Aggressively Passive

The State of Health of Migrant Workers in Israel

October, 2002

Written by: Rami Adut

Translation: Shaul Vardi
Textual Editing: Michal Rapoport
Cover Image: Miki Kratsman
Printed by: Arie Golan Printing Inc, Tel-Aviv, Israel

Some of the major conclusions are a product of our cooperation with Adv.
Dori Spivak and his students in the Human Right Center, Tel-Aviv
University.
Contents
Introduction…………………………………….….….... 3

Chapter One: Children

1A. The Current Situation………………………..……... 6
1B. Health Services for Migrant Children……….…….. 8

Chapter Two: Documented Migrant Workers

2A. Health Insurance for Visa Holders………............... 12
2B. The Right to Health of Documented
Migrant Workers …………………….………..….. 13

2C. The Health Services Order to the New Law…….…... 14

Chapter Three: Adult Non-Documented
Migrant Workers
3A. The Current Situation …………………….…….…. 20
3B. International Rights and Norms…………....……… 25

3C. Possible Solutions………………………………...….. 29

Chapter Four: Small Groups with Special Needs

4A. HIV Carriers………………………………..….….. 34
4B. Women Sold and Working in the Sex Industry…… 35
4C. Asylum Seekers and Refugees1…………………… 38

Conclusions……………………………………….……. 42
Responses………………………………....…………….. 45

1 We
have recently finished a full updated report on asylum seekers and
refugees in Israel together with Adv. Anat Ben-Dor of the Tel-Aviv
University clinic for legal clinical aid. The report will be available in
our office and web-site as of November, 2002.

2
Introduction

During the late 1980s and early 1990s, Israel saw the arrival of a
growing number of migrant workers2. As a result of the closure
policy prevalent at the time, which prevented Palestinians from the
West Bank and Gaza Strip from working within Israel, the
government acceded to pressure from employers and issued them
permits allowing them to bring migrant workers into the country,
mainly for construction and agriculture. By the end of 1997, the
number of migrant workers holding visas was already at 85,000.3

Some migrant workers who initially held valid visas have since then
lost this status for various reasons. Workers who “escaped” their
employers, either because of disagreements, extreme exploitation, a
desire to secure increased earnings on the black market, or various
other reasons will automatically lose their valid visa. In addition to
visa-holding workers, a large number of workers have arrived and
have been working in Israel since the 1990s without visas at all.
Most of these workers come from countries in which it is impossible
to obtain an Israeli working visa, such as Latin America, West and
South Africa and Eastern Europe. All the while Palestinian workers
have continued to enter Israel from the Occupied Territories
whenever the closure is lifted. While some return home at the end
of the day, others will stay in Israel for a week or longer.

According to figures of the Central Bureau for Statistics,

approximately 240,000 migrant workers resided in Israel by the end
of the year 2000, including those with visas and those without. All
of the migrant workers discussed here are not eligible for public
health services, which are provided to Israeli residents 4 under the
National Health Insurance Law (1994).

2 This document uses the internationally recognized term

“migrant workers.” In Israel, migrant workers are usually referred to as
“foreign workers.”
3 From: Yitzhak Shanel, Guidelines for Policy toward Foreign
Workers, Social Policy Research Center, Jerusalem, 2001 (all works
cited are in Hebrew unless otherwise noted.) The employers, and
sometimes certain government ministries, refer to these employees as
“escapees.”
4 The term “resident” is used here in its official sense, which
includes permanent and temporary residents as well, of course, as
citizens.

3
The National Health Insurance Law is one of the finest
achievements of the Israeli welfare state. It establishes the
eligibility of any resident in Israel to a minimum 'basket' of health
services as defined by the law. In other words, any person holding a
resident’s certificate (citizens are also residents) is entitled to health
services through one of the HMOs. The HMO is not permitted to
reject a member on the grounds of their religion, race, sex or state of
health. This eligibility is connected to the payment of health tax by
all employees and self-employed persons, but is not conditioned on
payment. Even a person who, for whatever reason, fails to pay
health tax or is not a member of an HMO, but who holds a
resident’s certificate, is entitled to the full health basket. As noted
above, all migrant workers, by definition, are not residents. They
hold working permits which far “lesser” status than those of
residents. The National Health Insurance Law, consequently, does
not apply to them.

It should be noted that the National Health Insurance Law includes a

special clause that allows the Minister of Health to extend the scope
of applicability of the law to additional groups (also to those who
are not residents). The Minister may also determine the
composition of the health basket to be provided, and the means by
which tax for these services is to be collected. In order to do so no
exceptional legislation is required. If he so wishes, the Minister of
Health (i.e. the Israeli government) can make public health services
available to migrant workers, thus solving the problems detailed
below. However, the present Minister of Health, like all his
predecessors, has refrained from applying this clause, even in the
case of small groups with particular needs, such as children.

Thanks to lobbying activities initiated by PHR-Israel and other

organizations, progress has been made in recent years in the
provision of health services to two groups: children without civil
status5 and adults who hold work visas. The laws and regulations
passed regarding these two groups have created a complex situation
that will be explained in detail in chapters one and two.

5 The progress secured regarding children did not include the

application of the National Health Insurance Law to this population;
rather, a special arrangement was introduced which will be discussed
below.

4
The reality for adults who do not hold visas − the largest group
within the population of migrant workers in Israel − remains,
however, the same as in the early 1990s. These workers have no
eligibility or access to health services and no attempt has been made
to provide them with such. Chapter Three will examine this group
and will include a number of proposals and conclusions.

The greatest problem facing migrant workers, as we see it, is the

fact that eligibility and access to medical services − preventative
medicine, primary and secondary care and hospitalization − are
completely ignored in the public debate and are non-existent on the
agenda of decision-makers in the field of health policy.
Accordingly, we encourage the Israeli public, policy makers and
media to initiate a public discourse on this subject on the basis of
this report.

5
Chapter One: Children
1A. The Current Situation
No information is available regarding the number of children born
in Israel to the families of migrant workers or brought into Israel
from their country of origin. This lack of information is a by-
product of the fact that, from the standpoint of the Israeli authorities,
these children effectively do not exist, even if they were born in
Israel and have lived in the country all of their life. They have no
civil status in Israel and do not appear in the State’s population
registry. While Israeli hospitals issue a certificate testifying to the
birth of a child and the Ministry of Interior registers the child in the
population registry. These procedures do not apply to migrant's
children.

The Municipality of Tel Aviv is the most prominent official body

that has adopted significant and far-reaching policies (compared to
the situation in Israel in general), and has included these children in
the social service systems. “Mesila” ('The Welfare and Assistance
Center for Foreigners' under the auspices of the Municipality of Tel
Aviv) is currently preparing a more precise survey on the number of
children living in Tel Aviv. At present, approximately 1,500
children of all ages are registered in the various systems associated
with the Municipality. If one assumes that the number of children in
Tel Aviv, including those not registered in any system, is
approximately 2000, and assumes that hundreds of families live in
areas outside of Tel Aviv (the Tel Aviv periphery, Haifa, Jerusalem
and Eilat), one may cautiously estimate that the total number of
children of migrant workers living in Israel is between 3,000 to
4,000.

Several social services are potentially available to these children.

Israel’s Compulsory Education Law requires that any child living in
Israel for over three months be enrolled in an educational institution.
Yet even this unequivocal requirement is not fully enforced, since
various agencies are often unaware of this community's existence.
Local education authorities have had difficulties coming to terms
with the concept of a child who lives in Israel but has no legal
status. Here, too, the Municipality of Tel Aviv and a number of
schools in the south of the city, such as the 'Bialik School', have
played a pioneer role, taking various steps to welcome these

6
children into the education system.

The second important service provided to the children of migrant

workers are development and preventative health services provided
through the 'Mother and Child' clinics. The Municipality of Tel
Aviv has opened these clinics to all migrant families. Following
this example the Ministry of Health has opened all Mother and
Child clinics under its auspices in Israel to the families of migrants,
and has collected payment for these services as it does from Israelis.

The Municipality of Tel Aviv and the education system (followed

by the public health system) have embarked on a process of
integration, namely the inclusion of children of migrant workers in
the social service systems, without legalization, i.e. a change in their
legal status. These children still lack a formal status, but they at
least have partial access to social services.

Until February 2001, the following health services were not

provided: family physicians, specialists, tests and hospitalization.
As of February 2001 these services have become available to the
children of migrant workers, yet the access is regulated through a
special arrangement, not through the National Health Insurance
Law. The following section explains the difference and process
involved.

7
1B. Health Services for Migrant Children.
February 2001 – February 2003
In 1999, PHR-Israel, together with The Association for Civil Rights
in Israel and The National Council for the Child, initiated a number
of lobbying activities. These included submitting a High Court
petition which stated that the National Health Insurance Law should
be applied on migrant children based on the UN Convention on the
Rights of Children which prohibits discrimination between children
on various grounds, including their parents’ status and social
origin6.

MK Tamar Gojansky (DFPE), Chairperson of the Knesset

Committee for the Advancement of Children’s Rights, contributed
to the work of the lobby, as did MK Yuri Stern ('Israel Beitenu'
party) during his period of office as Chairperson of the 'Committee
for the Problem of Foreign Workers'7. Gojansky's proposed law,
which stated the application of the National Health Insurance Law
(and its public health insurance plan) to migrant children, was an
additional source of pressure on the various authorities.

The Ministry of Health responded to these pressures, to a certain

extent, and initiated an administrative arrangement for the provision
of services through one of the HMOs- 'Kupat Holim Meuchedet'.
This arrangement began to operate in February 2001. Since then
PHR-Israel has been monitoring the implementation of this
arrangement. Our findings show that 'Kupat Holim Meuchedet' has
spared no effort in facilitating registration and in providing services.
The HMO has even waived, on its own initiative, the waiting period
for children not born in Israel (a six-month period during which
only emergency services are provided); in practice, these children
receive the full range of services from the moment of registration.

Dozens of children and babies whom we know to be suffering from

chronic and other illnesses have been registered for the arrangement
and are now receiving full treatment. For these children, this is a
tremendous improvement of the health services they receive.

6 UN Convention on the Rights of the Child. Article 2.

See http://www.unicef.org/crc/crc.htm
7 The two MKs come from the two extremes in Israeli
parliamentary politics. DEPE 'HADASH' from the far left and 'Israel
Beitenu' from the far right.

8
It is important to emphasize the great advantage of the arrangement:
the basket of health services received by children from migrant
families joining the arrangement is equal in all respects to the basket
of services enjoyed by Israeli children. The HMO cannot refuse to
insure a child on the basis of his medical condition or origin8. The
scope of registration, however, has been disappointing. No more
than eight hundred children have been registered out of several
thousand we believe to be living in Israel. The reasons for this are
unclear, though we believe that there may be a number of problems
with the arrangement that may be the cause. These will be discussed
below.

The introduction of the arrangement is not identical to the

application of the National Health Insurance Law (an action which,
as noted above, is within the authority of the Minister and requires
no legislation). We shall illustrate the difference between these two
steps and review the problems related to the arrangement:

 Free Choice for Parents: This is a voluntary

arrangement. Parents can decide whether or not to
register their children, and the provision of services
is contingent on registration and payment. This is
in contrast to Israeli children, who are entitled to
services regardless of payment and registration.
 Fixed Payment: A fixed payment of insurance fees
contradicts the reality of migrant workers' life,
namely constant uncertainty and a lack of economic
and social stability.
 High Payments: Insurance fees are 185 NIS per
month for one child, and 370 NIS per month for
two or more children. People who support
themselves from house-cleaning and other irregular
jobs find it difficult to commit to these payments.
 Familiarity with the Concept of Governmental
Insurance: Some groups of immigrants are
unaware of the distinction between private and
government sponsored insurance, since the concept

8 The only exception to this is a child who is ill on arrival from

abroad and immediately joins the arrangement. This exception is
intended to prevent “medical tourism.”

9
 of government insurance does not exist in their
country of origin. They will express reservations
and a mistrust of insurance that is "a promise" to
cover future services if necessary. Some families
have had negative experiences with private medical
insurance schemes marketed in Israel and have lost
confidence in insurance altogether.

Despite all of these reservations, it is important to note that the

arrangement represents a major step forward in terms of the attitude
of the Israeli authorities towards the children of migrant workers in
particular, and migrant labor in general. We hope the scope of this
project will be expanded rather than contracted by February 2003, at
which time the pilot period will have ended.

It is our belief that the National Health Insurance Law should be

applied to these children. While the differences between this
proposal and the existing situation may seem slight, they are, as we
have pointed above, quite significant. Our proposal is that all
children be eligible for health services by their right as children
who are not accountable for their parents’ actions and are entitled to
services comparable to those received by Israeli children. These
health services shall be provided regardless of the parents' ability to
meet arrangement demands. We believe that children should not be
punished for their parents’ failings, and that it is unacceptable that
in addition to their harsh living conditions they should be prohibited
from accessing reasonable health services.

This proposal will meet in full the requirements of the UN

Convention on the Rights of the Child. A far less desirable
alternative would be that the Health Ministry continues the payment
arrangement in its current format. In this case, it should include
amendments leading − we hope − to an increase in the number of
those registering. These amendments should include flexibility of
payment sums, the establishment of criteria for social assistance,
improved mechanisms for payments, and more.

10
 M. is a Colombian citizen. Her husband was deported from Israel
and she is currently raising two children by herself. Her 11 year-old
son suffers from behavioral problems at home and at school. M. is
barely able to support her two children. Her son can undergo
diagnosis within the education system, but cannot receive ongoing
psychological treatment, since he, like his brother and mother, does
not have medical insurance. When we told M. about the possibility
of receiving full insurance through Kupat Holim Meuchedet, she
replied that there was no way she could meet the payment - she
would have to pay 370 NIS every month for medical insurance for
her two children. PHR-Israel, through the 'Open Clinic for Migrant
Workers' has no funding available to help the family pay the
insurance9. 'Mesila' – the Municipal Welfare and Assistance Center
for Foreigners – is also unable to help, since it too has no special
funds. There exists no procedure in which the Ministry of Labor and
Social Affairs or the Ministry of Health can provide support in such
a case. At the time of writing, these children are not insured with an
HMO as part of the administrative arrangement.

In February 2001, the administrative arrangement for

providing health services to non-Israeli children was
introduced as a pilot program for two years. According to
the arrangement, the basket of services for these children is
the same as that for Israeli children. Yet, conditions and
procedures are different; any child who has been in Israel
for six months or more may be registered. His parents
must pay the insurance fees. Children not born in Israel
must wait six months before receiving the full basket.

9 A description of the routine activities of the Open Clinic

appears on the next page, and in PHR-Israel’s website: www.phr.org.il.

11
Chapter Two: Documented Migrant Workers

2A. Health Insurance for Visa Holders

Migrant workers who hold visas (Documented) continue to arrive in
Israel from Thailand (agriculture), China and Romania
(construction), the Philippines (nursing), as well as from other
countries. Construction workers from Romania and China
constitute the most exploited group of workers in Israel. Their work
visa, which should define their legal protection and their rights,
actually chains them to a single employer who consequently has
total control over their living and working conditions.

Since the 1990s work visas have been contingent on the purchase of
private medical insurance by the employer. This requirement has
allowed for the creation of a private market with an enormous
turnover.10 Competition has led to reduced policy prices, but not to
improved standards. Indeed, the opposite is true: there has been a
constant decline in the quality of health coverage provided by the
insurance companies. In previous reports, PHR-Israel detailed the
numerous loopholes in these policies and described the typical
behavior shown by insurance companies and employers towards
workers with visas who were misfortunate enough to become ill
during their stay in Israel. Insurance policies not only excluded a
wide range of treatments (such as chronic and malignant illnesses),
but also included clauses designed to force insured to leave Israel
once they became ill (as in the case where treatment can be
postponed). It is no coincidence that insurance policies have
become known as “flight ticket policies.” This was the situation
prior to October 2001, at which time the Health Services Order
came into effect. The order was intended to regulate the private
market and impose restrictions that would benefit the insured.

10 The following calculation offers some idea as to the scope of

the market: if each insured worker pays one dollar a day, and if there
are almost 100,000 such workers in Israel, all of whom are required by
law to secure insurance, it follows that the private insurance companies
earn $ 100,000 a day for medical insurance policies alone.

12
2B. The Right to Health of Documented Migrant Workers

Regarding Documented Migrant Workers, the Convention of the

World Labor Organization (to which Israel is a signatory) states:
“Any member of this Convention shall implement, without
discrimination on the basis of nationality, race, religion or sex, for
migrants legally present within its territory (documented) treatment
that is not inferior to that it provides to its citizens in the following
areas:
[…]
(B) National insurance (i.e., a legal means addressing injury at
work, motherhood, sickness, disability, advanced age, death… or
any other eventuality covered by local laws or regulations by a
national insurance program), subject to these restrictions:
2. Laws or regulations of migration countries may enact special
arrangements relating to benefits or parts of benefits paid in full by
public funds…”

On the one hand the convention establishes equality between

Documented Migrant Workers and residents in the provision of
health care, and raises the question of medical insurance. On the
other hand, the convention permits countries to introduce special
arrangements regarding migrant workers. The duty to collect
national insurance fees and health insurance from migrant workers
may also be deduced from the convention. In return, the State will
provide them with equitable social services.

Israel has chosen not to include health services for Documented

Migrant Workers in the same arrangement Israeli workers are
entitled to. Instead, the State has also chosen to take advantage of
the option of providing “special arrangements” for these workers.
This situation may be permitted according to the letter of the
convention, but is contrary to its spirit, which calls for equality
between local and legally employed migrant workers.

13
2C. The Health Services Order to the New Law for the
Employment of Migrant Workers: A Happy End?

The amended law for the employment of migrant workers was

passed in the beginning of January 2000 and included a provision in
the matter of medical insurance for migrant workers. The Minister
of Health could choose between one of two possibilities included in
the law: either to issue an order regulating private medical
insurance, or to apply the National Health Insurance Law to
Documented Migrant Workers. After considerable delay, the order
was enacted in March 2001 and took effect as of October 2001. The
Minister of Health chose the former option − an order regulating
private medical insurance − rather than imposing the National
Health Insurance Law on migrant workers (payment of health tax
and the provision of services through the HMOs). Criticism of this
decision was raised by PHR-Israel and reflected our extensive
experience with the methods of operation of the private insurance
companies. The Ministry of Health argued that the order issued
would address the problems raised by imposing restrictions on the
conduct of the insurance companies and by defining the basket of
services.

In light of the current situation, the order certainly constitutes a

significant improvement − at least on paper − towards ensuring
reasonable services for migrant workers. We shall, however,
attempt to summarize the advantages and disadvantages of this
arrangement.

Advantages:
 The order includes various mechanisms for appealing the
decision of the insurance companies, and protects the insured
(at least on paper) against arbitrary decisions by the company.
 The order includes most of the services in the basic basket of
services received by Israelis.
Disadvantages: (see flow chart below):
Since the enactment of the order, PHR-Israel has been
monitoring its implementation together with the Human
Rights Program at the Tel Aviv University. In dealing with
the insurance companies we have discovered their attempts to
return to the norms practiced prior to October 2001 and their

14
 endeavors to use various schemes to rid themselves of sick
workers.
We do believe, however, that the level of health services has
improved as a result of the order and of NGOs inspection.
Experience has shown that migrant workers who enjoy the support
of their employers, and turn to us for assistance are often successful
in receiving the health services to which they are entitled.
Unfortunately, the current situation has not provided a solution for
who will lose their eligibility for health services following the loss
of their work permit for whatever reasons.

In our opinion, the following are the main problems encountered

subsequently to the implementation of the order:
 The exception clauses of “former medical condition” and
“loss of working capacity” allow the insurance companies to
cease the provision of insurance coverage. An insurance
company may base its decision on the opinion of a specialist
physician (working on its behalf) who can determine − often
without documents or direct proof − that the illness existed
prior to the insured’s arrival in Israel, or that the patient will
not regain his capacity to work. In these cases the insurance
company may cease insurance coverage and send the patient
to his country of origin. Fortunately, the worker has access to
appeal mechanisms, which he may be able to activate if he
has the support of his employer and receives proper legal
representation.

 The insurance policy is purchased by and belongs to the

employer. Accordingly, once the employee falls ill the
employer may nullify the policy and thus cancel the
employee's insurance coverage. The employee will
consequently lose his visa (namely his working and staying
permit). The fact that employers have such power over
employees makes it difficult to protect a sick employee facing
an insurance company that is reluctant to pay for his
treatment. This is one aspect of the consequences of
“chaining” employees to their employers11.
 The insurance companies have recently reintroduced an old
'favorite': when the period of insurance expires, the company

11 For other devastating aspects of the "chaining" policy, see Hot Line for
Migrant Workers publications www.kavlaoved.org.il

15
 will refuse to renew the policy even if it covered treatment
expenses during the previous period. Without health
insurance the employee is unable to renew his working and
staying permit and loses his official status.

 Workers who cannot reach organizations that can provide

them with legal aid face the greatest problems. These
workers are generally the most exploited. Romanian and
Chinese construction workers are rarely able to physically
free themselves of their employer and secure legal protection.
In a number of cases we handled we suspected that workers
were being sent back to their country of origin without
enjoying legal protection. Unfortunately, we usually
encounter Romanian and Chinese workers long after their
presence in Israel has become unlawful and after they have
‘escaped” from their employer. These workers have almost
no chance of securing protection under the order or the law;
in most cases the medical insurance paid by their employer
had been nullified at the time of their “escape.”

16

The policy expires.

 The insurance company covers medical treatment.
surance company claims that the worker has a prior medical condition, or that he has lost the capacity to w
worker contacts us, we will help. If he does not, or if the appeals period expires, insurance will be nullified. T
es to renew the policy for an additional period and states that there is no need to present a legal basis for t
he insurance period ends. The concept behind the Foreign Workers' Law is that health services are continge
ddddsssssssssssssssss
, the employer is repaid the insurance fee for the period pending the expiry of the policy. Since the employ

A worker falls ill.

Most workers, particularly manual laborers, try to avoid going to the physician due to the
loss of working days it entails.

The sick worker contacts the insurance company health

services. The employer
dismisses the
worker and
nullifies the
insurance policy.
If the employer
dies, the policy
might also nullify
unless the man
power agency

The sick worker is

deported and
flown back to his
country of origin.

Medical expenses are no longer

M., a Filipino covered nursing
worker, came to Israel over
five years ago in order to care
for an elderly woman who
had cancer. The worker no longer has a valid Following her
working permit.

17
arrival in Israel she received a working and staying permit, and her
employer provided her with medical insurance through the 'Shiloah'
insurance company. At the end of February 2001 she was diagnosed with a
malignant tumor. 'Shiloah' announced that it would not renew the insurance
policy, but that it would be willing, beyond the letter of the law, to finance
outpatient services for a period of three months only. Since M. no longer
held valid medical insurance, the Ministry of the Interior refused to extend
her staying and working permit (since the visa was contingent on a valid
health insurance policy). Not only did M. find herself fighting a terrible
disease, but she had also become an illegal alien in Israel. On July 2, 2001,
M. underwent her third chemotherapy treatment. However, since the three-
month period set by 'Shiloah' had reached its end, and the company refused
to pay for the treatment. M. had no choice but to cover the cost of
chemotherapy (1,600 NIS ) by herself and she withdrew the limited
savings she had managed to accumulate during her years of work in Israel.
It should be noted that two weeks after leaving her sick bed, and before she
had fully recovered from the operation to remove the malignant tumor, M.
was obliged to return to work in order to earn the money needed to remain
in Israel. On October 16, 2001 – the day the new Medical Services Order
took effect – a hearing took place in the matter of the petition submitted by
PHR-Israel to the High Court of Justice, demanding that M. receive a
temporary working permit and medical treatment and calling for the
amendment of the new order. The State's representative refused to agree to
any compromise suggested by the Court, and the Court itself declined to
any compromise suggested by the Court, and the Court itself declined to
provide M. with any protection. M. was unlucky enough to fall ill during
the period when the Ministry of Health was procrastinating before issuing
the new order. She received no help from the Supreme Court of Justice, a
fact that was criticized by attorneys from the human rights field. What
would have happened had M. fallen ill after October 16, 2001? Would she
have received all the treatments she required? Perhaps not. Our experience
shows that the insurance company could have raised various arguments
(prior medical condition, loss of working capacity) and the employer could
have fired M. and ceased policy payments.

M. is a Romanian nursing worker who worked for some two years for an
elderly woman suffering from Alzheimer's disease. M. was insured through
the 'Shiloah' insurance company. On November 6, 2001 – ten days prior to
the introduction of the new order – M. went to the physician, was
diagnosed as suffering from cancer and began receiving treatment. At first
the insurance company covered treatments, but subsequently it began to
limit medication payments, claiming that these costs were limited in
accordance with the policy. Fortunately, the new order had already taken
effect. After legal intervention by Attorney Dori Spivak from the Human

18
Rights Program at the Tel Aviv University the insurance company dropped
its case. M.’s state of health is now satisfactory – she is in complete
remission and has an excellent chance of recovery.
She now faces a second crisis. Her most recent insurance policy was
purchased for one year, ending October 2002. The insurance company has
already announced that it will not renew the policy. This means that M.
will be unable to receive additional medical treatment. Moreover, since she
cannot receive a working permit without being medically covered, M. will
become an illegal alien and at risk of deportation. The elderly woman for
whom M. cares cannot manage without her help. On May 2002, PHR-
Israel sued the insurance company in court, demanding that insurance be
renewed and arguing that failure to do so strip the Health Services Order of
any meaning. We should emphasize that at least in this case the employee
is receiving real support from her employer. Were M.’s employer to
dismiss her – as other employers have done – her chances would be much
worse.
A few days after filing the statement of claim the elderly woman for whom
M. had been caring passed away. We do not know now whether M. will be
able to receive legal protection despite the fact that she has not lost her
capacity to work. At present M. still requires health services, but she has
no job and is at grave risk of losing her working permit.

On October 2001, a hearing took place following the High

Court petition filed by PHR-Israel. The petition demanded
that medical services be provided to two documented Filipino
women who had medical insurance and who had fallen ill
during the period preceding the issue of the order by the
Minister of Health. Their medical insurance had been
nullified and their treatments were no longer covered. They
were dismissed and therefore lost their working and staying
permit.
The Court declined to grant the relief we sought - the
provision of medical services for these two workers, the
return of their working and staying permits and the
amendment of the order – and the women did not recover
their health insurance.

Chapter Three: Adult Non-Documented Migrant Workers12

12 We use different terms for the same population: without visas, non-
documented, illegally employed etc.

19
3A. The Current Situation
Non-Documented Migrant Workers most likely constitute the
majority of the migrant (non-Jewish) population in Israel. To date,
no law, regulation or arrangement has been issued in the purpose of
providing health care services to this population and there is no real
migration policy e.g. there is no regulated way for the provision of
civil status to a Non-Documented Migrant. As illegal aliens in
Israel, these migrants face the constant threat of deportation. The
principal authorities involved in their fate are the Ministry of
Internal Security (the police), the Israel Prison Service and the
Ministry of the Interior, which is in charge of issuing deportation
orders13. The number of Non-Documented Migrant Workers is
currently estimated between 100,000 and 200,000 or more,
depending on the source of the estimate. This number includes
workers who had a working permit but who lost their legal status,
and others who arrived in Israel as tourists or with another kind of
status.

The rights of this population and ways by which to solve the

problems they face have hardly been addressed up to now. Our
involvement to date has centered on humanitarian aid for patients,
which we have attempted to provide through our voluntary Open
Clinic for Migrant Workers established in 1998. We shall discuss
this population in particular detail and suggest various ways to solve
the problems we have encountered.

As a general rule though, none of the services available to Israeli

residents through the HMOs and the basket of services − primary
and secondary medicine, therapeutic and preventative care,
rehabilitation and hospitalization − are accessible to migrants who
do not have a working permit. Despite this generalization, however,
a small number of services are attainable or provided to Non-
Documented Migrants:

1. PHR-Israel Open Clinic for Migrant Workers. The clinic

currently provides a wide range of primary and secondary
medical services at little to no cost, and does its best to help
13 A new "immigration police" was initiated as of September 2002
together with a deportation policy aiming at 50000 deportees. Until
now, the new police managed to deport some 500 people a month.
Meanwhile, at the pressure of employers, thousands of migrant
workers are entering the country every month!

20
 in more complex medical situations.
2. Private clinics and medical centers. Costs at these clinics
are usually high, since they are intended for prosperous
Israelis seeking immediate, quality health care services.
3. Hospitals and medical centers in East Jerusalem and the
West Bank. Due to the prevailing security situation, East
Jerusalem provides the only possibility for receiving medical
services at a low cost compared to Israel.
4. Private clinics and physicians in Israel offering
inexpensive services. These are generally physicians who
are “doing a favor” and earning relatively small sums in
return for providing services to migrant workers. Often these
are physicians who speak the migrants’ language; in other
cases these are physicians attempting to survive in the private
market (e.g. chip dental services for the poor).
5. Emergency hospitalization: According to the Patients’
Rights Law, “in a medical emergency situation, a person is
entitled to receive urgent medical treatment without
condition.”14 It must be pointed out that hospitals may try to
collect payment from patients following urgent
hospitalization - emergency hospitalization is not free in
Israel and the hospital will not be reimbursed. The inevitable
result of this situation is that hospital administrators will put
pressure on the medical staff in the emergency room and
wards. Payment is often mentioned and even presented as a
condition, in spite of the above-mentioned law that prohibits a
financial condition for the provision of a medical service. An
excuse for that may be that the law does not clearly define
what is considered an emergency. Our impression is that the
practiced definition of emergencies in emergency rooms is
becoming increasingly narrow as hospitals face growing

14 Patients’ Rights Law, 1996, Article 3(B). As defined in the

Law, a medical emergency consists of “circumstances in which a
person’s life is in immediate danger, or when there is immediate danger
that a person will incur severe and irreversible disability if he is not
given urgent medical treatment.” According to statistics from Ichilov
Hospital in Tel Aviv, 'bad debts' in 2001 totaled 1.1 million NIS, and
the accumulated debt over the years totals almost 5 million NIS. These
figures have been provided by Ran Zafrir, Director of Intake Services
at Ichilov Hospital, to Hamotal Barkan and Rinat Sagi, and appear in
their academic paper.

21
 financial pressure15. The cost of one day’s hospitalization for
a “tourist’ (i.e. a person who is not a documented Israeli
resident) is approximately 3,000 NIS, 600$. Hospitalization
debts quickly transform into “bad debts” that cannot be
collected from the patients.
6. 'Mother and Child' clinics. Enforced by the Municipality of
Tel Aviv and subsequently adopted by the Ministry of Health,
today any pregnant mother, regardless of her status, is entitled
to register at the 'Mother and Child' clinics and to pay the
same fee paid by Israeli women. In return, she will be entitled
to pregnancy inspection and immunizations of the infant.
7. The cost of hospitalization for birth should be covered by
National Insurance Institute, even if the mother is not legally
employed, provided that she has worked for more than six
months prior to delivery. In practice, however, hospitalization
costs are covered only in cases where the employer has paid
National Insurance fees regardless of the employees' status.
This entitlement is therefore accessible to Non-Documented
Migrants, yet it is difficult to obtain.

As noted, all remaining medical services are inaccessible, either

because Non-Documented Migrants are not residents or because
services are too expensive. Even if migrants are hospitalized in
emergency cases in accordance with the Patients’ Rights Law, they
face mental anguish due to the enormous cost of hospitalization –
sums that are completely beyond anything they can imagine. Some
patients refuse emergency treatment and leave the emergency room
or ward, endangering their health because they have no idea how
they can cover the incurred expenses.

PHR-Israel’s clinic cannot possibly meet the medical needs of such

a large population, and it should not have to do so. Nevertheless,
our clinic is sometimes used by decision-makers as a fig leaf (and a
very small one at that) in order to mask the broader issue.

The Open Clinic for Migrant Workers opened in 1998 and continues
to expand. Over the past years, the number of patients attending the
clinic has risen sharply. We are greatly concerned that it will be
impossible to maintain a high level of services on a voluntary basis
for much longer. The Clinic consists of three treatment rooms
15 e.g. in cases where the immediate danger is not obvious,
hospitals tend to deny the service.

22
staffed by one or two physicians and a nurse. It opens almost every
day of the week in the afternoon. Dozens of physicians, nurses and
staff volunteer in the Clinic, and dozens more provide additional
voluntary services. A number of medical institutions also provide
services, mainly consultations but also tests, for reduced fees, at
regular private rates or for free. Since the Clinic's opening more
than 10,000 new files have been opened, yet the number of visitors
is even higher. In 2001 alone, some 2,500 new files were opened
and approximately 6,000 patients attended the clinic (not including
referrals to volunteer physicians). In other words, 40% of those
attending the clinic were new patients. Every month, 60% of cases
are seen by a family physician, approximately 70 patients see a
pediatrician and approximately 60 see a gynecologist.

Ichilov Hospital is the main contact for emergency cases involving

migrant workers living in Tel Aviv. The hospital facilitates this
relationship in many ways and the staff shows a very high level of
willingness to help. Ichilov Hospital also provides a quota of
medical services − mainly consultations and laboratory tests − for
the Open Clinic. On average, 37 tests of various types are carried
out at Ichilov Hospital each month. Assuta Hospital provides very
substantial discounts for migrants referred by PHR-Israel as well,
and allows our volunteers to perform operations in its facilities at
very low rates. In some cases, an operation at Assuta Hospital is the
only way a migrant worker can receive treatment. Tel Hashomer
Hospital also contributes specific tests.

The following referrals are for a random month during 2001:

Emergency Operations Voluntary Clinics Clinics Clinics Clinic

room and other specialists: and and and of the
procedures ENT, hospitals hospitals hospitals League
surgical, - free – – full Against
orthopedist, reduced rates TB
urologist, rates (free)
gynecologist,
etc.

23
13 5 31 70 11 52 9

24
3B. International Rights and Norms

Given the serious nature of this matter − the right to health of Non-
Documented Migrants − we found much too few references to this
subject in the various international conventions to which Israel is a
signatory. The matter is discussed in the UN Convention on
Economic, Social and Cultural Rights and in an ancillary note on
the subject of health. The following quotes may seem far-reaching,
but given the possible financial expenditure involved and the size of
the population without visas in Western countries, they are actually
modest and unduly vague.
According to Note 14 to Article 12 of the UN Convention on
Economic, Social and Cultural Rights:
“Countries… are obliged to refrain from imposing
restrictions or preventing the equal access of any
person − including prisoners, detainees, minorities,
asylum seekers and Non-Documented Migrant
Workers, to preventative, therapeutic and palliative
medicine; to refrain from implementing discriminatory
practices as state policy.” 16 (Translation: PHR)

Elsewhere in the same note it is stipulated that public health services

must be available and accessible to all persons “in a reasonable
quantity:”17
“Medical installations, merchandise and services must
be available to all. Payment… should be based on the
principle of equality.”18 (Translation: PHR-Israel)

The convention does not provide a clear policy, and accordingly

cannot serve as the basis for demanding equal eligibility for health
services for migrants and local residents. We will therefore turn to
international norms: is there an international norm, or at least a
Western one, that requires health services to be provided to Non-

16 The notes to the Convention were made by the UN committee

responsible for its implementation and constitute an authorized
interpretation of the Convention, providing guidelines for the actions of
the signatory states.
17 Article 12(1) (2) of Note 12 to the UN Convention on
Economic, Social and Cultural Rights.
18 Article 12(3) of Note 12 to the UN Convention on Economic,
Social and Cultural Rights.

25
Documented Migrants?

Before drawing any conclusions we shall summarize the

information we have pertaining to countries in Western Europe:19
 Britain is the only country, to the best of our knowledge,
where public health services are effectively open to all
persons, with or without visas. Although in formal terms and
according to court rulings the right to receive health services
is confined to persons legally present in Britain, in practice
civil status, insurance coverage and economic ability and
origin are irrelevant at the general clinic where medical
services are provided.20 In regards to hospitals, restrictions
apply according to status and to the type of illness, but these
are loosely phrased. In most cases Non-Documented Migrants
receive free services. Emergency hospitalization (up to one
night) is free; beyond this period the hospital may, in
principle, request payment, yet there is a long list of types of
illness for which patients are exempted from payment.21
Asylum seekers may suffer due to the policy of “dispersal,”
which requires them to live in specific areas around the
country, sometimes removed from their own communities. If
these people move to other areas they are no longer
recognized by the authorities and lose their rights to special
assistance services. Sick asylum seekers whose applications
have been refused and who are awaiting deportation may
sometimes receive humanitarian residency permit.22

 In Belgium, reimbursement may be received for emergency

19 Our information is based mainly on the publication “Health

Care for Undocumented Migrants,” published by PICUM: Platform for
International Cooperation on Undocumented Migrants, De Wrikker-
Antwerp, Belgium, June 2001. This source confirmed and added to
data collected from other sources, such as NGOs, public reports, media
articles, the 'December 18' site (www.december18.net) and more.
20 The general practitioner receives payment from public funds
based on the number of patients he sees, regardless of their status. The
physician, however, may refuse to accept a person for treatment.
21 Such as infectious diseases, HIV and AIDS, and psychiatric
patients admitted in compulsory hospitalization. Patients with serious
diseases who are facing deportation may request, and may receive, a
special humanitarian residency permit.
22 Health Care for Undocumented Migrants, pp. 64-74.

26
 medical services through a government agency (CPAS23)
whose objective is “to ensure a decent existence for any
person present in Belgium.”24 It is important to note that the
definition of “emergency’ in Belgium appears in a royal edict
from 1996, and also includes “preventative and therapeutic
medical assistance that may be provided in an ambulatory
framework and in a hospital/institution.” In contrast to the
process we have identified in Israel, the definition of
“emergency” reflected in daily use by Belgian physicians has
extended rather than narrowed the legal definition.

 The situation in Germany is similar to that in Israel.

All foreigners “unlawfully present” (between half a
million and one million) are entitled to receive services
for infectious diseases (particularly tuberculosis, but
also infectious STDs, with the exception of drugs for
AIDS), and preventative medicine for babies and
emergency treatment (through payment).25 As for the
German equivalent of the provision requiring
emergency hospitalization (albeit for payment), the
situation may actually be worse than in Israel. In
theory, a hospital can claim reimbursement from the
Social Welfare Center for the emergency hospitalization
of a person without a visa. In practice, this involves
endless red tape. Worse still, a clause in the German
“Aliens Law” imposes on any public institution the
obligation to report suspected illegal aliens to the
immigration authorities. It is all too easy to imagine the
serious effect this has in terms of access to medical
services. Although it is uncertain whether or not this
obligation applies to hospitals, some hospitals believe
this to be the case, and therefore grossly violate medical
ethics by transferring information about patients that

23 Centre Publique pour Aide Sociale.

24 Health Care for Undocumented Migrants, p. 23.
25 Illegal migrants suffering from serious diseases, post-
traumatic syndrome or AIDS can, in theory, apply for a special
temporary visa (Duldung). This status – one step above that of no visa
– is usually awarded to asylum seekers who have been rejected but who
cannot be deported. The special visa entitles the migrant to highly
restricted eligibility – among which is reimbursement of expenses from
the Social Welfare Center.

27
 can lead to their deportation.

 In the Netherlands, the ability of Non-Documented Migrants

to access health services was recently impaired because of the
enactment of the “Linkage Law” − a law that links the right to
social services with possession of a residency visa. However,
Dutch law provides for free emergency treatment, and public
pressure has led to an increasingly broad definition of what
constitutes an “emergency.” Pressure has led the Minister of
Health to broaden the definition of an “emergency,” allowing
physicians more leeway in their work. The “Linkage Law”
also established a public fund, which compensates physicians
for the costs of emergency treatments (again, the practical
definition of the term is quite broad) for Non-Documented
Migrants, although it is far from easy to overcome the
bureaucratic hurdles and to secure reimbursement. In most
cases, general physicians still demand insurance or payment.
Mental health services, on the other hand, are covered by a
public fund and are open to all, including Non-Documented
Migrants. A residency visa in the Netherlands (entitling the
holder to health services) may be requested on various
grounds; for example, any minor who arrives in the country
on his own is automatically included in the process of
requesting asylum − a status entitling the minor to almost full
health coverage. Residency visas may be granted and
deportation may be postponed for humanitarian reasons, such
as illness and the need for treatment.

On the basis of this information and data gathered from other

countries, one may depict a reality in which persons without visas −
those who are outside of the legal framework and are not included
in any migration category − are not entitled to equal access to the
public health service. Access may even endanger them. However,
there does seem to be a norm – whether of a legal nature or of a
public and ethical one − according to which emergency treatment
should be provided to all persons while minimizing the financial
obstacle or simply stating that emergency treatment is given for
free. Some Non-Documented Migrants can begin a process leading
them to special residency status, which will entitle them to health
services.

In some places, institutions (religious or secular) provide

28
humanitarian medical services for those who cannot access the
public health system. In Los Angeles, for example, we know that
there is a network of clinics similar to our own, but operated by the
local authorities. These clinics provide health services for groups
without medical insurance. In Barcelona, 'Doctors Without Borders'
(MSF) operates the “Fourth World” project − a clinic serving Non-
Documented Migrants as well as homeless people and drug addicts
who do not have access to the public health system.

3C. Possible Solutions

The following proposals are new to the Israeli public debate in the
matter of health care for migrant workers. Some contradict each
other, while others are complementary.

1. Free Emergency Hospitalization.

2. Legalization A: A Temporary Work Visa Followed By
Departure from Israel.
3. Legalization B: Residency Leading to Naturalization.
4. The Provision of a Minimum Health Basket of Services,
provided through an Insurance Arrangement.
5. The Provision of a Minimum Health Basket of Services,
provided through a Open Community Clinic.

1. Free Emergency Hospitalization: The price of one day’s

hospitalization for a tourist (in the absence of any other
definition, Non-Documented Migrants are currently defined
as “tourists”) is approximately 3,000 NIS. It is hardly
surprising that in the Emergency Room financial pressure
becomes yet another concern for patients and medical staff
alike. This pressure can lead to tragic results, such as in cases
where patients refuse to be hospitalized or when hospitals
refuse to admit them. Financial pressure can cause delays in
hospitalization; some patients avoid being hospitalized due to
high costs and eventually require emergency hospitalization.
It is important to emphasize that “free emergency
hospitalization” would not necessarily cause an additional
burden on public funds. The burden already exists, since
essential emergency hospitalization already takes place even
if the patient cannot pay the fee. Substantial debts on account
of emergency hospitalization have been accumulating and

29
 remain unresolved in the hospitals’ accounts. As noted
above, Ichilov Hospital in Tel Aviv, for example, notes that
the debt for 2001 was in excess of 1 million NIS − an
increase of 70% over the figure for 1997. Cumulated debt
over the years now totals 4.8 million NIS. The prevailing
principle of “paid emergency hospitalization” seems to cause
more damage than good. It endangers patients who refrain
from obtaining treatment; hospitals may break the law by
conditioning treatment on payment; emergency rooms may
face undue pressure due to the financial considerations; and
the practical definition of the term “emergency” may be
narrowed, influencing the entire system. For a comparison
with the situation in European countries regarding emergency
hospitalization, see section above.

2. Legalization A: Legalization in varying forms has already

been at the focus of public discussion as it applies to Non-
Documented Migrants. The main interest from the part of
decision-makers was on how to insure that Non-Documented
Migrants leave the country. On the part of Human Rights
Organizations, legalization is also considered to be a
desirable proposal in principle. Indeed, a person who
receives a work visa will be covered by the new Foreign
Workers Law, which includes a minimum level of medical
insurance and offers legal protection. However, as explained
in Chapter Two, today working visa means “chaining” the
migrant workers to a particular employer and severely
impairs their standard of living and working conditions26,
damaging also their state of health.27 Our response to this
dilemma is to oppose legalization as long as it means
providing undocumented workers with “chained” working
visas. In other words, as long as the “chaining” arrangement
persists, and the living and working conditions of workers
with visas are not significantly improved, Human Rights
Organizations and the Israeli public should oppose
legalization proposals of this type.

26 As noted, the health services to which documented migrants

are entitled have improved on paper. For more information and detailed
depictions of the working conditions of documented migrants, see the
website of Hot line for Migrant Workers: www.kavlaoved.org.il.
27 Excessive working hours, lack of safety precautions at work,
emotional and physical stress, and more.

30
 3.Legalization B: The second possibility for legalization is to
allow for the option of temporary and permanent residency
status, which may even lead to naturalization. Such a step
would be a real revolution in Israeli immigration policy.
Proposal of this type will no doubt create shock waves in the
Israeli mainstream media. Natural candidates for such an
arrangement might include families that have been in Israel
for many years, particularly those with children who were
born, raised and reached maturity in the country, and for
whom Israel constitutes the center of their lives. This is, of
course, a relatively small group, but it might be the first step
in the long road for immigration policy in Israel. We should
recall that once a person is recognized as a resident (even a
temporary one), he is entitled to social services and above all
− to national health insurance. For the present, it is probably
realistic to demand legalization (residency) at least for adults,
who came to Israel as children or were born here, raised and
have reached maturity in Israel, and who are not familiar with
any other society. Let us give one example of legalization:
On January 22, 2000, Belgium initiated a process of
"regularization" through which all Non-Documented
Migrants could apply for a visa. One of four categories for
applying for a visa was "serious illness" - a criterion - a
criterion currently included under the heading of
"humanitarian reasons"28.

4. The Provision of a Minimum Health Basket of Services

provided by an Insurance Arrangement: A special
arrangement could be introduced by which one or more of the
HMOs would offer medical insurance to Non-Documented
Migrants based on a basket of services as determined by the
Ministry of Health. This arrangement could be applied either
through legislation (including secondary legislation), or
through an administrative arrangement (as with the current
arrangement for children). HMOs might consider it
reasonable to accept the migrants, who are generally
relatively young and healthy. Naturally, this population
would be required to pay a special tax − whether to the HMO
or to a governmental body - in return for the limited health

28 Health Care for Undocumented Migrants, p. 28.

31
 services to which it would be entitled. Interestingly,
insurance companies consider Non-Documented Migrants as
a potential market and have already made efforts to market
their private insurance policies in this sector; one of the
HMOs recently joined the race in an attempt to penetrate this
untapped market. This situation suggests that, at least as far
as the private market is concerned, insurance for migrants is
considered to be a viable economic proposition. Yet, in our
opinion, official arrangement supported by legislation or
regulation must be the basis for any insurance program.
Otherwise, it will be impossible to supervise the actions of
the insurance providers (private companies or HMOs), and
they will, therefore, continue to apply the unacceptable norms
that have characterized the private medical insurance market
for migrants before October 2001.

5. The Provision of a Minimum Health Basket of Services

provided through a Community Clinic: PHR-Israel’s clinic
could provide a possible model for a municipal or
governmental body. One of the HMOs recently offered to
operate a similar project budgeted by a local authority and
supported from abroad. While this seems to be a positive
idea in principle, the HMO’s proposal was rife with loopholes
and ambiguities. Nevertheless, it does seem that such an idea
could be acceptable to one of the HMOs if support were
forthcoming from the Ministry of Health and from the
municipal authority, and if the project were to operate in
cooperation with a local hospital. The HMO’s proposal leads
us to believe that this idea is feasible.

We believe that all those living of Israel have a stake in solving

the problem of access to health services for hundreds of
thousands of Non-Documented Migrants living in the country, if
only because of the inevitable connection between the health of the
migrants and the health of the public as a whole. A network of
primary and secondary care would also partially reduce emergency
hospitalization costs, which are, as noted above, a source of ever-
growing debts incurred by hospitals. In other words, it is both
morally and financially sound to provide preventative primary and
secondary medical care. Migrant workers will naturally be required
to contribute to the cost of these services through the payment of
reasonable insurance fees; the municipal hospital, as well as the

32
local authority and the government, should also partake in funding.

A. came to Israel from Ghana. He is married, and the couple’s 7 year-old

son was born and raised in Israel. A. has suffered from diabetes for the
past four years and can barely cover the cost of treatments. He comes
periodically to our clinic to be checked by our volunteer physicians. For
over a year he suffered from cataracts in both eyes. We suggested he
receive treatment in a private medical institution and checked the costs for
such treatment. We discovered that the cost inside Israel is over 6,000
NIS, while in East Jerusalem it is approximately 2,200 NIS. A. cannot pay
such sums. On a subsequent visit to our clinic it became apparent that the
condition of one eye was deteriorating, increasing the danger that A. may
go blind. We have lost contact with A. and do not know whether he
managed to collect enough money to pay for at least one eye operation.

33
Chapter Four: Small Groups with Special Needs

The Non-Documented Migrants community is highly diverse.

Within the large group a number of small groups with special needs
can be identified. These groups require a wider breadth of health
services than those required by the majority of migrant workers.

4A. HIV Carriers

According to official records approximately one-fourth of new HIV
carriers in Israel in the year 2000 were migrant workers; 29 the exact
figures may be even higher. The Israel AIDS Task Force cares for
dozens of non-Israeli HIV carriers and AIDS patients, some of also
visit our Open Clinic. Seemingly, there is no difference between
these patients and other undocumented patients, yet they face
intense mental pressure due to the social isolation they endure
within their community. Loneliness and a lack of support are
serious problems for Israeli HIV carriers, even more so for
migrants. It must be emphasized that the community is vital to the
survival of migrant. Carriers must undergo tests and, from a certain
stage, integrated treatment, all of which are very expensive. The
drug cocktail prescribed for carriers and AIDS patients costs several
thousand shekels a month − far beyond the ability of a migrant
worker in Israel. AIDS centers in hospitals and the AIDS Task
Force have been treating foreign carriers and patients who were, in
most cases, diagnosed only when they were already ill. Within the
hospitals the AIDS centers have managed to circumvent the fact that
these patients do not have any insurance by including them in
research programs, by providing personal favors and thanks to the
constant support of the AIDS Task Force.

Over time, the number of diagnosed carriers and patients has risen
and available slots in special programs have been filled. Physicians
and the AIDS Task Force volunteers fear that they will no longer be
able to guarantee proper help for foreign carriers and patients.

This reality served as the backdrop to our publication last year of a

report comparing the situation in Israel with that in other countries.
The report included specific demands addressed to the Israeli
29 The total number of foreign HIV carriers known to the Ministry of
Health is several hundred.

34
government, and suggested possible ways of solving the situation.

Working in cooperation with the AIDS Task Force and supported

by part of the medical establishment, we urged health authorities to
learn from positive European models.
 We demanded that children and pregnant women be provided
with the full range of treatment given to Israeli citizens,
regardless of their civil status.
 We strongly opposed the deportation of AIDS patients to
their country of origin in cases when no medical treatment
would be available to them there.
 We insisted that Documented Migrant Workers should
receive the same treatment as Israeli workers, as noted in
Chapter Two.
 We stated our belief that special health services and treatment
should be provided to Non-Documented Migrants who are
HIV carriers or AIDS patients, as is the case in European
countries. This could take place by means of a humanitarian
residency visa (if no treatment is available in the country of
origin), or through a national project providing treatment, one
which would not distinguish between Israeli and foreign
patients. Such a decision would be a clear statement that
humanitarian considerations and public health are being put at
the forefront.

4B. Women Sold and Working in the Sex Industry

It is estimated that thousands of women work in Israel in

prostitution and in similar jobs, which accounts for a significant
proportion of the whole sex trade. Some of these women are
employed in prostitution under coercion; others were brought to
Israel with the promise of better living conditions. Today there is
extensive evidence of trading in women and of employment under
poor conditions. In cooperation with the Assistance Center for
Foreign Workers, PHR-Israel recently contacted the Attorney
General through Adv. Dori Spivak of the Human Rights Program at
the Tel Aviv University, and demanded that full health services be
provided to women being held by the police in order to give
testimony against their former pimps. This small group (a sub-set
of migrant women traded and employed in the sex industry in Israel)
who have been victims of violence, trading and many other offenses

35
in the past and are now being held forcibly by the Israeli legal
system, should receive full health services preceding the trial.
In October, 2002, the state attorney replied prior to the court hearing
stating a plan for almost full medical insurance to 50 migrant
women that were brought to Israel, traded and victimized are now
part of the testimony project.

PHR-Israel Press Release, January 31, 2002:

36
 Press Release
January 31, 2002

The police have reneged on their responsibility to provide

medical care for women appearing as witnesses in the
prosecution of pimps and sex traders, despite the fact that the
women are held in police custody.

Two women held in police custody in the south of Israel, who are
serving as witnesses for the state in the prosecution of sex traders
and pimps, are not receiving medical treatment. The Israel Police
has reneged on its responsibility to provide medical care for these
women, and asked PHR-Israel to ‘find them a physician.” The
instruction to contact NGOs with this request came from senior
sources in the national police headquarters.

This is not the first time that the Israel Police has refused to finance
medical treatment for women held in its custody. In the past, PHR-
Israel and the Assistance Center for Detained Employees have seen
women in a serious medical condition due to procrastination and
delays in referral to a physician by the police.

The police is legally obliged to provide medical treatment for all

persons in its custody, and all the more so in cases when these
women are endangering their lives by providing testimony; they
would surely prefer to return to their home country. The Assistance
Center for Detained Workers and PHR-Israel are engaged in a
protracted legal battle against the police in order to oblige it to
recognize this obligation. Indeed, we believe that there is an
obligation to provide these women with a series of medical
examinations and treatments due to their special situation and the
legacy of injury and abuse they bear.

4C. Asylum Seekers and Refugees30

The number of people that are living in Israel and seek political
30 We have recently finished a full updated report on asylum seekers and
refugees in Israel together with Adv. Anat Ben-Dor of the Tel-Aviv
University clinic for legal clinical aid. The report will be available in
our office and web-site as of November, 2002.

37
asylum is estimated in the hundreds. Processing of asylum seekers
was recently transferred from the UN Commission for Refugees to a
domestic Israeli inter-ministerial body. This body is to be guided by
the UN Convention on the Status of Refugees (1951) and the
appendices thereto, to which Israel is a party. Refugees form a small
group of people in Israel. Most of them have undergone suffering,
turmoil and sometimes torture before reaching Israel.
Currently, an asylum seeker (i.e. a person who passed the first stage
and his application for refugee status is under investigation) is
supposed to receive a work visa, which legally enforces the
employer to arrange for medical insurance. In practice, nothing
works. Asylum seekers encounter extensive bureaucratic problems,
for reasons that are unclear to us, some of them appear as
deliberately planed. Approval the working visa is conditioned on
payment of a fine for illegal entry into Israel; the work visa is
limited to specific professions (nursing, construction, agriculture),
and so on. In short, this entitlement of asylum seekers does not
solve any of their problems, including the problem of health
coverage. Asylum seekers are just like any Non-Documented
Migrant.
Despite the numerous restrictions imposed by Western European
countries on the entrance of refugees, many of these countries have
made sure that asylum seekers (in the investigation stage) enjoy
some access to health services:

38
The Situation in the West31

Germany: When an asylum seeker arrives at the absorption center

he undergoes a medical examination. During the first 36 months the
right to health services is limited to serious or painful diseases. This
definition also includes chronic diseases that cause pain. The
German courts have ruled that expenses incurred by an asylum
seeker for psychotherapy are to be covered by the State. After the
waiting period, if there is no final answer, the asylum seeker is
entitled to the same medical services as a German citizen.

Greece: Asylum seekers are entitled to free medical services

including examinations, medication (one prescription a month), and
hospitalization, as established in the Aliens Law amended in 1996.

Britain: Asylum seekers and their children are entitled to free

medical care under the National Health Service. Services are
provided for asylum seekers by the general practitioner in the area
of residence. Asylum seekers are also entitled to an interpreter to be
paid for by the physician or through the local health authorities.
Asylum seekers supported by the NASS (a governmental agency
providing assistance for impoverished asylum seekers) may receive
additional services, including prescriptions, dental care and payment
for travel to the hospital, etc. – all for a period of six months. There
are also special reductions and exemptions for the purchase of
medication.

D is an asylum seeker who has not yet been recognized as a refugee. As a

result he is not presently eligible for the medical services he requires
neither can he be employed legally. The following is a summary of his

31 The information in the box is quoted from the above-

mentioned report. See comment 29. For additional information on the
situation in Europe, see Chapter 3B.

39
story;
"In my country, I was a Red Cross employee and a political activist
opposing the Communist regime. While I was at university, I met some
friends my own age and we founded a group… [the political situation
began to deteriorate and a number of armed militias were formed – PHR]
If you give weapons to people, to youngsters, you may think that they will
protect you, but they already sense the power they have and they try to use
their weapons to get things. I tried to persuade people – at least in our
province – not to take weapons and not to send their children to the
militias. One night the militias came and took my uncle and murdered
him. He left behind two wives and children. I wanted the murderers to be
put on trial, but I didn’t have any evidence. Then the militias took control
of the capital city. There was shooting during the day and curfew at night.
In May 199*, after the elections, we planned a large demonstration in the
capital in favor of peace and social progress. When we reached the square,
a car suddenly pulled up and militiamen began to shoot into the crowd.
Three people were killed and eight wounded. I felt that I mustn’t remain
quiet. I had to go out to the public and tell them what I had seen. I
identified the people in the car and wrote down its number. Two years
later, some people came to my house and told me they were police officers
and wanted to investigate the events at the demonstration. They arrested
me forcefully in front of my family. My little daughter began to cry and
one of the “policemen” pushed her with his foot and knocked her over.
They handcuffed me and put a black hood on my head. Since that day I
have not seen my family or my little daughter. She should be 14 years old
now. They took me to the cellar in the home of one of the commanders
and I began to realize that they weren’t the police, but one of the militias. I
spent about two weeks in the cellar. They shot my leg and cut me with a
knife on my lower back. They wanted to humiliate me because I was kind
of sophisticated and educated. During the two weeks they brought a
political friend of mine and told me that they were going to show me how
they would execute him, and they would do the same to me. I had to watch
them beating him. I was naked the whole time. Anyone could come in
and do whatever they wanted to me or watch me. They told me: “You’re
going to die anyway, but we want to torture you so you die slowly.” They
treated me like dirt, and did not give me any food or water. One of the
guys was my special torturer. I was half dead. I came from an educated
family, and I myself was an educated man. I had never been hungry, and I
had never even performed hard work. My father was an important man,
with possessions and houses. Suddenly everything fell apart. They told
me that they wanted to exchange me for friends of theirs who were in jail −
but I was in the opposition, why would the police want to exchange
someone for me? One day they came and told me there was no point, they
wouldn’t be able to exchange me. They should just kill me, but they were
waiting for the order. They sent someone to me who said he was a doctor.
He put me into bed and then left, leaving the door open. I managed to get

40
up and found an open window. I jumped out and ran away. I went back to
my home, which was completely abandoned. I just took some documents
and money and then ran to the home of my nephew, who was a policeman.
He hid me. They made me forged documents and he took me to the airport
in his car. I flew to a neighboring country where I tried to begin a new life.
I even bought an apartment and married a young woman I met there. She
hardly knew anything about my past. Sometimes I used to remember what
had happened to me. Everything went black. My brain got mixed up. I
went to a psychologist and began to have therapy. On the anniversary they
invited people from all the countries in the region, and people also came
from my country. Until then I had used a different name. I had to leave
the second country. I took my original passport and looked for an
embassy. By chance, completely by chance, I arrived at the Israeli embassy
and asked for a visa. I arrived in Israel in 1997 and my wife joined me
later. I went to the central bus station and made contact with other
immigrants from the same area. They found me a cheap apartment and a
cleaning job. Suddenly my wife was arrested for being an illegal alien and
she was put in Neve Tirzah prison. Since my previous job had arranged a
work visa for me, I tried to get her released. I went to attorneys and courts,
and eventually they let her out, but she wasn’t allowed to work. One day
the police came and arrested me. They told me that my visa was no good,
forged, and put me in jail. It was very hard for me in jail. At night I saw
black faces, like my torturers. It took me back to it all. I began to behave
strangely and talk to myself. Suddenly I remembered the worst torture, the
sexual torture, the pain and blood. The staged executions. I could actually
see the face of my torturer and feel him strangling me with an electric
cable. The physician in prison spoke to me like everyone else, for one
minute, and then said he had no time and gave me tranquilizers. I spent 20
days in jail. They wanted to send me to my country, because I had my
original passport. I told them that I had worked for the Red Cross, and
they sent a woman from the Red Cross and contacted the UN Commission
for Refugees. Only then, when a representative came from the UN
Commission for Refugees, did I finally manage to tell part of my true
story. When they released me, I was in a bad state. My wife also had a
hard time with me. She left home and moved in with friends. I used to
wake up at night with flashbacks, and I was sure I was in prison again [the
Crisis Center for the Victims of Sexual Violence and PHR-Israel helped D.
receive basic psychological assistance – R.A.] I really like Israel and I
want to stay here, despite the problems. Life isn’t easy here, but I could
stay and live a reasonable life, but our problem is that we’re all the time
scared because of the documents. I still don’t have any idea what happened
to my large family and I haven’t seen my daughter."

Conclusions

41
This report addresses a single key question: how can we ensure
access to health services for a population, which, by definition, lies
beyond the scope of Israeli social services? These men, women and
children live and work in Israel, but are not defined as residents and
are, therefore, unable to enjoy equal eligibility and access to health
services.

We believe that the presence of such a large population that does

not have residency status must be the subject of public debate in
Israel. Israeli society must accept their existence as a fact and
recognize that the State bears at least a minimum responsibility for
their health.

Major steps lie ahead. The greatest challenge lies in the ability of
Israeli society to cope with the problem of Non-Documented
Migrants who already constitute the majority of the migrant workers
population that, according to various estimates, totals between
200,000 and 300,000. Israeli society must recognize some
responsibility to provide essential health services to people who
contribute their working power to the Israeli economy.

The following steps need be taken in order to allow for a real

change:
 The public, as well as decision-makers, must accept the
existence of migrant workers as an inevitable feature in
Israel’s integration into the global economy, rather than a
phenomenon that can be eliminated by violent means.
There must be an immediate end to the attempts to deflect
social and economic unrest in Israel upon the migrants, and
an end to efforts to use the difficult situation of these
workers in order to justify attacks on minimum wage,
unemployment benefits and social services. Some
politicians and high officials accuse both the migrants that

They cause unemployment and the Israeli unemployed that

they do not want to work and deserve no state allowance"32
32 We refer again to note 3 in the summary to this report. Ohad
Marani, director-general of the Ministry of Finance, was quoted in
Ma’ariv on August 15, 2001 as saying: “The number of foreign
workers is far too high… higher than the number of unemployed […]
We should take drastic action against foreigners who damage salary

42
 Part of the population of migrant workers can and should be
included in Israeli social systems on an equal basis
(integration), and should receive work or residency visas
(legalization). This step is clearly in the interest of the
Israeli public as a whole, and especially of low socio-
economic groups who suffer directly, not exactly from the
presence of migrant workers, but from the outcomes of their
conditions, e.g. no social benefits and almost no defense
from exploitation. The migrant condition reflects directly on
their low wages and pulls the entire wage scale down.
Israel is really a semi-welfare state that is surrounded by
large margins of black and grey labor market.
 Even if our hopes materialize and Israel decides to adopt a
real immigration policy rather than behaving in an
'aggressively passive' fashion, it can be assumed that there
will still be some Non-Documented Migrants in Israel.
Some people (as few as possible, we hope) will always
remain outside of the circle of eligibility and accessibility to
basic health services. We believe that a system must be
developed that is capable of providing a minimum level of
health for these people for three principle reasons:
1) On the basis of the fundamental right to dignity and
the protection of life, and in order to prevent the loss of
life and irreversible injury due to the lack of access to
health.
2) To protect the health of the general public as a
whole, which may be affected by the presence of a
large population denied even minimum health services.
3) In order to come closer to Israel’s self image as an
enlightened welfare state.

levels and the image of various sectors.” The conclusion the director-
general of the Ministry of Finance drew from his economic
observations was that steps should be taken against foreigners, and
child benefit – which supports mainly the poorer section of society -
should be cut. We advocate a completely different approach: refraining
from injuring the weak in Israel, and integrating migrant workers in the
fabric of Israeli economic life (ending the “chaining” of workers to
employers, legalization, etc.) These steps will protect Israelis and non-
Israelis alike, will minimize the illegal labor market and will increase
the cost of employing migrant workers.

43
We urge the health system to continue leading the field in this
respect and to integrate migrant workers into the social services
system. We urge it to continue efforts to integrate the children of
migrants on an equal basis, regardless of their parents’ status, and to
solve the serious problems faced by workers with visas due to their
employment conditions (the practice of “chaining” workers to a
specific employer) and to the policies of health insurance
companies. The Health Services Order must be amended; it should
adopt one of the models proposed in this report (or a combined
model) in order to develop a basic health system for Non-
Documented Migrants.

44
Responses

The report was sent to several governmental authorities for

response.

The Health Minister, Mr. Eliahu Dahan, did not send any written
response. In answer to our phone call, his secretary replied that:
"The minister has read the report and he has no comment".

Publication of this report was made possible by

contributions from foundations and individuals, and
thanks to the support of the Ford Foundation and
The New Israel Fund.

45