Mighealthnet State of the Art Report - Switzerland

Mighealthnet State of the Art report - Switzerland

Milena Chimienti

1. Background information on migrant and minority populations, immigration and integration policies, etc

Definition

People who live in Switzerland but had a “foreigner” citizenship when they were born are considered as having a migrant background, whether they were born in Switzerland or abroad (Switzerland following the ‘Jus sanguinis’ policy). This term regroups both people from first or second generation and people who were granted Swiss citizenship. The term ‘foreigner’ regroups those who have a foreign passport.

Swiss Migration Policy

Switzerland already had, at the beginning of the 20th century, one of the highest rates of immigration, along with Luxembourg, counting in 1913 - before the First World War – 609,000 foreigners as approximately 14.6% of the total population (see Piguet 2005).

The Swiss population and the government did not acknowledge this fact. The Swiss migration policy, at the beginning of the 20th century, was developed under the fear of the social "parasite". Migrants who arrived at that time in wealthy Switzerland, benefiting from the liberal immigration regime of the 1920s were, however, perceived in the public sphere as a risk for social work - primarily social assistance - (Niederberger 2004). These migratory flows coincided with the development of the welfare state. In this respect legal changes (Cattacin 2006) and social assistance at the canton level have been newly defined (Höpflinger and Wyss 1994). The question of inclusion - who may be eligible to claim the new aid - stands at the centre of the migration policy and cast a shadow over it.

A second fear characterises the Swiss policy at that time, i.e. the fear of the political influence of migrants who found refuge from (communist, fascist or Nazi) persecution in Switzerland, as a liberal “island” within Europe (Cerutti 1985). In the face of these "agitators", a political discourse regarding the "Überfremdung" – (“over-foreignization”) (Vuilleumier 1989), together with the issue of social inclusion, have been developed and were at the centre of the first legislation of 1931, namely the federal law on “residency and settlement of foreigners” of the 26th March 1931 (ANAG).

Despite the decrease in Switzerland of the number of migrants because of the aforementioned persecution, the “Überfremdung” legal statute (in force in 1934) has remained effective until recently. During the Fordist years (the period after the Second World War), the migrant population grew rapidly renewing the discourse of fear. Migrants were seen as potential revolutionaries at the time of the Cold War, (Cerutti 1995) and social problem cases.

It was only in the 1990s that the Swiss policy tried to solve the “Überfremdung” perspective. The new post-national constellation since the 1980s, which increased international mobility and flexibility, obliged the government to overcome its ideological or purely utilitarian policy. The Swiss dependence on highly qualified people from abroad, as well as the need for a modern immigration policy, (which was not determined solely by fear), obliged the government to find a new perspective.

Political and economic pressure (of inclusion in the European Economic Arena) led to the development of an integration policy, as is reflected in the new legislation and new programmes (Cattacin and Chimienti 2006):

• The “integration edict” (in the new “Foreigners Act”) promulgated in 2000, invested approximately 12,000,000 Swiss francs in integration projects in Switzerland.
• The “bilateral agreements” with the European Union, which allow the free movement of persons, (transitional phase in force since 1st June 2002 and implemented on 1st June 2007).
• The federal law on “residency and settlement of foreigners” of the 26th March 1931 revised in the new “Foreigners Act” entered into force on 1st January 2008. This revision introduced in the law not only the integration policy, but also the bilateral agreements between Switzerland and the European Union (EU), thus establishing the "two circles" model which distinguishes the liberal European internal migration and migration from outside Europe/EFTA. The migrants from the "second circle" may enter Switzerland only in very specific situations: short term, with a temporary work permit or as highly skilled in order to fulfil the needs of the economic market. Marriage to a Swiss citizen represents a third option. This legal change increased the difficulty of migrating to Switzerland through the selection and distinction between highly skilled and non European migrants.
• The asylum law has also been revised, on 1st January 2007. The revision of the asylum law brings with it three relevant innovations. It will be faster, with automatic rejections of those seeking political asylum who come from countries defined as safe and from those who have been resident in EU or EFTA countries before (following Schengen and Dublin agreements). Secondly, social assistance will no longer be given to those who have been rejected. Thirdly, the procedure of control regarding suspected “fake” marriage will be increased.
• Finally, Schengen and Dublin agreements are in force in Switzerland in November 2008 regarding a co-ordinated fight against crime, also unifying in this way the asylum policies between Europe and Switzerland.

Despite these significant changes in the Swiss migration policy, a coherent approach is still missing as is attested, for example, by the lack of a development policy. However, as already stated by Wicker (Wicker 2003), the direction of the policy is clear: whilst promoting the integration of residents, it simultaneously opens up the borders for high-skilled or European migration and closes the borders for irregular migrants coming from countries outside Europe. In fact, this orientation states a clear rejection of mass migration, focusing on targeted migration. The fact that Switzerland has thus implicitly recognized itself as an immigration country, is probably one of the most important elements of the new policy although it is correlated with the increase of selection among the admission of new migrants (Cattacin et al. 2005; Chimienti 2000).

Policies on migrant health

Access to the health system is guaranteed by the obligation to subscribe to private health insurance. In general, the insurance is open to all residents, asylum seekers included but, in fact, there are different schemes and situations, ranging from a liberal position such as that in Geneva, permitting undocumented migrants to subscribe to an insurance, to other parts of the country in which insurance companies can refuse undocumented migrants and in which a gate keeper model regulates access to health for asylum seekers.

The first specific initiatives regarding migrants’ health were taken in urban contexts in an attempt to give better information to migrants. A strategy whereby information, attempting to explain the main elements of the HIV/Aids prevention strategy to the principal established communities, has been developed since the beginning of the 1990s on a national level. This programme was transformed at the beginning of this century into a programme for 2002-2007 with a wider view (Chimienti et al. 2001; FOPH 2003) although still based on a pragmatic foundation, that many health questions are related to migration and need a specific answer in terms of sensitivity of institutions and particular projects.

The programme tries, in particular, to put forward decentralized initiatives and to create sensitivity in all health institutions regarding the topics of migration and health. A small unit at the Federal Office of Public Health has the function of stimulating initiatives and learning processes on this topic. The orientation is similar to that of subsidiarity in Germany,B but, as in other policy domains, subsidiarity is interpreted as a more dynamic concept, permitting central government to activate civil society organisations, local and regional government to act in a co-ordinated way and to introduce new regulations. These activating state policies can be based on an innovative dynamic in the urban centres of Switzerland, in particular, Geneva.

In 2006-2007, this programme was evaluated (Ledermann et al. 2006) and a new strategy was formulated for the years 2008-2013 (FOPH 2007): “For the most part, the programmes and measures from the first phase will be continued in the second phase. Specific areas of implementation are also to be rooted more effectively at the institutional level and among the migrant population. Consolidating the strategy and making it more firmly established will further secure the investments made in phase I”.

Population with a migrant background in Switzerland

This re-orientation of the migration policy of Switzerland led to changes in the composition of the population. Although the percentage of foreigners has been 20% for years, the composition of this population has changed. On the one hand, the promotion of skilled migration (SECO et al. 2007: 26) is logically characterised by a European migration. The first four migrant groups came in 2006 from Germany (more than 15,000 persons), Poland (more than 6,200), France (more than 2,545) and the United Kingdom (more than 1135). In 2006, an increase of 0.8% of migrants arose in Switzerland, among them more than 80% accounted for by EU internal migration (FOM 2007b).

On the other hand, the number of irregular migrants, which increased with the growing restriction towards asylum-seekers, is difficult to estimate. Several studies agree with an approximate average of 100,000 persons (see Piguet et al. 2002, Federal Office for Immigration 2004; Wanner 2002, Efionayi-Mäder and Cattacin 2002; Longchamp et al. 2005). This mostly concerns people who enter Switzerland directly illegally or through a tourist visa, and less the rejected asylum seekers who overstay and therefore remain illegally. With the new Law, the number of those might, however, increase in the coming years.

In addition to the authorized or unauthorized migration of foreign workers living in Switzerland at the end of 2006, there were 70,000 persons from the field of asylum. More than two thirds of these are asylum-seekers: 25,000 are provisionally admitted, 11,000 are asylum seekers whose application is in the process of examination and 2,500 are rejected asylum-seekers who have not yet been expelled. The remaining third represents 24,000 recognised refugees (FOM 2007a).

Among the temporary admissions, two groups can be distinguished: firstly, those persons whose asylum applications have been rejected because their refugee status does not fulfil the Geneva Convention. They represent the large majority of temporary admissions. A second group concerns the ones whose request meets the Geneva Convention but not the Swiss criteria. These refugees represent 2% of all those with a temporary admission (Kamm et al. 2003: 21). Because of their refugee status, their legal situation differs from others who have been provisionally admitted.

Most of the migrants living in Switzerland have a European background, they therefore encounter no significant problems, whether concerning access to the job market, or regarding social handicaps. Irregular migrants, those with a temporary permit of stay, and asylum seekers, on the other hand represent people who do not have the same rights as the rest of the population. Because of this inequality they are in a situation of vulnerability, both economically and legally-speaking. This population represents about 2-3% of the total population, or 8-12% of all foreigners in Switzerland. Table 1 gives an overview of this repartition.

2. State of health of migrants and minorities

The health of the migrant population in Switzerland has become, especially since the 1990s, a research subject and a source of concern. However, the data sources offering detailed information on this issue are rare (for a state of the art see Chimienti et al. 2001; Weiss 2002; FOPH 2007). In order to fulfil this gap several qualitative and quantitative research projects have been carried out in the framework of the “Migration and Public Health Strategy 2002-2006”, which was adopted by the Federal Council in July 2002. One of the axes of this strategy is the research and monitoring within the field of migration (for the results of these different projects see FOPH 2006). The monitoring of the migrant population’s state of health in Switzerland (GMM) particularly targets populations who are under-represented in statistical sources and large researches (see Gabadinho 2007). This monitoring is based on a total sample of 19,797 persons of ten different backgrounds (Swiss, Italian, German, Austrian, French, Ex-Yugoslavian, Portuguese, Turkish, Sri Lankan and Kosovan). Notably absent are data for people from Asia, Africa and Latin America.

In brief, the different surveys on migrants’ health pointed out the following results :

• Migrants’ mental health is often worse than that of the Swiss.
• Certain groups of migrants encounter a higher prevalence of HIV/Aids, Tuberculosis, Hepatitis, Malaria and Sexually-transmitted diseases than the Swiss.
• Miscarriage, a lack of contraception during intercourse and female genital mutilation are more frequent among migrants than among the Swiss.
• Young migrants have inferior dental health.
• Certain groups of migrants are more likely than the average member of the population to have cancer (stomach cancer of Southern European migrants, rhinopharynx cancer of Chinese and liver cancer of Africans and Asians).
• Certain groups of migrants display a more risky attitude regarding tobacco consumption, their food and lack of exercise.
• Let us now observe these results in detail, highlighting the indicators of variation and the differences among groups.

State of Health – general indicators of variation

(based on Gabadinho 2007: pages 60-64)

Increasing risk for both sexes according to age regarding self-reported health, disability, long-term functional and physical disorders. The situation is more uniform regarding the psychical (stet) balance.

The socio-economic situation also appears as a variable, particularly important with a systematic improvement of health when the social stratification is higher.

The presence of a child under 15 years of age in the household is also associated with a systematic decreasing risk, except for the psychical (stet) balance. This can be linked to several factors, including the effect of selection, since men and women with a child under the age of 15 tend to be relatively young and healthy.

The role of marital status is more diffuse, but the authors note that being married improves the emotional balance for both men and women, while the fact of being separated or divorced has a negative effect on health.

Finally, even when the above factors are taking into account and equalised, nationality remains a significant marker of health status. Among the Italians in Switzerland, only the women present differences as compared with the Swiss, regarding the self-reported health and psychical balance, which is more often poor, as well as more frequent physical disorders.

For citizens and nationals of the former Yugoslavia and more so for those of Turkey, the situation is unfavourable for all indicators in comparison with the Swiss but also with other nationalities. This is also the case for Kosovan asylum-seekers and to a lesser extent, for Tamil. The probability of presenting poor self-reported health and emotional balance also increases for Portuguese women and men in comparison with their Swiss counterparts. However, the profile of female and male Sri Lankans is positive for all indicators and is even better than that of the Swiss, regarding functional disability, long-term physical disorders (men only) and handicaps limiting the exercise of professional or everyday activities (women only). The model taking into account only foreigners shows that the Sri Lankans have a better situation than the ex -Yugoslavs for all of the indicators, while on the contrary, the Turkish women encounter higher systematic risk. In addition, the Kosovan and Tamil asylum-seekers often face a poorer mental balance than the other groups. However, when the Tamil asylum-seekers (female and male) are compared solely to the former Yugoslavian asylum-seekers, rather than to the Swiss, they show a lower percentage of risk concerning all issues.

Several indicators of integration also have an impact on health status. Arriving in Switzerland aged over 14 years old is associated with a worse subjective state of health (for women) and emotional balance (for women and men) than for the Swiss, as well as more frequent physical disorders (women).

Not knowing one of the national languages of Switzerland represents an increased risk, which could also be related to the socio-economic status or the arrival in Switzerland. The victims of political repression or violence in the country of origin, both men and women, encounter worse mental health, whilst those facing discrimination in Switzerland present an increased risk for most indicators.

In brief, nationality remains an important factor in attempting to explain the variation in health status, even after taking account of important variables such as age, socio-economic level, the situation of life or region of residence. The authors ‘highlight the fact that the information used in this research report is from declarations of respondents themselves, possible variations in cultural perception of the symptoms and the disease cannot be excluded. However, many studies have shown that the condition of self-rated health is a reliable indicator for morbidity or mortality risk.

Subjective health