Physicians for Human Rights-Israel: Aggressively Passive - The State of Health of Migrant Workers in Israel, October 2002 | Insurance | Hospital

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.

Introduction…………………………………….….….... Chapter One: Children
1A. 1B. The Current Situation………………………..……... Health Services for Migrant Children……….…….. 6 8 3

Chapter Two: Documented Migrant Workers
2A. 2B. Health Insurance for Visa Holders………............... 12 The Right to Health of Documented Migrant Workers …………………….………..….. 13 14

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

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

Migrant Workers

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

Chapter Four: Small Groups with Special Needs
4A. 4B. 4C. HIV Carriers………………………………..….….. 34 Women Sold and Working in the Sex Industry…… 35 Asylum Seekers and Refugees1…………………… 38

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

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.


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 byproduct 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


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.



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 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.


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.


A description of the routine activities of the Open Clinic appears on the next page, and in PHR-Israel’s website: 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.


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.



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


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 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.”

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


, 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 The employer services.
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 worker, came to five years ago in for an elderly had cancer. The worker no longer has a valid working permit.

nursing Israel over order to care woman who Following her


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 threemonth 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


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, PHRIsrael 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, nondocumented, 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 NonDocumented 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

2. 3.



in more complex medical situations. 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. 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. 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). 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


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











International Rights and Norms

Given the serious nature of this matter − the right to health of NonDocumented 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 Non16
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  19 In Belgium, reimbursement may be received for emergency

Our information is based mainly on the publication “Health Care for Undocumented Migrants,” published by PICUM: Platform for International Cooperation on Undocumented Migrants, De WrikkerAntwerp, 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 ( 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 24 25 Centre Publique pour Aide Sociale. Health Care for Undocumented Migrants, p. 23. Illegal migrants suffering from serious diseases, posttraumatic 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

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 NonDocumented 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. 2. 3. 4. 5. 1. Free Emergency Hospitalization. Legalization A: A Temporary Work Visa Followed By Departure from Israel. Legalization B: Residency Leading to Naturalization. The Provision of a Minimum Health Basket of Services, provided through an Insurance Arrangement. The Provision of a Minimum Health Basket of Services, provided through a Open Community Clinic. 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


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 NonDocumented 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.


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: 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.

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 evergrowing 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


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.


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.


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

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:


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, PHRIsrael 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:


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


The information in the box is quoted from the abovementioned 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


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."



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 socioeconomic 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 directorgeneral 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 nonIsraelis 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 NonDocumented Migrants.


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.


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