Regulation Policies of Access to Healthcare by Undocumented Immigrants in Spain (PRASINIE)

Reference: CSO2013-44717-R

Funding agency: Spanish Ministry of Economy and Competitiveness, National Programme for Research Oriented to the Challenges of Society (National R+D+ I Plan 2014).

Beginning date of the project:  30-10-2014

End date of the project: 31-12-2017

Tabs group


The implementation of reforms in decentralized healthcare systems raises a number of particularly complex challenges, especially when those reforms refer to the definition of eligibility criteria of those systems. Since the General Health Law (LGS) was passed in 1986, and until the entry into force of the General Public Health Act (33/ 2011) in January 2012, the Spanish National Health System (SNS) experienced a gradual expansion of its range of coverage, to include almost all of the resident population of Spain. The approval of the RD 16/2012 in April 2012 constituted a turning point in that process, by dictate the withdrawal of medical cards for undocumented immigrants older than 18 (with the exception of pregnant women, those affected by infectious diseases, as well as those in need of emergency care). The current context of economic and fiscal crisis facilitated the adoption of a series of reforms in the healthcare sector in Spain, among which we can include the RD 16/2012, passed by the central government, and which should limit the range of coverage of the 17 Regional Healthcare Services (SRS). The complex articulation of the multilevel structure that characterizes the Spanish State meant, however, an extremely uneven application of this measure: explicitly ignored by some, partly implemented by others, literally applied by a third group of regional governments.

This project, framed within the discussions on the complexity of the multi-level governance structures, aims at explaining the factors that account for the different positions taken by regional governments in relation to this legislation. Among the hypotheses to be tested are the role of “path dependencies”, the relevance of the ideology of the party in power (in particular when there are differences between the parties in power in the different levels of government), and the impact of public opinion about the welfare rights of immigrant populations (“deservingness”). Beyond the position taken by regional health authorities, the implementation of this rule seems to have resulted in a widening of the margins of bureaucratic- administrative discretion. Available information reveals a wide dispersion in the practices of access to the SRS by undocumented migrants. In order to account for this “implementation gap”, this study analyzes the degree of discretion deployed by healthcare “street-level bureaucrats”, ultimately responsible for the implementation of the regional health authorities’ guidelines through their everyday practices resulting in guaranteeing, limiting or preventing access of undocumented immigrants to the services provided by the SNS. Within a comparative public policy analysis approach, and with a research design that will combine both quantitative and qualitative research methods, this project continues in the line of the previous competitive research projects (INMEBEA, SOLFCARE, and WAE) directed by the team members of this research project.