Turning gatekeeping into resistance: power struggels surrounding healthcare access of undocumented migrants in Belgium

Introduction: Belgium has a federal legal framework about who should account for medical services and Urgent Medical Aid provided to undocumented migrants. They can obtain a medical card, a 3-month permit to access the regular health care services, after going through a parallel administrative procedure via a physician and the municipal Public Welfare services. However, epidemiological findings show this legislation is poorly implemented: compared to the Belgian population, both the utilization rate and the per capita expenditure are far lower. In this paper we explore some challenges that are faced in the implementation of this health policy, thereby focusing on the complex crisscrossing relations between (i) municipalities and the federal government, (ii) humanitarian actors and public healthcare services, (iii) migrants and federal migration policies. Methods: we performed multi-site ethnographic research in Brussels to study how social workers and clinicians manage the access to medical cards for undocumented migrants. We performed participant observations in a community of undocumented migrants, in a municipal Public Welfare institution, and at the emergency department in a hospital. This approach offered a way to research how health policies are translated into practice. Results: Our observations show that municipal Public Welfare institutions often question their territorial competence for the hypermobile undocumented migrants, thus repudiating their legal responsibility to provide medical cards. Furthermore, the administrative burden of the procedure and the requirement of a social enquiry, are found to be important obstacles for undocumented migrants to obtain a medical card. Public Welfare institutions in Brussels increasingly outsource these bureaucratic control activities to humanitarian organizations. By doing so, humanitarian actors as well as spokesmen of collectives of undocumented migrants, become key figures to meet the administrative requirements of Public Welfare institutions and to facilitate the access to health services. Lastly, our observations show this offers some humanitarian actors and leaders of collectives of undocumented migrants an instrument of power regarding large groups of undocumented migrants. This leads, amongst others, to ethnic differentiation and gendering of access to health care, but also to processes where the distribution of the medical card are used as a leverage to mobilize undocumented migrants for political protests. Conclusion: These findings illustrate how strategic struggles between different actors influence the implementation of the law Urgent Medical Aid. Municipal borders become strategic tool to repudiate legal responsibility for undesired hypermobile undocumented migrants. Governmental mechanisms of control and distrust regarding undocumented migrants accessing health services can be turned into an unforeseen instrument of political resistance. As a result the access to Urgent Medical Aid is selective and restricted, despite an official discourse of universal health rights.