5.1 Introduction

The provision of healthcare for the population residing in a country is defined in related laws. A major issue is the coverage and cost of healthcare for individuals. There may be universal public healthcare, with users paying only a very small share of the cost, or healthcare based exclusively on being employed and/or having health insurance. A main issue is how the state defines the right to public health services for people in its territory, and whether human rights principles should override such legal healthcare rights and responsibilities (Nielsen 2018; Peers 2015; Savino 2016). Despite international agreements on human rights, not all countries apply them fully or consistently in the case of undocumented migrants and their access to healthcare (Biswas et al. 2012; Cuadra 2012; De Vito et al. 2016; Smith and LeVoy 2017; Woodward et al. 2014). This chapter discusses the background to the provision of public healthcare for undocumented migrants, who have no legal permission to stay in Finland.

Inequalities persist in the EU between non-EU migrants and non-migrants regarding access to healthcare services. Discrimination, and various legal, language, and communication barriers, result in unmet healthcare needs—in particular, through the underuse of primary and mental healthcare services and dental services (Lebano et al. 2020). Major differences exist between countries regarding their healthcare provision for undocumented migrants, even inside the EU (see Spencer and Hughes 2016). Almost all countries provide them with at least emergency healthcare (i.e. to recover from the sudden and unexpected onset of a health condition that requires immediate medical treatment and/or an operation). This does not mean that such provision is free of charge although, in practice, it is usually impossible to obtain financial contributions from these people. Few countries provide necessary healthcare services beyond emergency ones, and very few offer preventive healthcare. Nevertheless, earlier studies have indicated that the provision of wider healthcare services to undocumented migrants is less expensive for states than providing them with only emergency healthcare. The prevention of illnesses and other health problems requires investment, but is less expensive than treating actual illnesses (European Union Agency2015).

Despite undocumented migrants being provided with at least emergency healthcare, not all undocumented migrants use these, or even use wider official public or private healthcare services. The reasons vary and include, for example, challenges regarding language, culture or communication, inadequate information about the available services, difficult opening times and hours of attendance, lack of specialised services, fear of using the services, and lack of official and unofficial networks relating to social and healthcare services (World Health Organisation 2017). Another obstacle is what Bendixsen called micropractices of control in healthcare provision, whereby ‘individual authorities and street-level bureaucrats pursue micropractices of citizenship … in their encounters with citizens or non-citizens’ (Bendixsen 2018b: 168). These micropractices control the health of these people, excluding them from healthcare provision, while at the same time enhancing their agency, whereby they find new, creative ways to look after themselves.

Literature on healthcare for undocumented migrants in Europe is extensive and healthcare is among the most studied topics regarding undocumented migrants. Our own findings in Finland corresponded with the findings of other researchers on the matter: a tight (and dangerous) interrelation exists between immigration and healthcare policies, whereby a person can receive proper treatment only if he/she is a regular resident of the country (Chauvin et al. 2009; van Ginneken and Gray 2015). The Nordic countries seem to be particularly challenging in this sense, because of their personalised welfare society, meaning that people outside the system are easily spotted and questioned (Bendixsen 2018a, b), potentially leading to discriminatory practices (Hacker et al. 2015) at the local level. Undocumented migrants are often in great need of both physical and, as importantly, psychological treatment (see Andersson et al. 2018), but they might choose not to seek it for various reasons, such as fear of being identified and deported, combined with cultural and linguistic barriers (Hacker et al. 2015; Hultsjö and Hjelm 2005): ‘Undocumented migrants do not seek medical aid even in emergencies because they fear arrest’ (Khosravi 2010: 105).

In this chapter, we discuss the undocumented migrants’ access to healthcare and their use of healthcare services in Finland. After this introduction, in Sect. 5.2, we illustrate the viewpoint of Finnish local authorities regarding the healthcare (and other) services provided for undocumented migrants. As mentioned, the Constitution of Finland guarantees the availability of emergency healthcare services for everyone staying, permanently or temporarily, in Finland. Local authorities are responsible for providing healthcare for the people who live in the municipalities they govern; thus, undocumented migrants who live in a municipality may or may not turn to the services there. This chapter also discusses the impact on undocumented migrants of the measures taken against the COVID-19 pandemic, especially regarding their access to healthcare. In Sect. 5.3, we highlight access to healthcare from the perspective of undocumented migrants. Although undocumented migrants have access to emergency services and, in some municipalities, also to other necessary healthcare services, in practice they face many challenges in using them. We also highlight specific aspects of their mental and physical health. In Sect. 5.4, we present the conclusions of the chapter.

5.2 Access to Healthcare: Perspectives of the Municipalities

Regarding undocumented migrants in Finland, one crucial aspect is their access to healthcare. In fact, the National Institute for Health and Welfare (Terveyden ja hyvinvoinnin laitos, THL) argued that whether a person is an undocumented migrant in Finland depends on whether or not he/she has valid health insurance. Having such insurance means that a person has access to universal healthcare in Finland, but not having it means that a person only has a right to emergency healthcare and he/she must pay for the full costs of other services (Terveyden ja hyvinvoinnin laitos 2017). In principle, healthcare professionals have a right and duty to offer healthcare services to those who need them, including undocumented migrants. Furthermore, they have an obligation to maintain confidentiality and provide assistance (Terveyden ja hyvinvoinnin laitos 2018). Nevertheless, the practices vary—partly because of the rather complex healthcare system and partly due to a lack of clear guidelines regarding the access of undocumented migrants to healthcare.

In Finland, local authorities (municipalities) are responsible for the provision of healthcare. To arrange specialised healthcare, a municipality must belong to a joint municipal authority for medical services. The joint municipal authority for specialised healthcare manages hospitals and other operative units, whereas municipalities are responsible for basic healthcare centres. The joint municipal authority can also provide specialised healthcare at healthcare centres, if the health centres themselves cannot provide such services. Nevertheless, all major and severe illnesses are treated in hospitals. In addition, many private clinics offer healthcare services, which are, however, several times more expensive than the ones offered by the public sector.

Universal healthcare is heavily subsidised for the insured population in Finland. In view of the increase in the number of undocumented migrants, an inter-ministerial working group for migration decided, at the end of 2016, that it is the responsibility of local authorities to provide necessary services for undocumented migrants. At the same time, the state promised to subsidise the related costs for the municipalities (Sisäministeriö 2016). This policy followed the recommendation set by the THL, which had conducted a review of healthcare for undocumented migrants in Finland a couple of years earlier (see Keskimäki et al. 2014). The review suggested three models for guaranteeing healthcare services for undocumented migrants: (1) access to healthcare services to the same extent as people domiciled in Finland; (2) services with a similar scope to those offered to asylum seekers; or (3) urgent care pursuant to current legislation and care for children under the age of 18, for pregnant women, and for women who have recently given birth (see Keskimäki et al. 2014).

As discussed below, in Finland the resulting policy adopted the minimal model (model 3). The local authorities were given general guidelines on how to proceed with the issue and what needed to be included in the services. Decisions about undocumented migrants’ needs for health services must be based on medical evaluations, and emergency healthcare must be provided. In Finland, emergency care usually refers to immediate assessment and care required by a sudden illness or injury, a long-term illness that takes a turn for the worse, or reduced functional capacity that cannot be postponed without making the illness or injury worse, as well as urgent oral healthcare, mental healthcare, intoxicant abuse treatment, and psychosocial support (THL 2018).

As mentioned, only a minority of municipalities (42 municipalities; i.e. 15% of all municipalities) in Finland had undocumented migrants in their territories (or were aware that they had them up to the end of 2018); therefore, in practice, the migrants’ access to healthcare was a critical issue only in these 40–50 municipalities. According to our telephone interviews with the municipalities, 82% of municipalities with undocumented migrants also helped them. All these municipalities provided them with healthcare. Moreover, 82% of the municipalities with undocumented migrants provided other social services and 70% of them provided specific accommodation services (Jauhiainen et al. 2018; Jauhiainen and Gadd 2019). Accommodation services were also provided by many NGOs and private individuals. The number of undocumented migrants is low, so the main issue of healthcare provision is how to provide the services in practice (see Sect. 5.3) and how to cover, in practice, the relatively low costs of these services.

The principle is that undocumented migrants (like any non-registered non-EU or Nordic country citizens) are liable for all the costs of their healthcare. If they cannot afford these services—as is usually the case—local authorities must provide services, and the national welfare institute (Kela) will reimburse the related costs to the local authorities. The principal decision regarding service provision was based on the Constitution, which states that everyone in Finland should be provided with adequate necessary services and support for living; however, the financial process became rather complex for the service providers, local authorities, and undocumented migrants. It imposed a heavy administrative burden on the municipalities to receive the reimbursement funding from Kela, including registering and accounting for the provided services for undocumented migrants. Since that sometimes created problems regarding anonymity, some municipalities were left without reimbursement, sometimes by their own choice. Kela also applied to the Administrative Court regarding its obligation to provide subsidies for undocumented migrants, and the court decided that Kela was liable for providing such subsidies. Undocumented migrants also face many challenges when applying for Kela subsidies. The application process for such subsidies requires patience and skill from undocumented migrants, so many have never applied for this money, despite being legally entitled to do so (Akimo 2017; Lakka 2017; Roslund 2017).

Due to such variations in the provision of the healthcare services, and differences in accounting for such services for undocumented migrants, it is difficult to obtain an overall view of the situation and estimates of the costs of the provided services. Keskimäki and co-workers (2014: 35) estimated that, in 2014, the healthcare costs for undocumented migrants in Helsinki were around 0.4 million EUR and, nationally, up to 0.65 million EUR. Despite undocumented migrants not having to pay local authorities in Helsinki for the provided healthcare services, the amount was insignificant relative to the total costs for public healthcare. Overall, it was much less than one EUR per adult inhabitant of Helsinki; however, with the arrival of larger numbers of undocumented migrants, the service costs for them increased. The direct costs for Helsinki in 2019 were estimated to be 2.1 million EUR. These included direct costs for providing healthcare, social assistance, and short-term accommodation, together with the employment costs of the municipal staff dealing with undocumented migrants (Jompero-Lahokoski 2020). The total annual costs rose to slightly over three EUR per inhabitant in Helsinki; however, these costs did not include legal counselling or the provision of long-term accommodation.

Local authorities are not the only agencies providing healthcare services to undocumented migrants in Finland. In addition, Global Clinic, the organization specialising in the provision of healthcare for undocumented migrants by professional healthcare volunteers, operates in Helsinki, Tampere, Oulu, Turku, Lahti, and Joensuu, and undocumented migrants can use their services. There are small differences in the ways how the organization and its services are organized in different cities in Finland. Global Clinic Helsinki was established in 2011 to provide information, guidance, and healthcare services for people with irregular immigration status in the capital region of Finland (Global Clinic 2019). In 2016, Global Clinic Helsinki usually served undocumented migrants once per week and had, in total, 556 patients from 45 different nationalities. Typical reasons for visiting the clinic were digestive issues, skin problems, and musculoskeletal and connective tissue disorders (Tjukanov 2018).

The number of undocumented migrants grew substantially in 2016–2017, especially in Helsinki, due to rapidly growing numbers of asylum application rejections and the reluctance, and sometimes inability, of many rejected asylum seekers to leave Finland. Facing the challenges of a worsening healthcare situation for undocumented migrants, and the increasing risks for the municipalities and population of Helsinki, Helsinki City Council, at the end of 2017, decided that, besides the provision of emergency healthcare as required by the law, undocumented migrants would also be provided with necessary healthcare, including treatment for serious chronic illnesses, vaccination, and certain other necessary healthcare services. Furthermore, pregnant undocumented migrants and undocumented migrant children would be given healthcare under similar conditions to all residents in Helsinki. The proposal to extend the services caused a heated political debate and the council decision was not unanimous (Jauhiainen et al. 2018). Opponents claimed that it would be another burden on the local taxpayers and would attract more undocumented migrants to Helsinki. On the other hand, preventing illnesses from becoming serious would ultimately save money. Developments in 2018–2019 showed a movement of undocumented migrants from other parts of Finland to Helsinki, but this was not due to healthcare provision; it was because there were more opportunities for work and social contacts, as discussed in Sect. 4.7, and to ‘invisibilise themselves’ in a larger city. Helsinki later implemented an informal policy to restrict the access of undocumented migrants to its healthcare services by asking them for evidence of them living in Helsinki. Later, some other large Finnish cities provided broader access to healthcare for children and pregnant migrants; however, the use of such healthcare services is a rather complex issue for many undocumented migrants, as discussed in Sect. 5.3. However, a continuing issue was the differences in the provision of health care to undocumented migrants within different municipalities in the capital region.

5.2.1 COVID-19 Pandemic

The sudden emergence of the COVID-19 pandemic in March 2020 created additional challenges for undocumented migrants in Finland. COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Globally and locally, various coronavirus challenges became evident almost everywhere in the spring of 2020. In particular, risks were highest in densely populated areas in which social distancing and maintaining hygiene were very difficult. These included densely populated camps and settlements in which asylum seekers and rejected asylum seekers were waiting during the asylum process (Jauhiainen and Vorobeva 2020). In addition, risk areas included also cities and other places, where undocumented migrants did not know exactly what to do under these new circumstances or did not have proper means to protect themselves from the virus.

In Finland, soon emerged several major challenges for undocumented migrants as regards the COVID-19 pandemic: from where and how to receive accurate information about the virus; how to practice the prevention to lessen the exposure to the virus; what to do if one suspects of having the virus or at least some symptoms of it; and finally, how to cope in the new everyday situations with many new restrictions on access to public space (especially indoor space) and general mobility, no physical access to NGOs helping undocumented migrants, and how to follow the authorities recommendations such as to wear masks.

Many undocumented migrants became anxious due to the lack of proper information about the virus and how to prevent it. As regards receiving information about COVID-19, the national body responsible for healthcare—THL—provided soon in the spring of 2020 general information on its website in English, as did the World Health Organisation (WHO) in several languages. In addition, the City of Helsinki provided a website with basic instructions about what to do if one had symptoms of the virus. Such online information was available in Finnish, Swedish, and English. In.pdf format, it was also available in Arabic, Dari, English, French, Russian, and Somali. However, many undocumented migrants could not check or download these pages because of not having a proper access to the sites or not being able to find them. In addition, the online symptom assessment site was available only in Finnish or Swedish. Later in the autumn of 2020, during the second wave of the pandemic, were provided services that reached more directly the inhabitants. In Helsinki were organized pop-up information desks in shopping malls and other sites in the districts in which the majority of foreign-background population lived. The aim was to provide information about the virus and deliver complimentary masks for passers-by. In these pop-up sites was present also foreign background staff who knew some of the most commonly spoken languages in these districts, including those spoken by undocumented migrants. The services were provided to all passers-by so also undocumented migrants could take advantage of these if they wished so.

A particular challenge for undocumented migrants was that they were unable to self-quarantine or avoid physical contacts with other, possibly infected, undocumented migrants and other people they were dependent on, and some were afraid to turn to hospitals when they became severely ill. Although, for most people, COVID-19 was a manageable, mild illness, it was serious for those, including undocumented migrants, with chronic medical conditions, high blood pressure, etc. (Page et al. 2020). In Finland, numerous undocumented migrants have such chronic illnesses. Some undocumented migrants were tested for COVID-19 and some had contracted this illness; however, according to the interviewed NGOs, until the autumn of 2020, the known cases were mild and had no major outcomes. An additional challenge for an undocumented migrant residing illegally in Finland was that the person might be reluctant to have any virus testing or monitoring, because this would require providing detailed information about oneself, and especially with the evidence of having COVID-19, one would need to give an exact address, as well as information about people with whom one had contact.

In practice, in case of the COVID-19 symptoms, an undocumented migrant should have first called the helpline (instructions available in Finnish, Swedish, and English). If medical assessment of a suspected respiratory infection was then needed, the person should have been directed to a health station. This was difficult for many of undocumented migrants. In Helsinki, initially two health stations were dedicated to the treatment of coronavirus (City of Helsinki 2020); however, the national authorities decided that the tests and treatment for COVID-19 for undocumented migrants would be based on a fee. Nevertheless, some municipalities decided to provide COVID-19 tests and, if needed, treatment at the same price as for the registered inhabitants. In these cases, the state would not reimburse the costs originating from undocumented migrants (Kela 2020); however, the Ministry of Social and Health Affairs recommended that the full cost of treatment should not borne by municipalities for COVID-19-related urgent care for undocumented people (PICUM 2020b).

Physical measures against COVID-19 such as masks were not very commonly used by undocumented migrants. Many undocumented migrants had experienced wars and serious conflicts in which a visible danger was present every day. Some authorities argued that therefore some of these migrants were not able to properly perceive the potential risks of the virus (which impact on healthier younger and young middle-aged population was usually limited) and the need to wear masks. Furthermore, there was no legal obligation to wear masks, only recommendations by the authorities. In general, at least until the late autumn of 2020, masks were not commonly used in Finland in outdoor public space as the pandemic situation had been relatively less severe compared to most European countries. In addition, masks should be changed frequently, which was difficult to achieve, and many undocumented migrants did not have the cash or bank cards to enable them to purchase masks; therefore, some authorities agreed to issue vouchers that the migrants could redeem for masks in pharmacies. In Helsinki, there were sites where undocumented migrants, among other vulnerable and poor people, could obtain complimentary masks, but few of them took advantage of this opportunity.

Additional challenges became with the strict restrictions on the everyday mobilities. In March 2020, the Government of Finland announced a state of emergency in the country, due to the coronavirus outbreak, and a lockdown was imposed between the Uusimaa region (Helsinki and its surrounding area) and the rest of the country for 2 months. The authorities received additional powers to limit the rights of the population. In such situations, the Platform for International Cooperation on Undocumented Migrants (PICUM) (2020a) asked to ‘put in place measures (‘firewalls’) that shield people from possible transfer of their personal data from services to immigration authorities, and the risk of deportation if they seek care’. As mentioned, having a positive COVID-19 test result would create a situation in which the person would have to reveal all contacts and the addresses of the people he/she had been in contact with recently. This would expose other undocumented migrants—whether ill or not—to the authorities.

During the lockdown most organised services for undocumented migrants were suspended or substantially limited, and the NGOs had to close the advisory centres or substantially reduce access. Undocumented migrants lost their contact with NGO staff who could have provided accurate information, not only about the virus but also about all aspects undocumented migrants needed. Obtaining this information via the internet or even by telephone was difficult for many. In Helsinki, due to the COVID-19 pandemic, Global Clinic initially had to suspend its face-to-face activities; however, as the need to provide medical aid for undocumented migrants continued, it organised weekly pop-up clinics in a secret place in Helsinki. The health services in this outdoor tent were more limited than in the usual sites (Kataja 2020). In other locations, Global Clinic had to (at least temporally) reduce or even cease its activities during the pandemic. The reasons varied, but they included the authorities’ recommendations for social distancing and some of the (elderly) volunteer staff belonging to COVID-19 high-risk groups. Furthermore, the access to their earlier frequently used indoor public space, such as public libraries was often limited or there was not access at all. Also in shopping malls and other more private indoor places were substantially fewer people thus creating a risk that particular attention would have paid on them, especially if one would be there without wearing a mask.

In Finland (as in many other countries), the most severe spread of COVID-19 occurred in the largest city of the country, Helsinki and its surroundings, where also the majority of undocumented migrants lived. It became evident that COVID-19 spread more rapidly and extensively in Helsinki among certain immigrant groups, among whom were also undocumented migrants. During the first wave of the pandemic in the spring of 2020, one specific ethnicity was singled out in the media that caused displeasure and fear of additional marginalisation and discrimination among the members of this ethnic community (Teivainen 2020). There were cases of COVID-19 among undocumented migrants, but the exact number of cases is not known. By summer 2020, the COVID-19 cases lessened, but they rose substantially again in autumn 2020, especially from the mid-November onward (Worldometers 2020). The capital region was the area with absolutely and relatively the highest number of COVID-19 infected people in Finland. In December 2020 it became evident that the spreading of the COVID-19 in Finland was substantially higher, even manifold among the foreign background population compared with the Finnish background population (Terveyden ja hyvinvoinnin laitos 2020). This suggests also high risks of the COVID-19 exposure among undocumented migrants and more challenges for them to actively prevent the exposure to the disease.

5.3 Access to Healthcare: Perspectives of the Undocumented Migrants

As discussed previously, in Finland, undocumented migrants have limited access to health services. Emergency services are provided to them and some municipalities also provide other necessary health services. It is important to recall that Helsinki was among those municipalities that slightly extended its services for undocumented migrants, although with certain limitations as discussed previously.

Of the undocumented migrant survey respondents, three out of four (76%) knew where to go if they felt sick, but one out of four (24%) did not know. A positive answer to this question did not necessarily indicate that these people would turn to public or private healthcare in case of need. In addition, ‘knowing a place’ may only have meant knowing where to go if one became sick. This might not be an official healthcare unit but, instead, the home of a friend (perhaps with some medical skills) or simply a return to one’s accommodation in case of illness. In fact, a large number of the undocumented migrants did not know where to go if they felt sick. This could have indicated a lack of information among them or that they, despite having this information, did not dare to use the health services provided by the public authorities, private authorities, and NGOs. Most often, those who did not know where to go when feeling sick were men, underage, with lower education levels, who were unemployed and without a regular place to stay.

Despite there being administrative structures to meet the needs of undocumented migrants (as discussed in Sect. 5.2), some undocumented migrants are afraid of using them. Some undocumented people are not willing to go to (and to be seen in) official public spaces such as hospitals. Some are afraid of being denounced by the healthcare professionals, caught by the police, and then removed, if they do not show the personal identification card proving that they are residents of the country (similar challenges of access to healthcare for undocumented migrants with personal identification numbers also exist in Sweden; see Andersson et al. 2018). In Finland, practices that serve undocumented migrants vary locally and even within large cities. In some municipalities, the healthcare administration registers the use of healthcare by undocumented migrants, merely to provide evidence to the national authorities and reclaim some of the costs. While serving the visiting undocumented migrants, some municipalities suggested the voluntary return migration programme, as recommended by the Ministry of the Interior (2019). In other municipalities, these services were provided without any registration of the visiting person or recording of the services provided.

There was a general lack of information among undocumented migrants about access to healthcare services and what kind of access was available. Some chose to ignore their symptoms (Bendixsen 2018b), or did not have the energy to ask for help when it was needed or even look after themselves; hence, they allowed their conditions to worsen. As a psychotherapist we met reported:

For example, there was this guy who thought he didn’t have access to anything … but in fact he did, at least to something. I realised that, asked around a bit, and now he is able to get treatment. They don’t know which services are available to them and often, even when they know, they do not go.

Cultural habits might prevent other undocumented migrants from visiting a healthcare provider; for example, it might not be possible for a woman to visit a healthcare provider alone. In addition, she might not know where to leave her children during that time, and might need to be accompanied by a male family member who was not necessarily available. There might also be a language barrier (i.e. an undocumented migrant who visits a healthcare provider is never sure whether the receiving person will understand him/her or whether they can be trusted). One out of five survey respondents (20%) mentioned that they did not trust the people who helped them (19% did not know; 61% disagreed on this).

The challenges in providing healthcare for undocumented migrants are common everywhere in Europe (de Jong et al. 2017; Gray and van Ginneken 2012; Jensen et al. 2011; Ledoux et al. 2018; Spencer and Hughes 2016; Strassmayr et al. 2012; van Ginneken and Gray 2015; Weller et al. 2019; Winters et al. 2018) and especially in the Nordic countries, where the relationship with the state is personalised and constitutes the essence of their welfare programmes (Andersson et al. 2018; Bendixsen 2018c; Biswas et al. 2012; Jørgensen 2012; Thomsen et al. 2010). Not having a legal status is scrutinised by healthcare front-end personnel, so that the need for treatment is overlooked while the bureaucracy checks whether people have the actual right to that ‘privilege’. In Finland, the access of undocumented migrants to healthcare is normally limited to emergency care (Ministry of Social Affairs and Health 2019; Terveyden ja hyvinvoinnin laitos 2018), even though municipalities can decide themselves whether to extend the basic services or not (e.g. as the City of Helsinki did) and how to do it.

Moreover, undocumented people may ‘encounter several formal and informal barriers when seeking access to health care, including the financial barriers for general access to health care services, [and] the reported unwillingness of some health care providers to treat undocumented migrants’ (Biswas et al. 2012: 56). They may also feel mistrusted when accessing official healthcare services, as this interviewee in Bendixsen’s (2018b: 170) study highlighted: ‘Even if you are sick, you have to convince them that you really are sick’. This is related to the fact that they are offered (free of charge) only emergency services and they should pay for other services. Undocumented migrants suffer from diverse health problems. According to Ehmsen and co-workers (2014: 1), some patients with critical diseases, and an alarming number of pregnant women, did not seek medical care until a late stage, and the new mothers did not return for infant care after giving birth. Despite national and local programmes that offer good healthcare for every pregnant woman in Finland, some undocumented migrants preferred to give birth at home without going to a hospital or being attended by Finnish healthcare sector representatives. Home births are a normal procedure in many undocumented migrants’ countries of origin, and can also be chosen in Finland; however, in case of complications, it is risky to give birth at home with no medical equipment or attendance of medically trained personnel.

Stress, anxiety, difficulty in breathing, a sense of disorientation, memory loss, high blood pressure, and sleepless nights (Bendixsen 2018b, 2019; Graham et al. 2014; Myhrvold and Småstuen 2017) are common among undocumented migrants and are issues that many undocumented migrants we met explicitly talked about. In addition to these, ‘common keywords for their lives as undocumented migrants as they appear in the Nordic countries are loneliness, fear, hopelessness, dependency, unpredictability and powerlessness’ (Myhrvold and Småstuen 2017: 826). The winter is usually especially challenging for them. Many have high levels of psychological distress, which should be brought to the attention of healthcare professionals, as was evident from a comment made by one undocumented migrant (Tedeschi 2021):

I am much stressed, and things from the past just don’t go away. Now, even if I applied again and got a positive decision on my asylum application, ok yes, maybe a small piece of the whole puzzle would be in place, but all that happened to me won’t go away, just like that. In that sense, it won’t make any difference as I am still back there, where my colleagues got killed, and I then needed to flee. I don’t know who I am, or where I am now.

The majority of undocumented migrants have had traumatic experiences in their countries of origin and/or during their journeys to Finland. Their precarious living conditions, the impossibility of clearly visualising or planning their futures, the risk of being removed, and their continuous irregular legal situation worsen their already compromised psychological states. As the previous quotation hints, this distressed psychological condition may still affect those who, in the end, manage to obtain asylum or residence permits. Indeed, we heard cases of undocumented migrants whose stay in Finland was finally legalised, but whose psychological condition barely improved (Tedeschi 2021):

The change of legal status did not have any effect on my body. My past is still here. I cannot rest; sometimes I become so restless and stressed-out that I have to go out, just anywhere. I cannot sit still. I cannot see myself in the place where I currently live. I do not find myself anywhere. I cannot see the future.

Even though this person (who was originally an undocumented migrant) had received legal status as a refugee, his words echo the ones an undocumented person might have uttered. These people have typically experienced war or other violence, such as torture, or have suffered traumatic journeys (e.g. crossing the Mediterranean was, for many, a dreadful experience, which was not easily forgotten). Such precarious psychological conditions do not only affect undocumented migrants, but also those whose legal status has been regularised and who are, consequently, part of official society. As Lebano et al. (2020) indicated, refugees and undocumented migrants tend to have a higher prevalence of mental distress compared to non-refugees in Europe. In their study about undocumented migrants in Sweden, the majority of respondents suffered from post-traumatic stress disorder (PTSD; 58%), moderate or severe anxiety (68%), and moderate or severe depression (71%; Andersson et al. 2018). Undocumented migrants’ mental health conditions should not be considered as a separate issue from the official welfare state, but should be dealt with systematically, supported by forward-looking, proactive policies and practices aimed at preventing negative consequences. People who are mentally unstable may be more fragile and, hence, more vulnerable to the risk of human trafficking. Furthermore, untreated mental illnesses may lead to unpredictable behaviour, such as mentally unstable people harming themselves or others—which has already happened in the Nordic countries.

The urgent need for psychological help was also explicitly acknowledged by doctors working in Global Clinic, which is run by volunteers who provide healthcare services:

The services are primarily for patients who are not entitled to public health care in Finland regardless of nationality or migration status. [They] give information about health services in Finland. Services are free of charge, anonymous and in strict confidence. (Global Clinic 2019)

As said, Global Clinic runs clinics in six Finnish cities: Helsinki, Turku, Oulu, Tampere, Lahti, and Joensuu. Some undocumented migrants know about Global Clinic, but few are aware of how to access its services as undocumented migrants and tend to rely on their informal ‘protected’ networks if they need treatment. We interviewed doctors at one of the clinics, and they reported on the psychological condition of undocumented migrants they personally met:

We also have a psychologist in our team, because the number of mental health issues has sharply increased. Sleeping problems are just the tip of the iceberg … there are always other symptoms, such as depression …

Indeed, an undocumented person we met attended a Global Clinic and was ultimately hospitalised: ‘I was depressed. My psychologist was very afraid that I could hurt myself, kill myself’. When an undocumented migrant does not receive adequate help—from a physical, but also from a psychological perspective—it can lead to a mental state that can place the person, and possibly surrounding people, at risk. The mental burden can cause psychosis in urgent and untreated cases. In such a situation, this undocumented migrant may think that he/she is in his/her country of origin (despite being in Finland) and may act accordingly, as we witnessed during our fieldwork (see Tedeschi and Gadd 2021); therefore, the link between a lack of healthcare and actual risks to undocumented people’s, and society’s, safety and security should not be ignored. Rather, it should be addressed by considering whether extended access to healthcare for undocumented migrants might secure their wellbeing and the one of present and future society and, at the same time, reduce and/or prevent potentially dangerous events from occurring. This would include abiding by human rights legislation, as defined at the European level (PICUM 2010, 2017). As mentioned, the lack of information during the COVID-19 pandemic in 2020 caused additional psychological pressure for undocumented migrants, who did not know exactly what this disease was or what they should do about it.

Untreated physical illnesses are of no less importance, especially considering that they might be risky for both the undocumented people themselves and for local inhabitants (including children) who have not been vaccinated or are weaker and potentially more at risk of being infected. Indeed, as the Global Clinic doctors highlighted:

These people have been running for years, first in the Middle East, then in Europe … some of them have been running for 10 years … and for 10 years they have never had a health check-up … which is bad, because it is much better to prevent than to cure, cost-wise.

We met many undocumented migrants who had more or less serious physical health issues. One suffered from asthma and needed regular injections; one was hospitalised for heart problems; another collapsed after receiving a negative decision on his asylum application and was urgently sent to hospital, because his health condition was already precarious. He also had many visible scars.

Healthcare for undocumented migrant children is also challenging (Søvig 2011), as a study from Denmark highlighted:

We found that the number of contacts regarding care for infants and children was very low, which raises concern as to if these children are seen for vaccination and child examinations as they represent a particularly vulnerable group among undocumented migrants. (Ehmsen et al. 2014: 4)

All in all, for undocumented migrants, access to healthcare ‘is not only a question about legal regulations, but also a matter of migrants’ experiences and understandings of their rights and their practical access to care’ (Bendixsen 2019: 529). Moreover:

The feeling of not legally or in practice having access to healthcare services was formed by a combination of experiencing situations where they had felt rejected or humiliated by healthcare workers, responding to misguided information from various ‘helpers’ and socially relevant others, and relying on rumours about the risk of being turned in by healthcare personnel and then deported by the police. (Bendixsen 2019: 528)

5.4 Conclusions

Healthcare is a fundamental need for everyone. When one is healthy, there is no acute need for healthcare; however, when one suffers from an illness, access to healthcare is crucial, not only for quality of life, but for life itself. The Constitution of Finland therefore guarantees access to emergency healthcare for everyone, regardless of their status in Finland, including undocumented migrants. The responsibility for organising healthcare lies with local authorities; therefore, some local authorities have extended undocumented migrants’ healthcare to cover necessary healthcare. It is less expensive to treat certain illnesses (e.g. diabetes) before they have serious health-related consequences; however, only a few local authorities (around 2% of all municipalities in Finland) provide these ‘extended’ necessary health services for undocumented migrants in Finland. These cover about 15% of municipalities in which undocumented migrants live. Some municipalities recommend that undocumented migrants who are ill should move to municipalities that provide these extended services, thus increasing pressure on fewer municipalities.

Providing, in principle, urgent or necessary healthcare for undocumented migrants does not necessarily mean that they use it. There are many reasons for non-usage: they might not know about their right to use these services, they may be afraid of using them because they fear being caught by the police, they can face linguistic and cultural challenges (such as the availability of interpreters or male/female healthcare staff), and the bureaucracy and practices can be too demanding for undocumented migrants. Specific NGOs providing healthcare for undocumented migrants, in particular Global Clinic, have more appropriate practices for dealing with them, but not all undocumented migrants are aware of these services and some do not want to use them (e.g. being afraid of possible consequences leading into their deportation).

As in all populations, many undocumented migrants are physically healthy (especially because the majority of them are young male adults); however, they often have mental problems that they or the authorities might not be aware of. Ignoring undocumented migrants’ physical and psychological health can lead to unexpected and unpleasant consequences at both the individual and societal levels. In addition, the recent COVID-19 pandemic showed how important it is that everyone has access to healthcare and that relevant health-related information is provided accurately, on time, and in as many languages as possible. Knowledge-based policies concerning the health issues of undocumented migrants would help to prevent risks associated with their poor health, and would improve the living conditions of this already officially recognised vulnerable group.