic Co-operation (formerly the
Committee on Migration, Refugees and Displaced Persons), has repeatedly
drawn attention to migrants’ and refugees’ precarious access to
health and social services. A recent example is
Resolution 2613 (2025) “The challenges and needs of public and private actors
involved in migration management”, based on the
report by Ms Sandra Zampa. That work, which included fact-finding
visits to
France (2023) and
Italy (2024), provided valuable input for the present report.
11. Against this background, the present report adopts a broader
perspective, affirming that effective social inclusion requires
equal access to health and social services, including psychosocial
support, for all, migrants and refugees alike. The right to health
for everyone is both a human rights obligation and a public good
that benefits host communities.
12. Following an overview of the international texts and sources
at stake, and contributions from the Council of Europe’s various
relevant bodies, this report will examine the obstacles and difficulties
faced by migrants and refugees in accessing healthcare, including
the particular vulnerability of women, girls and unaccompanied children,
as well as the issue of externalisation and return hubs. While approaches
differ among member States, I have gone into more depth as an example
the situation in Montenegro following the fact-finding visit conducted
in that member State in March 2026. I finally propose a series of
good practices and responses to ensure human-rights compliant healthcare
for migrants and refugees.
2 International texts and sources, and
the Council of Europe’s bodies’ contributions
13. Articles 3 and 8 of the European
Convention on Human Rights
Note are pivotal in the European
Court of Human Rights’ case law on migrants’ access to healthcare.
This case law remains, however, underdeveloped.
Note Cases to date rarely address access
to healthcare in respondent States, focusing instead on States’
positive obligations regarding vulnerability. The Court has repeatedly
noted that certain individuals or groups warrant special protection
due to their vulnerability, which may arise from specific circumstances,
including serious health conditions, notably mental health.
Note
14. In its Case-Law Guide on Immigration,
Note the
Court states that conditions in transit zones may engage Article 3,
applying principles from detention cases (
Z.A. and
Others v. Russia [GC], 2019, §§ 181-195). Violations arose in airport
transit zones (
Z.A. and
Others v. Russia [GC], 2019;
Riad and
Idiab v. Belgium, 2008) and land-border zones (
R.R. and
Others v. Hungary, 2021, §§ 48-65), owing to inadequate food for an adult asylum
seeker and poor conditions for his pregnant wife (with health issues)
and minor children during four months in Röszke transit zone. No
violation was found where severity thresholds were not met (
Ilias
and Ahmed v. Hungary [GC], 2019, §§ 186-194;
Thiam v.
Italy (French only), 2022, §§ 32-41). In
H.M. and
Others v. Hungary (2022, §§ 13, 21-27), Article 3 was breached when an
asylum seeker was handcuffed and placed on a leash on his way to,
and during, a hospital visit to interpret for his pregnant wife.
15. It is important to highlight, among key international instruments,
the United Nations Global Compact on Refugees.
Note Adopted as a resolution of the UN
General Assembly, the Compact aims to operationalise the principle
of burden- and responsibility-sharing, mobilise the international
community as a whole, and strengthen responses to refugee situations.
In relation to health, the Compact calls on States to support protection-sensitive
arrangements for timely security screening and health assessments
of new arrivals; to expand and enhance the quality of national health
systems in order to facilitate access for both refugees and host
communities; and to build, equip, or strengthen health facilities
and services, including through capacity development and training
opportunities for refugees and members of host communities.
16. The European Committee for Legal Co-operation published a
Guide for Practitioners on the Administrative Detention of Migrants
and Asylum Seekers (2023), covering healthcare standards. It includes checklists
for healthcare professionals and lawyers addressing vulnerabilities.
Note
17. The Group of Experts on Action against Trafficking in Human
Beings (GRETA) monitors trafficking victims’ healthcare access,
including among asylum seekers and migrants, examining gaps in protection
in order to prevent vulnerabilities. Its 8th General
Report devotes a chapter to victim assistance, with a section on medical
aid.
Note
18. The European Commission against Racism and Intolerance’s (ECRI)
7th monitoring cycle prioritises equality
and inclusion in healthcare, with dedicated sections in all country
reports, covering foreign nationals.
Note From 2025 onwards,
initial reports (Albania, Austria, Monaco, Slovak Republic from
June 2026; then Belgium, Czechia, Denmark, Norway) will elaborate
further. Earlier reports addressed migrant healthcare under integration
sections, including in respect of beneficiaries of protection. In
2024, ECRI issued factsheets on
healthcare
racism and
migrant
integration. Moreover, ECRI
General
Policy Recommendation No. 16 (2016) on irregularly-present migrants highlights the
need for access to basic healthcare for this category of migrants
and recommends that measures be put in place (so-called “firewalls”)
which would prevent state and private sector actors from
de facto excluding these persons
from access to healthcare through regulations or policies requiring
the sharing of personal data or other information with the immigration
authorities for the purposes of control and enforcement. (paragraphs 11-15,
21-24).
19. The
Council
of Europe Development Bank (CEB), also advances, through its social mandate, social cohesion
and support for vulnerable groups, including migrants and refugees,
by strengthening health-system resilience and equal access. In 2024-2025,
it approved €1.1 billion for hospital upgrades and €2.2 billion
for migrants, refugees and displaced persons. The 2015
Migrant
and Refugee Fund (€39 million endowed; €37 million approved) funded,
for instance, €1.15 million to Spain (2018) for equipment and training
in Ceuta and Melilla. For Ukraine, €31 million in grants and loans
included €100 million (2023,
HEAL
project) for mental health and rehabilitation, aiding in particular
internally displaced persons. In Türkiye,
SHIFA built or renovated facilities (65 new, 44 migrant centres),
adding 110 rehabilitation units with equipment.
3 Health
issues and obstacles faced by migrants and refugees in accessing
healthcare
3.1 The
overall situation
20. The obstacles and difficulties
faced by migrants and refugees in accessing healthcare are multifactorial. In
addition to the fact-finding visit to Montenegro, discussed in a
separate chapter of this report, other fact-finding visits organised
by the committee have provided opportunities to highlight these
issues. The series of hearings held during committee meetings has
also made it possible to hear from a range of actors working with migrants.
21. During a
fact-finding
visit to Calais, France, held on 25-26 October 2023, the
ad hoc sub-committee established
for that purpose visited,
inter alia,
the infirmary at the Coquelles administrative detention centre and,
on the basis of information received from NGOs, was apprised of
hunger strikes, limited access to medical services and serious health
problems, with psychological disorders often downplayed by the authorities.
The report issued following the visit also underlined that “[a]ccess
to healthcare is deficient too, fortunately partly compensated by
mobile infirmaries and clinics ensured by NGOs, either mandated
or not, but not in a sufficient proportion. There are specialised
departments in hospitals for access to healthcare dedicated to migrants, asylum
seekers and refugees in Calais and Dunkirk hospitals, but they are
most of the time not known by them. Due to the described policy
of negligence and harassment, it is moreover difficult to reach
the individuals in need and for them to reach hospitals considering
the long distance from their living places. The delegation was told
by NGOs that volunteers often use their own vehicles to transport
patients to hospital.”
22. During the
fact-finding
visit to Sicily, Italy, held on 16-18 September 2024, the
ad hoc sub-committee established
for that purpose was informed by the local authorities that the
most common health issues included hypothermia in winter, dehydration
and heatstroke in summer, diabetes, burns, and inhalation of toxic
fumes from boats’ engines. Within the reception system, the delegation
observed the initial medical assistance provided to migrants after
disembarkation at the port of Lampedusa. Once this first care is
administered, migrants are transported by bus to the Lampedusa hotspot,
where a dedicated health centre continues to provide medical support.
Hotspots are governmental centres set up at places of disembarkation
to provide information on how to apply for international protection.
23. During her fact-finding visit to the United Kingdom, held
on 24-26 March 2025 in the context of the preparation of her
report on “The challenges and needs of public and private actors
involved in migration management”, our current committee chairperson
Ms Sandra Zampa (Italy, SOC) visited Manston Asylum Processing Centre,
which follows first-arrival processing at Dover’s Western Jet Foil
processing centre. She explained that “[i]n this centre, the migrants
go through a biometric room, which is managed by staff from the Home
Office. The following phases with interviewers questioning the migrants
about their crossing, intentions etc. are however sub-contracted
to a private company. Similarly, the medication units are also sub-contracted to
the private sector and are in charge of the assessment of health
issues, diagnoses, and treatment.”
24. In addition to these various fact-finding visits, I held several
exchanges of views and hearings, which gave me the opportunity to
complement the overview of migrants and refugees’ health conditions
and their access to healthcare services in Europe.
25. At a committee hearing held on 11 March 2026, Mr Yves-Laurent
Jackson, doctor and professor at Geneva University Hospitals and
the Faculty of Medicine of the University of Geneva, examined migrants’
and refugees’ access to healthcare, stressing that effective provision
depends on both demand-side and supply-side dynamics. On the demand
side, migrants’ health-seeking behaviour is influenced by age, health
status and priorities such as housing and security. Fear, mistrust,
administrative obstacles and distance frequently discourage engagement
with healthcare systems, while NGOs and community initiatives often
fill these gaps. On the supply side, and drawing on the World Health
Organization’s health-systems framework, Mr Jackson emphasised the
need for trained, culturally competent staff and comprehensive services
extending beyond emergency care. Coherent policy frameworks, sustainable
funding and reliable information systems are critical, especially
for mobile populations requiring continuity of medical records.
26. He warned that fragmented services exacerbate chronic illness
and mental health problems, leading migrants to rely on costly emergency
departments. Inequalities in access harm both migrants and host communities,
as seen during the COVID-19 pandemic. Addressing broader social
determinants, including housing, employment and the environment,
is essential to improve health outcomes, given migrants’ disproportionate
exposure to risk.
27. Mr Jackson cited evidence showing that inclusion in national
health-insurance schemes, the use of interpreters and cultural mediators,
and integration with social-support programmes all improve health outcomes.
Health systems should bring care closer to affected communities
through local partnerships with NGOs. He highlighted the positive
impact of legal regularisation and the protection of personal data,
and rejected the notion that healthcare availability acts as a migratory
“pull factor”.
28. In conclusion, Mr Jackson identified four priorities: integrated
migrant health policies generate financial and public health benefits
without creating migration incentives; social conditions must be
addressed alongside medical care; sustainable funding frameworks
underpin equity; and trust between healthcare providers and migrant
communities is fundamental.
29. During an exchange of views held by the committee on 20 October
2025, Ms Sally Hargreaves, Professor of Clinical Public Health,
City St George’s, University of London, and Ms Inka Weissbecker,
expert on Mental Health, Brain Health and Substance Use at the World
Health Organization, underlined that migrants’ and refugees’ access
to healthcare must be understood as a broad public-health and human-rights
issue, with particular attention to infectious disease, chronic
illness and mental health needs, as well as the barriers that prevent
timely access to care. Both experts stressed that formal entitlement
alone is insufficient unless accompanied by inclusive systems, effective
outreach, culturally and linguistically appropriate services and stronger
data collection.
30. Ms Hargreaves presented migrant health as dynamic rather than
static. She noted that some datasets show a “healthy migrant effect”
overall, but that this should not obscure the higher mortality and
disease burden observed for certain conditions, particularly infectious
diseases, nor the fact that migrants are overrepresented in some
European infectious-disease datasets. She also pointed to delayed
diagnosis, including for HIV, and argued that such delays undermine
disease-control objectives and reveal the need for more proactive
and inclusive healthcare delivery.
31. She further emphasised that migrants may be under-immunised,
especially where health and vaccination systems have failed in countries
of origin, and that exclusion from services on arrival can worsen these
gaps. In addition, she warned that health often deteriorates over
time after settlement, citing evidence of worsening outcomes in
areas such as diabetes and cardiovascular disease.
32. Ms Hargreaves also highlighted the impact of employment conditions,
noting that migrants, refugees and asylum seekers are often concentrated
in “dirty, degrading and dangerous” work and face greater risks
of occupational injury and exploitation, with consequences for both
physical and mental health. She grouped the barriers to healthcare
into legal and policy barriers, structural and economic barriers,
and personal barriers, including lack of knowledge of rights, fear
of approaching services, language and health-literacy obstacles, stigma
and distrust.
33. Her recommendations were clear: Europe should move towards
a universal healthcare framework for migrants, guarantee fuller
access to mainstream services, maintain safety nets for undocumented
persons, invest in preventive care, develop migrant-inclusive service
models, work with community organisations, improve public health
messaging, engage employers, strengthen workforce competencies and
improve data collection across Europe.
34. Ms Weissbecker focused on mental health, stressing that refugees
and migrants are exposed not only to traumatic events before and
during displacement, but also to discrimination, exclusion and other
stressors in the receiving country, which can be equally damaging.
She distinguished normal distress from mental disorder, while noting
that refugees and migrants nonetheless show higher prevalence of
depression, anxiety and post-traumatic stress disorder than host
populations.
35. She explained that access to mental healthcare is necessary
not only because it is a human right, but also because untreated
conditions impair everyday functioning, worsen physical health,
hinder integration, affect families and communities, and generate
avoidable social and economic costs. She also stressed the significant
return on investment from treating common mental health conditions.
36. Among the main barriers she identified were poor understanding
of mental illness, stigma, lack of information, cost, confidentiality
concerns, language obstacles, underfunded interpretation, weak referral pathways,
shortages of specialists, long waiting times, limited community-based
services and insufficient cultural competence among providers. She
therefore recommended moving beyond specialist-centred models by
training non-specialists and community workers, integrating mental
health support into community settings such as schools and asylum
centres, ensuring financial coverage regardless of legal status,
building referral networks, expanding outreach in relevant languages,
collecting disaggregated data and improving continuity of care through
better communication and portable health information.
37. During an exchange of views held by the committee on 8 December
2025, Ms Amira Yahiaoui, a clinical psychologist and doctoral graduate
of Paris Cité University, presented the mental health challenges
observed in France’s administrative detention centres (CRAs), as
well as the psychological vulnerability of exiled women and their
children, drawing on ethnographic research conducted in eleven French
detention centres between May 2021 and July 2022.
38. Ms Yahiaoui detailed systemic shortcomings in healthcare provision
within CRAs. Although each centre includes a medical unit with general
practitioners and limited nursing staff, psychiatric and addiction
services remain gravely insufficient despite the prevalence of such
disorders among detainees. Psychological support is often restricted
to part-time interventions. Structural deficiencies, understaffing
and lack of interpreters compound the distress of detainees, many
of whom experience severe psychiatric symptoms, and exhibit violent
behaviour and/or self-harm. Ms Yahiaoui emphasised that these reactions
are not only expressions of individual suffering but manifestations
of institutional neglect. The coercive environment, uncertainty
of deportation and social isolation aggravate pre-existing trauma
and impede communication, creating a space where violence and despair
replace words.
39. She also underlined the economic and human inefficiency of
detention, noting that it cost the French State €265 million in
2024 while more than half of detainees were released without deportation.
The cyclical nature of detention and re-entry into France perpetuates
psychological deterioration rather than public security.
40. In conclusion, Ms Yahiaoui called for a shift from treating
these issues solely as psychiatric problems to addressing their
political and structural roots, namely social precarity, segregation
and the lack of legal and institutional protection, without which
genuine mental health recovery cannot be achieved.
3.2 The
economic perspective
41. From an economic perspective,
Mr Jackson underlined that migrants often delay seeking medical
care for a range of reasons until their condition is perceived as
urgent or severely limiting. As a result, emergency departments
frequently become the first point of entry into the healthcare system,
with a significant proportion of consultation and hospitalisation
costs potentially avoidable if earlier contact with health providers
had been facilitated. Care delivered in emergency settings is both
more costly, for healthcare systems and individuals, and less efficient
than primary care in addressing health needs comprehensively. This
includes the provision of preventive services that reduce the likelihood
of future consultations. The limitations are even more pronounced
in cases involving multiple health needs, as emergency-based systems
are not designed to ensure continuity of care, thereby constraining
the effective management of chronic conditions and increasing the
risk of further avoidable consultations.
42. Mr Jackson referred to studies conducted in Germany and Switzerland
demonstrating that inclusive policies can substantially reduce per
capita healthcare costs by shifting care towards prevention and
primary services. The Geneva regularisation pilot resulted in higher
insurance coverage, improved mental health outcomes, and reduced
reliance on emergency care. He also described an integrated, publicly
funded health unit in Geneva that serves vulnerable groups through
multidisciplinary teams and task-sharing, thereby ensuring comprehensive
and equitable service provision. Overall, the most cost-effective
healthcare systems are those that prioritise facilitated and universal
access to primary care, complemented by emergency services reserved
for severe and unavoidable situations.
43. From the same economic perspective, primary healthcare services
in Türkiye are funded by the Ministry of Health through general
budget allocations. Secondary and tertiary services, including those
delivered by university and private hospitals following appropriate
referral, as well as 112 Emergency Healthcare Services, are financed
by the Presidency of Migration Management in accordance with the
annually renewed “Global Budget Protocol”. The Presidency also covers
the costs of outpatient medicines and medical supplies, such as orthoses
and prostheses. In practice, the public sector bears the healthcare
and medication costs for individuals under temporary protection
and for victims of human trafficking, while health insurance for
foreign nationals holding a work permit is covered by their employer.
3.3 Women,
girls and unaccompanied children, a particularly vulnerable migrant
population
44. Women and girls – who comprise
roughly half of all migrants – are particularly at risk,
Note as are unaccompanied minors. Migrant
women are disproportionately affected by trafficking and sexual
violence, including rape. During migration, they frequently face
complications in childbirth, unwanted pregnancies and anaemia. Both
women and unaccompanied children encounter major barriers to accessing
diagnosis, treatment, prevention, counselling and medication. Migrants
with disabilities also constitute a particularly vulnerable group
requiring targeted attention.
45. With regard to migrant and asylum-seeking women and girls,
the findings of the Group of Experts on Action against Violence
against Women and Domestic Violence (GREVIO) highlight persistent
barriers to healthcare access. These women and girls are often disproportionately
affected by intersectional discrimination. Across its baseline evaluation
reports, GREVIO has noted insufficient attention to the compounded
risks faced by such women and girls, including inadequate awareness
of rights and lack of accessible information in languages they understand.
The
mid‑term
Horizontal Review of 17 baseline evaluation reports identified recurring
shortcomings. GREVIO has expressed concern over the absence of systematic
vulnerability screening on arrival in countries such as Italy, Malta
and Spain, which has led to inappropriate accommodation for women
and girls with specific protection needs. It urged States to introduce systematic
screening procedures to identify vulnerabilities and ensure appropriate
placement.
46. The reports further emphasise the failure to guarantee access
to, and information on, specialist support services, which are essential
for victims of gender-based violence to disclose abuse and obtain
psychological, medical and trauma-related assistance. Similarly,
GREVIO has observed that in Finland, the Netherlands, Serbia and
Sweden, support services remain insufficiently tailored to the needs
of vulnerable groups, including migrant women and girls, who face
cultural and linguistic barriers. GREVIO has also underlined a lack
of standardised national protocols for identifying and responding
to female genital mutilation and other forms of violence, noting
significant disparities in healthcare responses across countries
such as France, Finland, Malta, Serbia and Spain. The absence of
uniform procedures has resulted in inconsistent quality of care. Finally,
GREVIO has found widespread inadequacies in the training of healthcare
professionals. It has called on States, including Albania, Austria,
Belgium, France, Italy and Malta, among others, to introduce compulsory training
aligned with the Istanbul Convention to improve the identification,
treatment and support of victims of female genital mutilation and
sexual violence.
47. With regard to unaccompanied migrant children, and as emphasised
by the Council of Europe’s Steering Committee for Human Rights,
Note when considering family-based placements,
it is important to recognise that unaccompanied and separated children
have particular needs and circumstances.
48. The Council of Europe’s
Lanzarote
Committee has also highlighted the Organisation’s sustained efforts to
strengthen international protection for migrant and refugee children
through legal standards, monitoring and co-operative initiatives.
Its urgent monitoring rounds on protecting children affected by
the refugee crisis from sexual exploitation and abuse culminated
in key reports, a declaration in 2018 and practical tools, including
a handbook supporting practitioners across crisis contexts. Under
the Strategy for the Rights of the Child (2022–2027), the Steering
Committee for the Rights of the Child has advanced implementation
of recommendations on guardianship and age assessment, stressing
the need to strengthen national frameworks. The Committee has also
developed co-operation projects in Ukraine, the Republic of Moldova
and Armenia, which enhance child protection systems during and after
crises.
49. During the above-mentioned exchange of views held by the committee
on 8 December 2025, the psychologist Amira Yahiaoui described the
extreme poverty, gender-based violence and social marginalisation faced
by migrant mothers, which severely harms their own and their children’s
mental health. She additionally noted increased risks of developmental
and psychiatric disorders among children living in deprivation.
3.4 Externalisation
and return hubs
50. Since the mid-2010s, European
Union and several member States have progressively outsourced border
control and asylum responsibilities to states along African and
Mediterranean routes (for example Niger, Libya, Tunisia and Morocco),
combining funding, training and equipment for migration control
with efforts to block departures and facilitate returns. Such policies
are widely documented as worsening barriers to healthcare and creating
avoidable public-health risks for migrants and refugees.
Note
51. In a
report entitled “Externalised asylum and migration policies
and human rights law”, issued in September 2025, the Council of
Europe’s Human Rights Commissioner, Michael O’Flaherty, highlights
that externalised asylum arrangements frequently jeopardise migrants’
and refugees’ access to healthcare and other core rights by shifting
responsibility away from Council of Europe member States to countries
where protection and reception systems are weaker. Legal standards
such as the principle of
non-refoulement,
the right to life, freedom from torture and the right to an effective
remedy under the European Convention and United Nations treaties
require that States do not transfer people to places where they
face real risks of serious harm, including through denial of medical
care or deterioration in physical and mental health.
52. Practical barriers include the use of “safe third country”
or external-processing schemes (for example the former United Kingdom-Rwanda
and current Italy-Albania models), which may leave asylum seekers
stranded in overcrowded, under-resourced facilities with limited
or inadequate access to healthcare and prolonged uncertainty as
to their status. The report stresses that assessments of such transfers
must cover not only formal legal guarantees but also real-world
conditions, such as whether healthcare services, livelihoods and protection
for vulnerable groups are available and sustained over time.
53. Safeguards recommended in the report include rigorous, individualised
risk assessments before any transfer; clear legal bases and enforceable
rights to challenge transfer decisions with suspensive effect; and continuous
monitoring of conditions in host countries, including healthcare
and protection standards, to prevent refoulement and onward displacement.
Member States are urged to ensure that externalised schemes do not rely
heavily on detention, do not target children or other vulnerable
persons, and are accompanied by robust transparency, independent
monitoring and accountability mechanisms to protect migrants’ and
refugees’ access to healthcare and other rights.
54. The Assembly’s General Rapporteur on European migration and
asylum policies, Lord Michael German, has recently called for similar
safeguards.
Note He stressed the need for appeals
against expulsion orders to have suspensive effect, warning that
expelling a person before their appeal has been decided could expose
them to serious and irreversible harm and undermine the rule of
law. He also recalled that the detention of migrant children is
never in their best interest, and urged EU stakeholders to enshrine
that principle in future legislation.
55. The only offshore “return hub” is currently the one operated
by Italy in Gjader, Albania. The Lazio Detention Ombudsperson visited
the centre last year and found potential risks for healthcare.
Note ASGI, a well-known legal studies
NGO, found an extremely worrying picture of detainees’ physical
and mental conditions in the centre, with many cases of severe psychological
distress, self-harm and several suicide attempts.
Note The report
criticises migrants’ and refugees’ access to healthcare in Albania’s
Gjader pre-removal detention centre under the Italy-Albania Protocol,
focusing on irregular migrants detained pre-removal. EU standards
in Return Directive 2008/115/EC (Articles 15(2) and 16(3)) mandate
timely and adequate essential medical care, contact rights and immediate
release where detention is unlawful. Practical barriers include
the absence of access to Italy’s National Health System, which deprives
detainees of specialist treatment, ongoing therapies, addiction services
and mental healthcare. Albania’s healthcare system has structural
shortcomings and is unable to match EU and Italian standards; Gjader’s
remote location, with no nearby hospitals, further delays emergency care.
Monitoring has revealed severe psychological distress, self-harm,
suicide attempts and overuse of psychotropic drugs, worsening vulnerabilities
without proper support. Safeguards are therefore insufficient, as these
facilities, under Italian jurisdiction on Albanian territory, cannot
meet complex health needs. Moreover, co-operation with Albanian
stakeholders, particularly hospitals, is inadequate when hospitalisation
is required, thereby compromising health rights and human dignity.
56. More broadly, concerning the Return Regulation, newly adopted
by the European Parliament,
Note notable voices have raised alarms
about its impact on healthcare. Beyond the health consequences of
the expanded use of detention and forced deportations, the main
new risks arise, first, from new measures to “detect” irregular
migrants, which could oblige healthcare professionals to report
them to the authorities (Article 6); and, secondly, from a new provision
allowing the transfer of migrants’ health data to third countries
for the purpose of deportation (Article 41). The proposed changes
have been heavily criticised by Commissioner O’Flaherty,
Note by a joint letter of sixteen United
Nations Special Rapporteurs and by more than 250 non-governmental organisations.
Note
57. Some elements of the EU Pact on Migration and Asylum may have
moreover questionable implications for migrants’ access to healthcare.
While the Pact includes certain health-related provisions, several
risk limiting effective access to care in practice. Under the Screening
Regulation, the mandatory health check is narrowly framed as part
of identifying vulnerabilities and determining measures needed during
the screening process. It does not establish a broader right to
healthcare, nor does it guarantee follow-up treatment for conditions
identified at that stage. Moreover, the requirement for individuals
to remain at designated locations during screening may result in
de facto detention-like conditions,
where access to medical care is often limited, particularly with
regard to mental health and specialised services.
Note The Reception Conditions Directive
also leaves significant discretion to Member States, requiring only
“necessary health care, including at least emergency care and essential
treatment of illnesses”.
Note This formulation may permit restrictive
interpretations that exclude specialist, rehabilitative, or psychosocial
care. Taken together, these provisions create a risk that healthcare
remains formally guaranteed but substantively inaccessible, especially
for applicants with chronic illnesses, trauma-related conditions,
or mental health needs.
58. In the above-mentioned 2025 report, Médecins Sans Frontières
concludes that a decade of EU externalisation policies south of
the Mediterranean has had “damaging effects”, including deaths along
trans-Saharan routes and at sea. The organisation calls for urgent
review, suspension, or termination of co-operation agreements that
fail to ensure due diligence and the protection of rights.
4 Case
study, the fact-finding visit to Montenegro
59. In preparing this report, I
undertook a fact-finding visit to Montenegro, a small yet strategically
significant member State. Montenegro is currently the most advanced
EU candidate country, having entered what the EU Council and Commission
describe as the “final phase” of accession negotiations. All chapters
are open, many provisionally closed, and the EU Council has signalled
its readiness to proceed, subject to reform progress, towards drafting
the Accession Treaty. Montenegro also represents a valuable case
study as a key transit country on the Western Balkans migration
route. Migrants regularly pass through its territory, primarily
arriving from neighbouring Albania, Kosovo*
Note,
and Serbia.
60. The visit, conducted from 4 to 7 March 2026, formed part of
broader efforts to assess migrants’ and refugees’ access to healthcare
in Council of Europe member States. The programme combined meetings
with national authorities, including the Ministries of Health and
Interior, parliamentary committees and the Ombudsperson institution,
with visits to reception and border facilities and consultations
with key international and civil society actors such as the IOM,
UNHCR, and the Red Cross. These engagements sought to obtain first-hand
insight into Montenegro’s institutional framework and practices
concerning healthcare and protection for migrants and refugees,
identify challenges and good practices, and inform the committee’s
wider work on equitable access to essential health services for
all persons, regardless of status.
61. Interlocutors explained that most migrants originate from
the Middle East, Afghanistan, Pakistan, Sudan, and other countries
of these regions. This diversity reflects varying backgrounds, cultures,
and religions, all of which must be taken into account in addressing
migrant needs, even though the majority are merely transiting through
Montenegro.
62. Representatives of the Ministry of Health and relevant public-health
departments described the secondary legislation governing migrant
and refugee healthcare. Migrants and asylum seekers benefit, under the
national health insurance law, from basic healthcare protection,
including medical examination and emergency treatment, in accordance
with EU directives. Three levels of protection apply: emergency
care and basic medical support, coverage for essential medicines,
and basic treatments. Persons under international protection, including
their family members, enjoy enhanced coverage, especially women
and children. Rulebooks are in preparation to support implementation
of this legislation, although the Red Cross noted that these instruments
are not yet operational.
63. The Ministry of Interior oversees border monitoring and management.
Migrants are registered upon arrival at crossing points and may
indicate their intention to seek international protection, which
entitles them to remain in a reception centre and travel within
the country. However, many leave after registration, often continuing
their onward journey to unknown destinations.
64. At the Božaj border crossing point, I met border officials
responsible for three crossing points and a 90‑kilometre stretch
of “green and blue” border, including the land area and Shkodra
Lake between Albania and Montenegro. The 167 border officers maintain
security and control, addressing cross-border crime and managing
heavy lorry traffic. Frontex supports their work through personnel
and equipment. The Red Cross reported that most migrants enter Montenegro
through this border, either via the crossing point or the green border.
65. Balancing security and humanitarian considerations, the Ministry
of Interior conducts security checks on arriving migrants, supported
by the Police Administration, the National Security Agency and Frontex.
These checks include biometric data collection, fingerprints and
photographs. Migrants intercepted along the green border are interviewed
to determine whether smugglers were involved, and their belongings
are inspected for weapons, while mobile phones are checked for travel
routes. They may be held for up to six hours, during which they
receive medical assistance at nearby facilities, as none exist directly
at the border.
66. In 2025, approximately 2.76 million vehicles crossed the Božaj
point – up to 20,000 daily during the summer months. That same year,
338 migrants were intercepted at the crossing, although many more
are believed to have entered undetected via the green border. The
figures have remained stable in recent years. Most migrants cross
through green areas in groups, assisted by smuggling networks operating
from abroad, avoiding official checkpoints and only rarely hiding
in lorries.
67. The Ministry of Interior also manages the two existing reception
centres in Montenegro – Spuž and Božaj – which accommodate 104 and
60 persons respectively. At Spuž, a medical unit staffed by two
nurses and a visiting doctor, who attends twice weekly, operates
with the support of the Red Cross and provides part-time psychological
assistance. A triage system has been adopted, and agreements with
local clinics and hospitals allow for referrals, including psychiatric
treatment at Kotor hospital.
68. Border officials noted that intercepted migrants frequently
suffer from dehydration, exhaustion, and minor injuries. The Red
Cross observed small wounds and chronic diseases and, on occasion,
viral infections.
69. Co-ordination on healthcare access is facilitated by the Ministries
of Health and Interior and by the Red Cross. Both reception centres
have medical units, although staffing is limited. Costs are borne
by the State budget. UNHCR and the Red Cross help to overcome linguistic
barriers, including through online interpretation services in Arabic,
French, Spanish, and Ukrainian.
70. Registration of migrant populations has recently begun, yet
challenges persist in planning and financing because of inadequate
data and limited public funding. Staffing shortages are critical:
physicians are increasingly leaving public service for better-paid
employment in the private sector, and nursing shortages were underlined
by the Red Cross. Government measures to address these issues have
not yet proved sufficient.
71. Consequently, systematic medical examinations are not available
for all migrants entering reception centres. Interlocutors called
for incentives to retain healthcare professionals in the public
sector, exchange programmes to learn from effective practices abroad,
and better equipment. Meanwhile, international organisations, notably
the Red Cross, help fill gaps in services, although medical teams
are not legally secured, as observed by UNHCR.
72. Where possible, doctors and nurses collect information on
migrants’ medical history. Residents of reception centres receive
initial medical screening to identify disease and contagion risks.
Representatives of IOM highlighted that this assistance applies
only to those admitted to centres; migrants merely transiting through
Montenegro, or unregistered at the border, do not benefit from medical
services and are often unaware of their rights to access care.
73. Accessibility and timeliness of healthcare remain challenging,
as they do for Montenegrin citizens. However, ad hoc solutions –
such as hospital referrals through co-ordination with the Ombudsperson
institution or the Red Cross – help mitigate problems, as confirmed
by UNHCR. Special attention is required for vulnerable groups, notably
women, girls and unaccompanied children. The Ombudsman reported
cases of minors entering Montenegro without official registration.
74. The absence of systematic registration also undermines vaccination
coverage, posing potential risks to public health and complicating
vaccine procurement and immunisation planning. Interlocutors further
identified the high cost and limited availability of medicines.
The Red Cross partly covers these expenses, funding approximately
30 essential medicines, although donor restrictions prevent the
purchase of many others required by migrants.
75. Access to mental healthcare and psychiatric support remains
limited. The authorities have established contracts with private
providers when public services are overstretched. These constraints
also affect Montenegrin citizens. At the Spuž Centre, the psychologist
– present part-time – interviews residents mainly upon request.
She reported frequent stress, trauma and depression, and her assessments
help to identify victims of trafficking and survivors of violence,
especially women, girls and unaccompanied children. However, most
migrants do not remain long enough to receive sustained psychological
assistance.
76. The Parliamentary Committee on Security and Defence oversees
border management and the prevention of migration-related crime,
including human trafficking. The Ombudsperson institution also plays
a key role in monitoring migrant and refugee conditions, reporting
no major human rights violations. It co-operates closely with national
and international bodies, especially UNHCR, conducting visits to
reception centres and border areas. The Ombudsperson noted occasional
tensions with local communities, mitigated by patrols in affected
zones.
77. In conclusion, Montenegro has made commendable efforts to
address migrants’ transit and healthcare needs with humanity. Nevertheless,
improvements are needed to enhance co-ordination among institutions and
ensure reliable data collection on migrant flows and residence –
essential for both domestic authorities and international partners.
Strengthening legal certainty through stable national migration
legislation would reinforce this progress, supported by the forthcoming
national migration strategy mentioned by the Red Cross. As Montenegro
approaches EU accession and may shift from transit to destination
country, interlocutors emphasised the need for a stronger legal
framework, inclusive health coverage, sustainable funding, equipment,
human resources – especially in the context of demographic ageing
– training, medical units, interpretation services and access to
medicines. The exchange of good practices among member States will be
invaluable in this regard. Harmonisation of age-assessment procedures
for unaccompanied children remains crucial, consistent with
Recommendation
CM/Rec(2022)22 of the Committee of Ministers to member States on human
rights principles and guidelines on age assessment in the context
of migration.
5 Good
practices and responses to ensure human-rights compliant healthcare
for migrants and refugees
78. The committee’s fact-finding
visits, as well as the visit I conducted to Montenegro, demonstrated
that simple and low-cost solutions exist to ease migrants’ and refugees’
access to healthcare. The hearings organised with the committee’s
support also promoted pragmatic solutions, and at times more ambitious
ones, to facilitate such access to healthcare services for migrants
and refugees.
79. In parallel, I gathered background information on international,
European, and domestic laws and practices in selected member States,
notably through a consultation launched via the European Centre
for Parliamentary Research and Documentation (ECPRD).
80. Thirty-four member States responded to the consultation. The
exercise revealed a variety of measures adopted to improve migrants’,
refugees’, and asylum seekers’ access to healthcare, particularly
in relation to legal and policy guarantees, co-ordination and governance,
service delivery in reception facilities, health screening and mental‑health
support, financing and insurance arrangements, as well as language,
cultural support and information policies.
81. As regards legal and policy guarantees, most responding States
have constitutional or legislative provisions ensuring the right
to health and non‑discriminatory access to healthcare regardless
of nationality or migration status.
Note Several countries extend specific entitlements
to beneficiaries of international protection, often aligning them
with nationals regarding access to the public health system.
Note Other
States provide universal‑style coverage that includes foreigners
in a regular situation, refugees, asylum seekers and stateless persons,
as in Spain’s “universal health system”.
Note In addition,
many countries guarantee at least emergency and essential healthcare
for persons without legal residence, including hospital care and,
in some cases, full coverage within public‑tariff limits after a
short period of residence, as under France’s State Medical Aid scheme.
82. With regard to the rights of vulnerable groups, several States
have adopted age‑specific and gender‑specific provisions. For example,
Norway grants all children under the age of eighteen and women without
legal residence access to essential healthcare and pregnancy‑related
services, including pre‑ and postnatal care and abortion. France
likewise provides free prenatal and child‑health follow‑up through
the maternal and child health protection system (PMI). In several
responding countries, children and unaccompanied minors, regardless
of their status, are explicitly entitled to basic healthcare services.
Note
83. In terms of governance and co-ordination, responsibility for
migrants’ and refugees’ access to healthcare is organised in various
ways, ranging from centralised models
Note to
multi‑level systems involving national, regional, and local authorities.
Note In some
States, the national health ministry defines the overall framework, while
migration‑focused agencies co-ordinate medical assistance for asylum
seekers and related contracting.
Note Other
countries operate a multi‑tiered structure, with municipalities
delivering primary care, regional authorities managing specialist
services, and dedicated immigration bodies identifying new arrivals
at reception centres and facilitating their access to healthcare.
In Georgia, for example, the Ministry of Internally Displaced Persons,
Labour, Health and Social Affairs sets policy, supported by an Integration
Centre and local health departments.
84. With regard to services available in reception and accommodation
facilities, most responding States reported that healthcare services
can be provided within reception centres,
Note often
through direct contracts or agreements with the public health system.
Note Where necessary,
patients are referred to higher‑level facilities, for instance,
in Slovakia, public hospitals are used when care provided within
centres is insufficient. Slovenia and Montenegro operate dedicated
health centres or on‑site medical services, with transport and referrals arranged
through the accommodation infrastructure. In Montenegro, primary
care is available directly within reception centres and at a border
crossing, staffed by medical professionals from the Directorate
for Reception of Foreigners, with referrals to the Clinical Centre
of Montenegro when required.
85. Concerning health screening and mental-health support, several
States conduct initial medical examinations and infectious‑disease
screenings for newly arrived asylum seekers, typically co-ordinated
by dedicated health or refugee‑health services.
Note However, while most States
report the provision of at least basic healthcare, emergency services,
and disease‑control measures, coverage of mental‑health services
in reception facilities remains uneven, despite some States offering
psychological support
Note or additional assistance
for vulnerable groups.
Note
86. Concerning financing and insurance schemes, healthcare for
migrants and refugees, including women and unaccompanied children,
is predominantly financed through the State budget across the responding countries.
Note Many
States integrate refugees and beneficiaries of subsidiary protection
into the national public health‑insurance system, sometimes after
a probation period or following a short residence requirement.
Note Where
they are not employed, individuals may pay reduced contributions
while the State continues to cover costs for vulnerable groups.
Children and unaccompanied minors are generally fully covered from
the outset, regardless of status, and are frequently supplemented
by humanitarian and civil society organisations that provide free
or low‑cost care and psychosocial support.
87. With regard to language, cultural support and information
policies, several member States provide interpretation or translation
assistance in healthcare facilities,
Note such
as telephone interpretation in Spain and Switzerland, NGO‑delivered
services in Albania, Bosnia and Herzegovina and Slovenia, and in‑person
or remote interpretation in Montenegro. In some countries, however,
no formal interpretation services exist, although multilingual information
materials and counselling may be offered.
Note In
other States, such as Lithuania, interpreters charge fees, which
may create a barrier to access. Several countries train healthcare providers
on services available to beneficiaries of temporary protection or
on cultural competence and trauma‑informed care, including through
IRCC‑funded initiatives in Canada. In Türkiye, Syrian doctors have been
employed in Migrant Health Centres, which has supported the employment
of Syrian doctors and enabled patients to receive care in their
native language. In addition, under the EU‑funded SIHHAT project,
Note sworn interpreters have been employed
in hospitals located in regions where persons under protection are concentrated.
88. Information on healthcare rights is systematically disseminated
to migrants and refugees on arrival,
Note through brochures,
official websites, posters and information sheets in multiple languages.
Countries such as Canada and Montenegro also provide practical guidance
on accessing federal or local health and social programmes, including
airport reception, temporary accommodation, needs assessment and
onward referrals. In Türkiye, emergency and information services
are available in five languages through the central 157 YIMER hotline
(Communication Centre for Foreigners). Despite these measures, full
implementation, particularly in cultural mediation and staffing,
remains an ongoing challenge in several States.
89. Spain decided in March 2026
Note to introduce a measure to recognise
the right of foreign nationals without legal residence in the country
to receive medical care, presenting healthcare as an inherently
universal human right. This followed the regularisation of 500,000
migrants in the preceding months. The regulation is designed to
recognise a number of vulnerable groups who will henceforth be entitled
to receive immediate care, regardless of their administrative status
in Spain, including unaccompanied children, pregnant women, victims of
gender-based violence, victims of exploitation and trafficking,
and applicants for international protection or stateless status.
6 Conclusion
90. Migrants and refugees encounter
persistent barriers to healthcare arising from administrative complexity,
legal status, limited system capacity and language and cultural
differences. Effective responses combine professional interpretation,
culturally responsive care and stronger service integration. Evidence shows
that restricted access stems less from migrants’ behaviour than
from systemic obstacles created by laws, administrative procedures
and fees. This is especially true for undocumented migrants, whose
lower use of services reflects administrative and legal impediments
rather than lack of need.
91. Communication is central: interpreters, translated materials
and cultural mediation are vital, yet insufficient if health systems
remain understaffed or culturally insensitive. Clinicians often
adapt by simplifying care or relying on informal support when strict
compliance may harm patients. Primary care improves migrant health
when staff capacity, communication and service integration are strengthened.
Migrants’ access to healthcare, including to mental healthcare,
must be seen as a measure of health‑system quality, not merely a minority‑health
issue. Persistent challenges include language barriers, cultural
misunderstanding, and legal or financial exclusion; key remedies
are the use of interpreters, professional training and integrated
primary care.
92. Ensuring equal access to healthcare is both a human rights
obligation and a public-health necessity, as denial or delay may
endanger the wider population. Access to adequate nutrition, housing,
and preventive and curative treatment remains essential to improving
migrant and refugee health across Europe.
93. The Assembly must continue addressing these issues, recognising
that health care in the context of migration is integral to achieving
the United Nations’ Sustainable Development Goals, including universal health
coverage and effective management of health emergencies. Health,
as a fundamental right under international law, requires a social,
holistic, regionally grounded, and risk‑group‑oriented approach.
94. In line with
Resolution 2627 (2025) “Promoting universal health coverage”, the recommended
strategy calls for a Europe‑wide shift towards universal frameworks
ensuring full access to mainstream services, maintaining safety
nets for undocumented persons, investing in preventive care, and
engaging communities through inclusive service models, public-health
messaging, and data collection.
95. Experts further underline that inclusion in national health-insurance
schemes, the use of interpreters and cultural mediators, and integration
with social-support programmes enhance outcomes, while legal regularisation
and data protection promote trust. Integrated migrant-health policies
improve public health and financial sustainability; social determinants,
including housing, employment and the environment, must be tackled
alongside medical care; and the qualifications of migrant health
professionals should be swiftly recognised.
96. Member States are furthermore encouraged to consider bringing
more projects forward for loans from the Council of Europe Development
Bank, to strengthen healthcare infrastructure, equipment, and staffing
in reception and detention centres.
97. Finally, as regards age assessment for unaccompanied children,
attention is drawn to
Recommendation CM/Rec(2022)22 of the Committee of Ministers to member States on human
rights principles and guidelines on age assessment in the context
of migration, which member States should implement through appropriate legal
and practical measures.
