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Health Policy 113 (2013) 236 246

Contents lists available at ScienceDirect

Health Policy

j ourna l ho me pag e: www.elsev ier .com/ locate /hea l thpol

re migrants health policies aimed at improving access touality healthcare? An analysis of Spanish policies

ara Luisa Vzqueza,, Rebeca Terraza-Nneza, Silvia S-Hernndezb,ngrid Vargasa, Lola Boschc, Andrea Gonzlezb, Sandra Pequenoa,aquel Cantosb, Juan Ignacio Martnezb, Lus Andrs Lpezb

Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services ofatalonia, Avinguda Tibidabo, 21, 08022 Barcelona, SpainEscuela Andaluza de Salud Pblica, Cuesta del Observatorio, 4, Campus Universitario de Cartuja, 18011 Granada, SpainServeis de Salut Integrats Baix Empord, Carrer de lHospital, 36, 17230 Palams, Girona, Spain

a r t i c l e i n f o

rticle history:eceived 29 November 2012eceived in revised form 7 June 2013ccepted 12 June 2013

eywords:olicy analysismmigrationealth careigrantspainccess

a b s t r a c t

Although until April 2012, all Spanish citizens regardless of their origin, residence status andwork situation were entitled to health care, available evidence suggested inadequate accessfor immigrants. Following the Aday and Andersen model, we conducted an analysis of policyelements that affect immigrants access to health care in Spain, based on documentaryanalysis of national policies and selected regional policies related to migrant health care.Selected documents were (a) laws and plans in force at the time containing migrant healthpolicies and (b) evaluations. The analysis included policy principles, objectives, strategiesand evaluations. Results show that the national and regional policies analyzed are basedon the principle that health care is a right granted to immigrants by law. These policiesinclude strategies to facilitate access to health care, reducing barriers for entry to the system,for example simplifying requirements and raising awareness, but mostly they address thenecessary qualities for services to be able to attend to a more diverse population, such as the

adaptation of resources and programs, or improved communication and training. However,limited planning was identified in terms of their implementation, necessary resources andevaluation. In conclusion, the policies address relevant barriers of access for migrants andsignal improvements in the health systems responsiveness, but reinforcement is requiredin order for them to be effectively implemented.

2013 Elsevier Ireland Ltd. All rights reserved.. Introduction

After a decade of intense increase, Spains foreign popu-ation (non-Spanish nationals) which currently represents2.2% of the total population, has begun to stabilize [1].

long with Germany, the United Kingdom, France and Italy,t now has one of the highest proportions of foreign resi-ents in Europe [2]. This has led not only to an overall

Corresponding author. Tel.: +34 93 253 18 20.E-mail address: mlvazquez@consorci.org (M.L. Vzquez).

168-8510/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.healthpol.2013.06.007increase in population size but also to a significant changein its diversity, a factor which poses a challenge for healthservices.

Migrants right to health care was established andsubsequently ratified in various agreements at global [3]and European level [46]. Moreover, the World HealthAssembly urges governments to develop health policieswhich respond to diversity and to specific risks for immi-

grants [7,8]. However, migrant health policies traditionallyfocused on risks to public health, mainly in terms of the con-trol of communicable diseases such as tuberculosis [8,9]. Inrecent years, with the exception of certain countries such

dx.doi.org/10.1016/j.healthpol.2013.06.007http://www.sciencedirect.com/science/journal/01688510http://www.elsevier.com/locate/healthpolhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.healthpol.2013.06.007&domain=pdfmailto:mlvazquez@consorci.orgdx.doi.org/10.1016/j.healthpol.2013.06.007

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as Canada and France where the traditional focus has per-sisted [1012], a new approach has been taking on greaterrelevance in the form of health policies based on migrantsrights to health and the challenges associated with theirhealth care [8].

Policies aimed at migrants health can be classifiedinto two types according to their development and scope[10,11,13]: firstly, those of a legislative nature in which therights of migrants to health and health care are establishedby means of laws and decrees and secondly, those designedto put these rights into operation. According to the Adayand Andersen model [14], the latter should tackle thosedeterminants of access to care related to characteristicsof both the provision of services (availability of resources,organization, quality, financing) and the migrant popula-tion (awareness of health services and practices) which aresusceptible to policy interventions.

In Spain, policies have evolved in parallel with theincrease in foreign population. Initially laws were enactedto regulate and control the flow and stay of foreigners [15].Following this, policies were designed to address the life offoreigners and their cohabitation with nationals and lawswere issued on their rights to health care, among others[16]. Until April 2012, when the new conservative govern-ment limited the healthcare rights of immigrants withouta residence permit (i.e. undocumented immigrants) [17],foreigners residing in Spain who were registered at thecity council had the same rights to health care as Spanishnationals, regardless of their residence status. Emergencycare for unregistered persons and health care for pregnantwomen and under-18 s was also guaranteed [18,19]. Fromthe early 1990 s onwards, the scope of policies was widenedwith the drawing up of multi-sector immigration plans(including the health sector), known as plans for citizen-ship and integration or immigration [20]. These have beendeveloped periodically at national and regional level overthe last two decades [19,21,22]. Alongside these specificplans, policies directed at immigrants have also been incor-porated into the Spanish health system quality plan andregional health plans [11].

In spite of the fact that health care has been a rightgranted to the migrant population for three decades and ofthe different policies drawn up to enforce this right, previ-ous research indicates that there are inequalities in healthamong this population which signal social inequalities inaccess to care [2325]. An analysis of migrant healthcarepolicies would therefore allow us to determine how theyare affecting or may affect access to care and thus to reori-ent them in order to reduce inequalities in access and movetoward a more equitable healthcare system.

Analyses of migrant health policies have mostly focusedon those of a legislative nature, particularly on the com-parison of the right to health care in different countrieswith respect to undocumented immigrants [13,2629], theimmigrant population in general [10,30], or the parliamen-tary debate on this right [31]. In recent years, progress hasbeen made in the analysis of responses at health policy

level with the production of analytical frameworks [32]or comparative analyses of policy content or implemen-tation, either between countries [11,12,32,72] or withina given country [22,33]. However, these analyses do noty 113 (2013) 236 246 237

focus on access to care. In addition, the analysis should notonly focus on policy factors that influence access to care,meaning to be able to entry/use the services, but also con-sider those policy factors that might influence the quality(relevance, suitability) when providing care to a diversepopulation. This article aims to contribute to our under-standing through an analysis of those elements found innational policy and in regional policies of Andalusia andCatalonia which influence access to care for immigrants.

2. Materials and methods

2.1. Design

A descriptive and comparative study was conducted ofmigrant health care policies through an analysis of theircontent, both at national level and at regional level forCatalonia and Andalusia. This study adopts Walt et al.s def-inition of policy: courses of action that affect the set ofinstitutions, organizations, services and funding arrange-ments of the health system [34]. The analysis is based,firstly, on Aday and Andersens (1974) theoretical frame-work of access, which defines the determinants of accessto care which can be affected by policy intervention. Thepremise is that policy formulation should address bothcharacteristics of the healthcare system and services (vol-ume and distribution of resources; organization of services:entry and structural factors) and characteristics of the pop-ulation (predisposing factors, such as health and healthcareknowledge, beliefs and attitudes; enabling factors: health-care coverage and regular source of care). Furthermorethe analysis focuses on the specific aspects which makeup all policies policy objectives and principles, targetpopulation, design of strategies to meet the objectives,resources allocated to implement the strategies and eval-uation design according to Jans analytical frameworkfor policies [35]. The study was limited to legislative doc-uments and those health policies that are enshrined innational and regional immigration or health plans. Catalo-nia and Andalusia were selected because they both havea high proportion of immigrants (15.7% and 8,6%) [1], yetthey also have different policy developments, governmentsand economic conditions.

2.2. Search strategy

An exhaustive search was conducted of policies relatedto migrant health care. In the initial search all existingpolicy documents were included without time limit andwritten in Spanish, Catalan or English. Search engine usedwas Google. Nonetheless, most of the documents werefound searching directly on the web pages of the Ministryof Labor and Social Affairs, the Ministry of Health, and ofthe Departments responsible for health and/or immigra-tion matters within Catalonia and Andalusia. The key wordsused in the search for relevant documents were: immi-grant, migrant, foreigner, ethnic minority, minority groups,

refugees, displaced persons, asylum seeker, undocumentedor irregular migrants, seasonal workers, persons of othernationalities, persons who have immigrated, vulnerablepopulation, social exclusion groups, access, accessibility,

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uality and health care. As a result 121 documents wereound containing or describing interventions directed athe health care of immigrants. The search was carried outrom March to September 2010.

.3. Criteria for selection of documents

National and regional legislative documents (laws,egulations, decrees) and plans of Spain, Catalonia andndalusia level were selected to meet the following crite-ia: (a) they were in force when the search was performedn 2010, and (b) contained health policies directed atmmigrants, or (c) contained evaluations of migrant healtholicies. Of the documents which were potentially relevanto the aims of our study, we selected 19 at national level,5 from Catalonia and 14 from Andalusia (Table 1).

.4. Analysis of documents

Documents were analyzed through systematic classi-cation, description and interpretation of their content36], with the support of the Atlas-ti software package.he main categories for analysis were: type of policy; prin-iples and objectives of the policy related to care accessnd quality; strategies that may affect access, which werelassified by sphere of action in accordance with Adaynd Andersens framework (1974) (entry to health system,haracteristics of the immigrants, entry to and utilizationf health services); allocated budget and policy evalua-ion design. In the first stage, national and regional policiesere analyzed on a stand-alone basis and in the second,

comparative analysis was conducted between nationalolicies and those of Andalusia and Catalonia.

.5. Quality of data

In order to ensure the quality of the data used in thenalysis, five analysts participated in the study, each with

different background (two public health doctors, oneealth economist, one health sociologist, one public healthiologist) and a good knowledge of the subject, the con-ext and policy analysis. Differences among analysts wereiscussed until a consensus was reached.

.6. Ethical consideration

This study is part of a broader research project to ana-yze migrants access to quality care in Spain. Conditionsf research, procedure, risk and benefit evaluation, confi-ence and privacy, and informed consent were approvedy the Clinical Research Ethical Committee of Parc Salutar (CEIC-Parc Salut Mar) in 2010.

. Results

.1. A number of different types of policies guarantee

ccess to health care for immigrants

Policies aimed at guaranteeing healthcare access formmigrants are defined at national and regional level bothy 113 (2013) 236 246

in legislative documents and in multi-sector plans (edu-cation, employment, housing and health) or health plans(Table 1) which become framework policies. Entitlementto health care and access conditions for immigrants are setout at national level in the law on the rights and freedomof foreigners [18] and are reiterated in the regional lawsanalyzed [3740], which establish the registration of for-eigners with the city council as the only requirement toenable them to exercise this right under the same condi-tions as the native population, regardless of their residencestatus.

The national and regional plans analyzed define objec-tives and strategies to enforce the right to health care ingeneral or with respect to certain specific health areas(mental health, sexual and reproductive health, etc.). Onenotable difference is that while national and Andalusianmigrant health policies, as well as appearing in multi-sector integration plans, are included in plans directedat the general population, in Catalonia a specific healthplan for immigrants was also drawn up. In addition, inAndalusia migrant-related objectives were included in thehealth providers program contracts (contract/agreementbetween the Department of Health and public healthcareproviders) [41,42,53].

3.2. Healthcare access as a right and equity, thefoundations of policy principles and objectives

Rights and duties form the principles on which theobjectives and strategies related to care access are basedin the policies analyzed. On the one hand, they referto health and medical care as a basic human right andas a citizenship right of immigrants, regardless of theiradministrative status [18,4346], and to the right of healthprofessionals to have access to the tools they need to dotheir job to the highest possible standards of quality, apremise which also includes training in Catalonia [46].On the other hand, duties are established, such as thatof the health system to adapt to the changes and spe-cific needs of the population [4650]; that of professionalsto perform their work to the highest possible standards[46,47]; and in the national policies on acquired immu-nodeficiency syndrome (AIDS) [51] and those of Andalusia[48,52], that of the immigrant to protect his/her ownhealth. Also included are the principles of equity, definedas equal opportunity and effective equality of access forequal need [18,41,43,44,4648,51,53], non-discriminationand respect for cultural diversity, reduction of vulnerabil-ity [43] and normalization i.e. seeking integration throughcomprehensive and adapted care within the general carestructures [48,50], avoiding specific parallel structures forimmigrants [37,44,46,54,55].

The general policy aims have certain points in common,but also display some differences: they all include improve-ments in access and accessibility of services and in qualityof care, and the analyzed regions also aim to adapt servicesto the diversity of the population. Only Catalonia incorpo-

rates the aim of facilitating the requirements for exercisingthe right to access registration and individual healthcarecard (TSI) [4446] although this is a strategy envisaged inboth regions. At the same time, all policies include aims

M.L. Vzquez et al. / Health Policy 113 (2013) 236 246 239

Table 1Documents analyzed by origin, type and sphere of action.

Origin Type Sphere of action

General or multi-sector Health sector

National Laws and Decrees Organic Law 2/2009 of 11th December, reform ofOrganic Law 4/2000, 11th January, on rights andfreedom of foreigners in Spain and their socialintegrationa [18]Law 12/2009, of 30th October, regulating the right toasylum and subsidiary protection [74]Royal Decree 2393/2004 on rights and freedom offoreigners in Spain and their social integrationa [75]Law 27/2003, of 31st July, regulating the Order toprotect victims of domestic violence [76]Royal Decree 203/1995, of 10th February, by whichregulation is approved for application of Law 5/1984,of 26th March, regulating the right to asylum and thecondition of refugee, modified by Law 9/1994 of 19thMay [77]

General Public Health Law 14/1986, of 25th April 1986a

[16]Law 16/2003, of 28th May, on cohesion and quality of theNational Health Systema [78]Royal Decree 1088/1989, of 8th September, by whichsocial security healthcare cover is extended to personswith insufficient economic resources [79]

Plans Strategic citizenship and integration plan20072010a [58]National action plan for social inclusion of thekingdom of Spain 20082010 [61]National plan for awareness and prevention ofgender violence 2007 [80]Plan for treatment and prevention of gender violencein the migrant foreign population 2009 [81]Common Protocol for a healthcare response togender violence 2007 [82]

National health system quality plan 20062010a [47]Multi-sector plan for combating HIV and AIDS 20082012[43]Mental health strategy in the national health system [83]National strategy on drugs 20092016 [51]National strategy on sexual and reproductive health-2009[60]Care strategy for normal birth in the national healthsystem 2008 [84]

Catalonia Laws and Decrees Law 10/2010, of 7th May, on reception of immigrantsand people returning to Catalonia [37]Law 5/2008, of 24th April, on the right of women toeradicate violence against women [54]Decree 188/2001, of 26th June, on foreigners andtheir social integration in Catalonia [38]

Law 21/2010, of 7th July, on access to public healthcarecoverage by the Catalan Department of Health ServeiCatal de la Salut [39]

Plans Citizenship and immigration plan 20092012 [44]A covenant on living together. National immigrationcovenant 2009 [45]Plan for policies on womens affairs of the Generalitatde Catalunya government 20082011 [55]Plan for social inclusion and cohesion in Catalonia20062009 [85]

Immigration and Health Master Plan 20062010 [46]Catalonia healthcare plan up to 2010 [62]Health services: looking to the future. Healthcare,long-term care and public health map 2008 [59]Catalonia management plan for mental health andaddiction 20102014 [86]Long-term care management plan 2006 [87]Strategic management plan for sexual and reproductivehealthcare services 2007 [88]Strategic management plan for maternity and child care inthe Catalan Public Hospital Network Xarxa HospitalriadUtilitzaci Pblica a Catalunya 2008 [89]

Andalusia Laws and Decrees Law 2/1998 of 15th June, Health Department of Andalusia[40]Circular 6/94 of Decree 60/99 [90]

Plans II Comprehensive Immigration plan for Andalusia20062009 [48]Comprehensive Child Healthcare Plan 2013 [91]

III Andalusian Healthcare Plan 20032008 [56]II Andalusian Health System Quality Plan 20052009 [52]II Andalusian AIDS Plan 20102015 [49]II Andalusian Comprehensive Mental Healthcare Plan20082012 [50]Andalusian Palliative Care Plan 20082012 [92]II Comprehensive Diabetes Plan 20092013 [93]Comprehensive anti-smoking Plan 20052010 [57]II Andalusian Drugs and Addiction Plan 20022007 [94]Primary Care District Program Contract Andalusian HealthServices (SAS) 20052008 [41]Health System Administrative Area Program Contract 2008[53]Hospitals Program Contract 2008 [42]

Evaluation Evaluation II Comprehensive Immigration Plan inAndalusia 20062009 [63]

Source: Produced by authors.Note: HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; SAS, Servicio Andaluz de Salud.

a Framework document.

240 M.L. Vzquez et al. / Health Policy 113 (2013) 236 246

Table 2Strategies aimed at immigrants.

Sphere of action Spain Catalonia Andalusia

Providinginformation

Active information policies [58] Welcome service [39,4446] Incorporation of new technology[49,52]

ContentRules of access, rights and duties ofusers [43,58]

ContentAccess, awareness and use ofservices [45,46]

ContentAccess, rights and duties [4042]Specific health problems[48,49,56,57]

MeansIn language of immigrant [43]Adapted to cultural context [43]

MeansIn language of immigrant [46]Printed materials and audiovisualformat [46]

MeansEthnically and culturally adapted[48,49,56,57]Involvement of NGOs

Active recruitmentand participationof immigrants

Recruitment of immigrantsDefining plans and measures forthe active recruitment ofimmigrant women and children[58]

Recruitment of immigrantsRecruitment activities for migrantpopulation: sexual andreproductive health, sexuallytransmitted diseases [46]

Recruitment of immigrantsRecruitment of immigrantsthrough the Basic Health Areas [53]

Participation of immigrantsParticipation of immigrants inprograms: drugs, HIV,anti-smoking, infant health [48,56]

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nvolving actions which, whilst not referring directly toccess, contribute toward improving access to quality care.or example, one aim at national level and in Catalonia iso improve awareness of immigrants health and health-are needs; in Andalusia, to reduce inequities in health care40,48,50,56]; and in the national AIDS plan and Andalusia,o improve training for health workers [41,43,48,52,57].

.3. Predominance of strategies aimed at the adaptationf services to a diverse population

The various strategies related to access to care set outn the national and regional framework plans analyzed areesigned to tackle those determinants of access which cane modified through policies [14]. Some are directed atntry to the health system or immigrants, but most areirected at adjustments of the health services in aspectselated to entry and above all to the provision of care to

diverse population. Specific health plans sexual andeproductive health, mental health follow these lines, butncorporate some additional measures for specific popula-ion groups. A general lack of precision is detected in theescription of strategies in terms of what they entail, howhey are to be implemented, who is responsible for theirmplementation and what resources are allocated to them.

.3.1. Facilitating entry to the health systemThese strategies are defined only at regional level and

im to make it easier to obtain the healthcare card (TSI)hrough the simplification of administrative procedures.his is also achieved in Catalonia through the creation ofpecial administrative pathways for specific groups (sex

orkers, minors) [44,46] and in Andalusia through the

ssue of a temporary healthcare card for undocumentedigrants [42,48,52,53]. In Catalonia the registration pro-ess is facilitated through the unification of criteria [44,46].Creation of spaces for interactiveparticipation [52]

s.

3.3.2. Aimed at improving immigrants knowledgeStrategies aimed at immigrants are mainly designed

to improve their knowledge of the functioning of thehealth system and services through providing information(Table 2): at national level, through information campaignsand, in both regions studied, through healthcare receptionservices and the production of culturally adapted infor-mation in different languages on access regulations andusers rights and duties [4043,45,46,58]. In Andalusia, theuse of new technologies is envisaged for disseminationof information [49,52]. Actions designed to recruit immi-grants into general health programs in Andalusia [53] andinto specific programs at national level and in Catalonia arealso envisaged (women in preventive programs for sexualand reproductive health and sexually transmitted diseases[46,58] or children [58]), without these actions being fullydefined.

3.3.3. Aimed at health services adaptationThese policies include a few strategies to facilitate entry

to the health services and particularly, once admitted, toensure the quality of the care received.

Entry to health services. These strategies envisageimprovements in the availability and organization ofresources (Table 3). At national level, the Citizenship andIntegration Plan envisages improvements in the range andquality of services, without specifying how this is to beachieved [58]. Catalonia and Andalusia establish the adap-tation and/or increase of professional staff according to theincrease in population [44,45,50,59], an increase in eco-nomic resources for public services [45,48,50] and also, inCatalonia, an increase in specialist units for emerging dis-eases [59]. Only Andalusia takes organizational aspects into

account, such as flexibility of appointment timetables andbringing care closer with home visits [50,52].

Ensuring quality of care for a diverse population. Mostof the strategies aimed at the services and described in

M.L. Vzquez et al. / Health Policy 113 (2013) 236 246 241

Table 3Strategies aimed at entry to health services.

Sphere of action Spain Catalonia Andalusia

Availability ofresources

Improving therange and qualityof health care [58]

Volume and distributionAdequate tailoring of staff volume[44,45,49]Specialist units for treatment ofemerging diseases [59]

Volume and distributionIncrease in number ofprofessionals [50]Incorporation of new technologies[52]Promote home visits [50]

Economic resourcesIncrease in budget [45]

Economic resourcesIncrease in budget [48,50]Financial and technical support forNGOs [49]

Organization of resources Organization of servicesOrganizational adjustments [45,49]

Organization of servicesMore flexible appointmentNote: NGO, non-governmental organization.

the national and regional framework plans analyzed arefocused on facilitating access to quality care for the migrantpopulation through (a) the adaptation of instruments andprograms, (b) improved communication between pro-fessionals and (c) users and better professional training(Table 4).

(a) Adaptation of programs and services, through twotypes of action: firstly, migration plans envisage the adap-tation of programs and instruments (clinical protocols andguidelines) to the migrant population, but only the nationalplan specifies that this entails adopting a standpoint ofnon-exclusion and equal treatment, promoting multicul-turality, psychosocial health and the design of new workingpractices [58]. Health plans either establish the inclusionof immigrants in existing interventions or define specificmeasures for them [43,46,60]. The National Quality Planalso envisages the identification and transference of posi-tive experiences in the care of immigrants [47].

Secondly, actions are envisaged to improve knowledgeon migrants health needs and their use of services. Atnational level, systematic data collection is establishedin order to analyze socio-demographic characteristics(country of origin, ethnicity, language) [58], and all theframework plans envisage the development of studies ondeterminants of health, access, social inequalities in health,morbidity and use of services [46,47,52,5558,61]. Like-wise, regional plans include the assessment of quality,satisfaction and costs of migrant health care, without stat-ing how this is to be carried out [42,46,52]. Only Andalusiasets out strategies to address social inequalities in health,while the rest do not explicitly state that the information isgathered with a view to optimizing the delivery of healthcare.

(b) Improvement in communication between professionaland user. These strategies mainly address linguistic diver-sity by introducing measures for communication in thepatients language. At national level, spoken and writtencommunication strategies are established without furtherspecification [58]. Cultural mediation and simultaneous

translation on-site or by telephone are included in thenational plan for sexual and reproductive health and in theregional plans analyzed [4446,48,49,56,59,60,62]. Theyall envisage the provision of culturally and linguisticallytimetable [52]

adapted materials for health education in general and sex-ual and reproductive health in particular [42,46,48,57,60].Improving the listening skills and empathy of health pro-fessionals is a strategy established only at national levelin the sexual and reproductive health plan. In Cataloniaimmigrant women are considered potential health agents,without their functions being clearly defined [55].

(c) Specific training for health professionals. Thesemeasures, mainly included in the national and regionalmigration plans [46,48,58], are aimed at the generaldevelopment of health professionals cultural compe-tence and knowledge of immigrant-related matters.The content focuses on cultural aspects affecting theprofessionalpatient relationship and the treatment pro-cess, the detection and improvement of health deter-minants, and specific health problems, such as highlyprevalent diseases or specific pathologies in the countryof origin [41,43,45,46,48,49,52,55,57,58,60]. The nationalAIDS plan includes raising awareness among health pro-fessionals, without defining how this is to be achieved[43]. Only Andalusia makes reference to additional train-ing for non-governmental organization (NGO) workers [48]involved in migrant health.

3.4. Limited planning in policy implementation andevaluation

The national and regional policies analyzed are not sup-ported by implementation plans, although some definethe actor responsible for this, mainly the Ministry andregional Departments of Health [41,42,44,53,58]. Thenational and regional migration plans [41,44,45,48,58]establish the resources to be destined to each core area.The evaluation of interventions, despite being consid-ered a priority, is only performed in a limited way atregional level [41,42,46,53,56,62,63]. Access to the healthcard is analyzed by calculating TSI coverage for immigrants[41,42,46,53,56,62,63]. Structure and process indicatorsare also established to monitor specific activities related

to communication: availability of mediators [46,63], useof mediation and translation services [46,62,63], healthprofessional training (number of courses completed)[46,62,63]. Results indicators are established with regard

242 M.L. Vzquez et al. / Health Policy 113 (2013) 236 246

Table 4Strategies oriented to access to care of quality, by sphere of action.

Sphere of action Spain Catalonia Andalusia

Adaptation ofprograms andinstruments

Adaptation of programs andinstruments to immigrantsInclusion of multiculturality andpsychosocial health,non-exclusion, equal treatment inhealth programs [58]Strategies to promote amulticultural approachtreatment,diet, violencewith regard towomen and children [47]Describe and disseminate goodpractices and instruments [47]

Adaptation of programs andinstruments to immigrantsProduction and adaptation ofclinical pathways and guidelines:sexual and reproductive health,infant health, mental health,parasitic diseases, nutrition anddiet [46]

Adaptation of programs andinstruments to immigrantsProduction and adaptation ofclinical pathways[41,42,48,50,52,53,57]Adaptation of conceptualframework: mother-childprograms, mental health,substance abuse, prostitution[48,50]

Specific interventionsDesign of newprofessional-immigrant workingpractices [58]Activities adapted to youngimmigrants [43]Programs for prevention and earlydiagnosis of HIV [43]Incorporation of pregnancymonitoring [60]Protocols for care of migrantwomen [60]

Specific interventionsSpecific interventions: substanceabuse, tuberculosis, sexuallytransmitted diseases [46]

Specific interventionsSocial interventions to reduceinequalities [50,52,53]Actions to encourage coordinationand team work [48,52,53]

Awareness of needsInclude in healthcare records:ethnicity, geographical area oforigin and spoken and writtenlanguage [58]Update population profile demographic, cultural andepidemiological [58]Studies on: determinants of healthand access, use of services,inequalities in strategies andhealth plans, incidence/prevalenceof diseases [47,58,61]

Awareness of needsIdentification of inequalities inhealth and access to care [46,55]Assessment of quality of services,satisfaction and costs [46]

Awareness of needsIdentification of inequalities inhealth and access to care [52,56]Identification of inadequatecoverage [52]Studies on: prevalence of diseases[57]Assessment of quality of services,satisfaction [42,52]

Improved communication Policies on verbal and writtencommunication [58]Simultaneous translation andcultural mediation [60]Health education material indifferent languages [60]Development of empathy andlistening skills [60]

Mediation in health care[45,46,59,62]Telephone translation services[44,45,59]Adapted health educationmaterial: sexual and reproductivehealth, tuberculosis, nutrition anddiet [46]Migrant women as healthcareagents [55]

Facilitation of linguistic andcultural understanding [49,56]Mediation through NGO programs[48]Telephone translation service [48]Adapted healthcare material:sexual and reproductive health,substance abuse, nutrition and diet[42,48,57]

Training of healthprofessionals

ContentCultural competence [43,58]Awareness [43]Health determinants [58]Specific health problems [58]Information and knowledge ondiseases according to origin [60]

ContentCultural competence [45,46]Specific problems: inequalities inhealth, migration and mentalhealth, international health,pediatrics, sexual and reproductivehealth, adaptation of nutrition anddiet [45,46,55]Identification of training needs [46]

ContentCultural competence[41,48,49,52,57]Specific problems of immigrants[41,52,57]Inequalities in health [52,57]Communication strategies [48]Functioning of the AndalusianPublic Health System (SistemaSanitario Pblico Andaluz SSPA)[48]

FormatTraining activities [46]

FormatCourses [41,48,49,52,57]Seminars [48]Exchange of experiences [48]Training material [48]Training of NGO professionals [48]

Note: HIV, human immunodeficiency virus; NGO, non-governmental organization.

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to use of primary care and hospital services [46,62] andsatisfaction of professionals and immigrants [46,62,63].Andalusia evaluated the migration plan by analyzing theutilization of services and the activities performed [63].

4. Discussion

This comparative content analysis of the policies aimedat migrant health care in Spain has allowed us to broadenour knowledge on its suitability and to identify short-falls with regard to access. This offers policy makers andhealth providers an opportunity to make improvements inmigrant health care, not only in Spain but in other countriesfacing similar challenges [12]. Any interpretation of theresults must take into consideration that the study com-pares policy content and not its implementation and refersto national policies and the policies of two specific regions,even if our results are consistent with an analysis con-ducted in a wider sample of Spanish regions which didnot specifically focus on access [22,33]. Moreover, as itapplies to a specific time period (2010), it has not includedpolicy changes which have come about since then as a con-sequence of the economic and social crisis and politicalchanges currently underway in Spain and Europe.

The results show that not only were immigrants entitledto heath care in Spain by law regardless of their adminis-trative status, like in some other European countries [29],but that this right was also enforced by issuing a numberof national and regional policies targeted at guaranteeingentry to the services and reducing potential problems ofquality related to providing care for a diverse population.These policies are backed up by specific strategies, as is gen-erally recommended [64]. However, it is worth noting thatthere is a predominance of strategies aimed at ensuringquality of care once in the system (adapting health services,improving communication and health personnel training)over those related to entry to the system and services, inline with the results of the abovementioned previous anal-ysis [33]. This may be explained by the fact that at the timeof the analysis, the Spanish health system offered universalcoverage, so care was a right granted to all citizens and itwas not anticipated that anyone would be excluded fromthe system. Moreover migrant health policies are explic-itly based on the principles of equal access for equal need,non-discrimination and equal opportunity; and a numberof strategies are addressed at identifying social inequalitiesin health or access to care, which is a way of monitoring theeffectiveness of the system in achieving its equity objective,as the presence of unfair inequalities (not related to need)would signal problems in the health systems equity.

For entry to the health system, both regions analyzedcoincide in establishing strategies to reduce the barriersfor obtaining the healthcare card (TSI), such as the vari-ability of requirements in primary care centers, some ofwhich were not set by law and were particularly rele-vant to undocumented immigrants, like requesting proofof social security contributions [65,66]. However, these

two regional policies differ in their approach to accessfor the undocumented migrant population: whilst Catalo-nia focuses its efforts on facilitating registration at thecity council, Andalusia appears to sidestep registrationy 113 (2013) 236 246 243

problems by issuing a temporary healthcare card at thehealth services. These results seem to indicate that whilstthe regular immigrant population faces similar situa-tions in both regions, healthcare access for undocumentedmigrants may be easier in Andalusia than in Catalonia, asin the former access depends on the health service itselfand not on any other administrative body. However, nostudies have been conducted to date on the potential diffi-culties involved in the administrative process to obtain thetemporary card or its effects on access in Andalusia.

Strategies to improve access targeted at migrants aremainly centered on raising awareness of the functioning ofthe health system and services, providing linguistically andculturally adapted information. This strategy should reduceproblems stemming from lack of awareness, such as delay,non-use or inappropriate use of services [65,6769], andis especially relevant to recently arrived immigrants. How-ever, it runs the risk of not reaching its target populationat the right time, due to the fact that information is dis-tributed within healthcare centers, once the migrant hasalready been admitted; moreover, it may be of little useto persons of a low socio-cultural level [65,67]. Taking thisinto consideration, in addition to promoting the use of newcommunication technologies, Andalusia lays out strategiesfor working alongside NGOs to disseminate informationon the services and facilitate access. This may be a moreappropriate way to reach this population when they firstarrive, as long as NGOs do not assume the responsibility forproviding health care which corresponds to public services.

With regard to the provision of quality health care,strategies are mainly aimed at adapting programs andinstruments, improving communication and providingtraining for health professionals, all of which points to awill to increase the responsiveness of the health system tonew users and to provide them with care which is con-sistent with their needs [70]. These strategies address acentral challenge in the provision of care to a diverse pop-ulation in terms of language, religion and health beliefs[71,72]. The strategies are similar in the national andregional policies analyzed and are in line with those con-sidered good practice in migrant health care in Europe [69].However, not all those deemed necessary are included,such as increasing consultation time per patient [69,73],which would help to solve a problem described in theprovision of care to migrants in Spanish health services[68].

The analysis also reveals other weaknesses in policyformulation which may hinder implementation: insuffi-cient definition of strategies, alongside limited allocationof resources and scant evaluation of results. Weaknessesin policy-making and implementation have also beendescribed in other European Union countries [12]. Forexample, introducing cultural mediators entails, in addi-tion to defining their role, an increase in staff and staffingcosts, yet this is not usually accompanied by a corre-sponding increase in budget [12,73], or by training forhealth workers in the use of mediators, without which

this resource tends to be underexploited [73]. This isa particularly relevant point for those strategies whichin themselves imply an increase in resources (such asadapting the volume and distribution of services to the

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opulation size and location), in the sense that if they areot accompanied by a commensurate increase in budget,hey will never be more than a mere statement of princi-les. This might have been partially overcome in Andalusiay including migrant-related objectives in the programontract. Further analysis of what is actually happeningn the health services would be necessary to establish tohat extent these policies are being effectively imple-ented.The health policies studied differ more in terms of

pproach than content. At national level and in Andalusia,trategies aimed at the migrant population are includedithin general policies and enforced in program contracts,hilst in Catalonia a specific health plan was developed.his may be a reflection of different trends: while in therst case, it is turned into an opportunity to consider theultural diversity of the population as a whole, in Cataloniammigrants are recognized as being at a social disadvan-age and specific plans are drawn up to facilitate access onqual terms.

. Conclusion

Spain has addressed the challenge of ensuring accesso appropriate care for migrants by means of the devel-pment of health policies to tackle potential barriers tontry to the health system and services and to ensureiversity-oriented care. The strengths detected based onhe right to health care on equal terms, improvementsn the responsiveness of services and convergence withnternational good practice are a good starting pointrom which to sustain the further development of poli-ies to improve access and ensure quality of care for aiverse population. However, the weaknesses identified nsufficient definition of measures, budgets and evaluation

highlight the need for more planning and monitor-ng, and reflect one of the great challenges to be facedn effective policy-making and implementation to ensureccess to quality care. With this in mind, further researchhould be conducted to analyze whether differences in pol-cy formulation between Andalusia and Catalonia (activeecruitment of immigrants into health programs throughGOs, direct issue of a healthcare card and policy reinforce-ent in program contracts in the former case) translate

nto different results with regard to immigrants access toealth care.Finally, the entitlement to health care has just been

estricted for undocumented migrants to emergency careith a new decree (16/2012), which is in contradiction withxisting policies and international agreements. It should bemphasized that on top of the fact that a right has been vio-ated, and the negative effects this will have on migrantsealth (loss of control of chronically ill patients, early diag-osis and treatment and other preventive activities), theseolicy changes will probably affect the health system due ton increase in the use of emergency services (the only path

till open to some) for situations which could be resolvedn primary care, and may even endanger public health,ue to the lack of control of communicable diseases. Thesehanges should thus form the focus of future research.

[

y 113 (2013) 236 246

Conflicts of interest

The authors declare that they do not have any conflictof interests.

Acknowledgements

To Hernan Vargas, for his contribution to the last resumof the paper and to Kate Barlett for the English version.This research was partially financed by the Instituto deSalud Carlos III. Accin Estratgica en Salud. Proyectos deinvestigacin PI09/02642.

References

[1] Instituto Nacional de Estadstica. http://wwwinees/jaxi/tablado?path=/t20/e245/p04/a2000/l0/&file=000ct008px&type=pcaxis

[2] Vasileva K. Population and social conditions; 2011http://eppeurostateceuropaeu/cache/ITY OFFPUB/KS-SF-10-045/EN/KS-SF-10-045-ENPDF

[3] United Nations Human Rights. International Covenant on Eco-nomic, Social and Cultural Rights, http://wwwohchrorg/Documents/ProfessionalInterest/cescrpdf; 1966.

[4] Council of Europe. Additional Protocol of the European Social Charter.Strasbourg: Council of Europe; 1988.

[5] Council of Europe. Convention for the Protection of Human Rightsand Fundamental Freedoms. Rome: Council of Europe; 1950.

[6] Council of Europe. http://bitly/rKs2YD[7] World Health Assembly. Health of migrants. Executive Board Reso-

lution. Geneva: World Health Assembly; 2008.[8] Zimmermann C, Kiss L, Hossain M. Migration and health:

a framework for 21st century policy-making. PLOS Medicine2011;8:e1001034.

[9] Gushulak BD, Williams LS. National immigration health policy. Cana-dian Journal of Public Health 2004;95:I29.

10] Moreno Fuentes FJ. Anlisis comparado de las polticas sanitariashacia las poblaciones de origen inmigrante en el Reino Unido.Madrid: Francia y Espana; 2003.

11] Vzquez ML, Terraza-Nnez R, Vargas I, Rodrguez D, Lizana T.Health policies for migrant populations in three European countries:England; Italy and Spain. Health Policy 2011;101:708.

12] Mladovsky P, Rechel B, Ingleby D, McKee M. Responding to diversity:an exploratory study of migrant health policies in Europe. HealthPolicy 2012;105:19.

13] Cattacin S, Chimenti M, Cuadra B. Difference sensitivity in the fieldof migration and health. Geneva: National policies compared; 2007.

14] Aday LA, Andersen R. A framework for the study of access to medicalcare. Health Services Research 1974;9:20822.

15] Ley Orgnica 7/1985, de 1 de julio, sobre derechos y libertades delos extranjeros en Espana. Boletn Oficial del Estado, BOE nm. 158(1-7-1985).

16] Ley 14/1986, de 25 de abril de 1986, General de Sanidad. BoletnOficial del Estado, BOE nm. 102 (29-4-1986).

17] Real decreto-ley 16/2012, de 20 de abril, de medidas urgentes paragarantizar la sostenibilidad del sistema nacional de salud y mejorarla calidad y seguridad de sus prestaciones. Boletn Oficial del Estado,BOE nm. 98 (24-4-2012).

18] Ley Orgnica 2/2009, de 11 de diciembre, de reforma de la LeyOrgnica 4/2000, de 11 de enero, sobre derechos y libertades delos extranjeros en Espana y su integracin social. Boletn Oficial delEstado, BOE nm. 299 (12-12-2009).

19] Ley Orgnica 4/2000, de 11 de enero, sobre derechos y libertades delos extranjeros en Espana y su integracin social. Boletn Oficial delEstado, BOE nm.10 (11-1-2000).

20] Consejo de Ministros. Plan para la integracin social de los inmi-grantes. Madrid: Consejo de Ministros; 1994.

21] Departament de Benestar i Famlia. Poltiques i plansdactuaci. Antecedents, http://www20gencatcat/portal/site/bsf/menuitemcb7c44c1c72cf6b43f6c8910b0c0e1a0/?vgnextoid=

1c9ca83079a55210VgnVCM1000008d0c1e0aRCRD&vgnextchannel=1c9ca83079a55210VgnVCM1000008d0c1e0aRCRD&vgnextfmt=default; 2009.

22] Escuela Andaluza de Salud Pblica. Revisin de polticas de atencina la poblacin inmigrante. In: Documento de trabajo, Granada; 2008.

http://wwwinees/jaxi/tablado?path=/t20/e245/p04/a2000/l0/38file=000ct008px38type=pcaxishttp://wwwinees/jaxi/tablado?path=/t20/e245/p04/a2000/l0/38file=000ct008px38type=pcaxishttp://eppeurostateceuropaeu/cache/ITY_OFFPUB/KS-SF-10-045/EN/KS-SF-10-045-ENPDFhttp://eppeurostateceuropaeu/cache/ITY_OFFPUB/KS-SF-10-045/EN/KS-SF-10-045-ENPDFhttp://wwwohchrorg/Documents/ProfessionalInterest/cescrpdfhttp://wwwohchrorg/Documents/ProfessionalInterest/cescrpdfhttp://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0020http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0025http://bitly/rKs2YDhttp://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0035http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0040http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0045http://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23] Jimnez-Rubio D, Hernndez-Quevedo C. Inequalities in the use ofhealth services between immigrants and the native population inSpain: what is driving the differences? European Journal of HealthEconomics 2011;12:1728.

24] Berra S, Elorza J, Bartomeu N, Hausmann S, Serra-Sutton V, Rajmil L.Necessitats en salut i utilitzaci dels serveis santiaris en la poblaciimmigrant de Catalunya. Barcelona: Revisi exhaustiva de la liter-atura cientfica; 2004.

25] Salinas C, Altube L, Espana PP, Capalastegui A, Quintana JM.Tuberculosis en la poblacin inmigrante de Bilbao. Archivos de Bron-coneumologa 2002;38:50610.

26] European Union Agency for Fundamental Rights. Migrants in anirregular situation: access to healthcare in 10 European Union Mem-ber States. Luxembourg; 2011.

27] Cuadra CB, Cattacin S. Policies on health care for undocumentedmigrants in the EU27 and Switzerland: towards a comparative frame-work. Malm; 2011.

28] HUMA Network. Access to health care for undocu-mented migrants and asylum seekers in 10 EU countries,http://www.episouthorg/doc/r documents/Rapport huma-network.pdf

29] Gray BH, van Ginneken E. Health care for undocumentedmigrants: European approaches. Issue Brief (Commonwealth Fund)2012;33:112.

30] Pace P. The right to health of migrants in Europe. In: Rechel B,Mladovsky P, Devill W, Rijks B, Petrova-Benedict R, McKee M, edit-ors. Migration and Health in the European Union. Maidenhead: OpenUniversity Press; 2011.

31] Agudelo-Surez AA, Gil-Gonzlez D, Vives-Cases C, Ronda-Prez E. Eldebate parlamentario sobre inmigracin y salud en Espana. Revistade Salud Pblica (Bogot) 2009;11:50313.

32] Mladovsky P. A framework for analysing migrant health policies inEurope. Health Policy 2009;93:5563.

33] Terraza-Nnez R, Vargas I, Rodrguez D, Lizana T, Vzquez ML. Polti-cas sanitarias de mbito estatal y autonmico para la poblacininmigrante en Espana. Gaceta Sanitaria 2010;24, 115.e1e7.

34] Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, GilsonL. Doing health policy analysis: methodological and conceptualreflections and challenges. Health Policy and Planning 2008;23:30817.

35] Vzquez ML, Jan E, Martnez T, Revents M, Barba V. Polticas deSalud. In: Vzquez ML, editor. Jan E (coord.) Los sistemas de saludy sus polticas (Tema 5). Master en gestin de centros y servicios desalud. Barcelona: Universidad de Barcelona Virtual; 2002. p. 440.

36] Mogolln AS, Vzquez ML. Tcnicas cualitativas aplicadas en salud.In: Vzquez ML, Da Silva MRF, Mogolln AS, Fdez.de Sanmamed MJ,Delgado ME, Vargas I, editors. Introduccin a las tcnicas cualitativasaplicadas en salud. Barcelona: Universidad Autnoma de Barcelona;2006. p. 5381.

37] Llei 10/2010, del 7 de maig, dacollida de les persones immigrades i lesretornades a Catalunya. Diari Oficial de la Generalitat de Catalunya,DOGC n.5629 (7-5-2010).

38] Decret 188/2001, de 26 de juny, dels estrangers i la seva integracisocial a Catalunya. Diari Oficial de la Generalitat de Catalunya, DOGCn.3431 (26-6-2001).

39] Llei 21/2010, del 7 de juliol, daccs a lassistncia sanitria de cober-tura pblica a crrec del Servei Catal de la Salut. Diari Oficial de laGeneralitat de Catalunya, DOGC n.5672 (7-7-2010).

40] Ley 2/1998, de 15 de junio, de Salud de Andaluca. Junta de Andaluca,BOE nm.185 (4-8-1998).

41] Junta de Andaluca, Consejera de Salud. Contrato pro-grama de los distritos de Atencin Primaria del ServicioAndaluz de Salud 20052008, http://www.juntadeandaluciaes/servicioandaluzdesalud/contenidos/publicaciones/datos/247/pdf/Contrato.pdf

42] Junta de Andaluca, Consejera de Salud. Contrato Programa2005-2008. Servicio Andaluz de Salud Hospitales del SAS,http://www.juntadeandaluciaes/servicioandaluzdesalud/contenidospublicaciones/datos/278/pdf/ContratoProgramahospitales2008.pdf

43] Ministerio de Sanidad y Consumo. Plan multisectorial frente a lainfeccin por el VIH y el SIDA 2008-2012, http://www.msps es/ciudadanos/enfLesiones/enfTransmisibles/sida/docs/PMS200812.pd

44] Generalitat de Catalunya. Pla de Ciutadania i Immigraci 2009-2012, http://www.20gencatcat/docs/dasc/03Ambits%20tematics/

05Immigracio/03Politiquesplansactuacio/03placiutad ania09 012/01Presentacio/pla ciutadania immigracio vcat 2010 06 03.pdf

45] Generalitat de Catalunya. Un pacte per viure junts i juntes. PacteNacional per a la immigraci 2009, http://blocsgencatcat/blocs/AppPHP/femxarxa/files/2009/04/pactenacimmigracio.pdf

[

y 113 (2013) 236 246 245

46] Generalitat de Catalunya. Pla director dimmigraci en lmbit de lasalut 2006-2010. Barcelona. 2006.

47] Ministerio de Sanidad y Consumo. Plan de Calidad para elSistema Nacional de Salud, http://www.msces/organizacion/sns/planCalidadSNS/docs/planCalidad2007.pdf

48] Junta de Andaluca, Consejera de Gobernacin. II PlanIntegral para la Inmigracin en Andaluca 2006-2009,http://www.juntadeandaluciaes/justiciaeinterior/opencms/portal/PoliticasMigratorias/Publicaciones/planintegral2?entrada=tematica&tematica=63

49] Junta de Andaluca, Consejera de Salud. Plan andaluz frente alVIH/sida y otras ITS 2010-2015, http://www.juntadeandalucia es/servicios/planes/detalle/11706.html

50] Junta de Andaluca, Consejera de Salud. II Plan Integral de SaludMental de Andaluca 2008-2012, http://www.juntadeandaluciaes/salud/sites/csalud/contenidos/Informacion General/c 1 c 6 planesestrategias/II pla n salud mental

51] Ministerio de Sanidad y Poltica Social. Estrategia Nacionalsobre drogas 2009-2016, http://www.pnsdmsces/novedades/pdf/EstrategiaPNSD2009-2016.pdf

52] Junta de Andaluca, Consejera de Salud. Caminando hacia laexcelencia. II Plan de Calidad del Sistema Sanitario Pblicode Andaluca 2005-2008, http://www.juntadeandaluciaes/salud/sites/csalud/galerias/documentos/c 1 c 6 planes estrategias/IIplan calidad/II plan calidad.pdf

53] Consejera de Salud, Junta de Andaluca. Contrato Programa2005-2008. Servicio Andaluz de Salud, rea de Gestin Sanitaria,http://www.juntadeandaluciaes/servicioandaluzdesalud/contenidospublicaciones/datos/280/pdf/ContratoProgramaAGS2008.pdf

54] Llei 5/2008, de 24 dabril, del dret de les dones a eradicar la violnciamasclista. Diari Oficial de la Generalitat de Catalunya, DOGC n.5123(24-4-2008).

55] Generalitat de Catalunya, Institut Catal de les Dones. Pla de pol-tiques de dones del govern de la Generalitat de Catalunya 2008-2011,http://www20gencat cat/docs/icdones/serveis/docs/publicacionseines12.pdf

56] Junta de Andaluca, Consejera de Salud y Bienestar Social. IIIPlan andaluz de Salud 2003-2008. Andaluca en Salud: con-struyendo nuestro futuro juntos, http://www.juntadeandaluciaes/salud/sites/csalud/galerias/documentos/c 1 c 6 planes estrategias/III plan andaluz salud/III plan andaluz salud.pdf

57] Junta de Andaluca, Consejera de Salud. Plan integral de tabaquismode Andaluca 2005-2010, http://www.juntadeandaluciaes/salud/sites/csalud/galerias/documentos/c 1 c 6 planes estrategias/plantabaquismo/Plan Integral Tabaco.pdf

58] Ministerio de Trabajo y Asuntos Sociales. Plan estratgicoCiudadana e Integracin, http://extranjerosempleogobes/es/IntegracionRetorno/Plan estrategico/pdf/PECIDEF180407.pdf

59] Generalitat de Catalunya, Departament de Salut. Els serveisper a la salut: mirant cap al futur. Mapa sanitari, sociosanitarii de salut pblica, http://www20gencatcat/docs/salut/Home/Ambits%20tematics/Linies%20dactuacio/Planificacio/Planificacioserveis i mapa%20sanitari/Mapa sanitari sociosanitari i salutpublica/Que es/Document s/ssalut futur.pdf

60] Ministerio de Sanidad Poltica Social e Igualdad. EstrategiaNacional de Salud Sexual y Reproductiva, http://www.msssigobes/organizacion/sns/planCalidadSNS/pdf/equidad/ENSSR.pdf

61] Ministerio de Educacin Poltica Social y Deporte. Plan Nacional deaccin para la inclusin social en el reino de Espana 2008-2010,http://www.msssigobes/politicaSocial/inclusionSocial/docs/20090 plan nac accion inclusion social 2008 2010.pdf

62] Generalitat de Catalunya, Departament de Salut. Pla de salut deCatalunya a lhoritz 2010, http://www20.gencat.cat/docs/salut/Home/Ambits%20tematics/Linies%20dactuacio/Planificacio/Pla%20de%20Salut%20de%20Catalunya%20a%20lhoritzo%202010/Informe%20de%20salut%20a%20Catalunya%20Avaluacio%20dels%20objectius%20de%20salut/M%C3%A9s%20informaci%C3%B3/0 Plade salut de Catalunya a l horitzo2010 1a%20part tot.pdf

63] Junta de Andaluca, Polticas Migratorias de la Consejera de Empleo.Evaluacin II Plan integral para la inmigracin en Andaluca 2006-2009. Sevilla. 2006.

64] Norredan M, Krasnik A. Migrants access to health services. In: RechelB, Mladovsky P, Devill W, Rijks B, Petrova-Benedict R, McKee M,editors. Migration and health in the European Union. Maidenhead:

Open University Press; 2011. p. 6780.

65] Terraza-Nnez R, Toledo D, Vargas I, Vzquez ML. Perception ofthe Ecuadorian population living in Barcelona regarding access tohealth services. International Journal of Public Health 2010;55:38190.

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b.elsevier.com/S0168-8510(13)00169-3/sbref0125http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0125http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0125http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0125http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0125http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0125http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0125http://www.episouthorg/doc/r_documents/Rapport_huma-network.pdfhttp://www.episouthorg/doc/r_documents/Rapport_huma-network.pdfhttp://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0145http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0150http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.elsevier.com/S0168-8510(13)00169-3/sbref0155http://refhub.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