Equal access to health services to ensure the health status of the population should constitute one of the priorities of developed countries, with particular attention to actions and measures aimed at guaranteeing the elimination of inequities based on age, sex, social class or country of origin. Nevertheless, inequities in health, and in the access to and use of health services, have been widely reported in relation with these social factors.1 Specifically, economic immigration and persons from countries that are economically disadvantaged in comparison to Spain are related with problems surrounding access to health services, a fact that cannot be ascribed exclusively to this population´s lower socioeconomic level.2
The notable increase that has occurred essentially since 1999 in the population of foreign-born residents in Spain is giving rise to a new social and demographic reality throughout the country. The numbers of economic immigrants need to be permanently updated inasmuch as there are notable differences between areas, between culturally-defined nationalities and administratively autonomous regions, between rural and urban areas, and between boroughs and districts within large cities. The data published by the Ministry of the Interior--updated as of 31 December 2001--note that the total number of foreign residents in Spain is 1 109 060; subtracting 449 881 residents from other countries in the European Union reduces the figure to 659 179 persons. On the basis of projections from the 1991 census for the year 2001, these figures represent 2.7% and 1.6% respectively of the entire population of Spain.3,4 The number of economic immigrants these figures include is probably somewhat lower, although assuming that the status of a considerable number of persons is irregular, the overall proportion of economic immigrants in Spain may currently stand at about 3% of the whole population.
The article in this issue titled «Estimation with the capture-recapture method of the number of economic immigrants in Mallorca» raises an interesting question that centers on how to determine the population of immigrants in Spain. According to the authors´ estimate, there are currently 39 392 economic immigrants in Mallorca, of whom only approximately 9000 enjoy fully legal status. The implication of these figures is that three out of every four immigrants in Mallorca do not hold the necessary documents that authorize them to reside or work there. Although the situation in Mallorca probably can not be extrapolated to the rest of Spain, the study reveals the large number of immigrants who are not identified in official sources.
It should be noted that although the rate of immigration in Spain during 2001 (24% of all immigrants) was the highest in the European Union, the total number of immigrants residing in Spain is far below that in other countries. For example, in 2000 the percentage of the total resident population born in other countries was 9% in The Netherlands and 11.3% in Sweden; the mean figure for Europe was 4%.
In Spain, the right of members of the immigrant population to health and health care is regulated by the set of laws dealing with immigration and naturalization (Ley de Extranjería): health care is guaranteed for minors and pregnant women, persons with a medical emergency, and immigrants registered with their local census bureau--a necessary prior step in the process of obtaining a personal health card (which permits access by the bearer to all publicly-provided health care services). According to some authors, registration at some local census bureaus is arbitrary, and the necessary health services are not always available; these factors do not facilitate immigrants´ right to health.5
In addition, the erratic immigration policies of the most recent government administrations (characterized by multiple processes of regularization and a number of changes in the law and its attendant regulations) have led to the current situation in which many immigrants in Spain have not obtained their immigration and work papers, with the consequent difficulties and stress this implies in their everyday life. These bureaucratic obstacles make it difficult to obtain a personal health card, and hence interfere with the planning of resources and services.
The incorporation of immigrant populations in the social security system--for which administrative regulation and an employment contract are prerequisites--should be a clear source of strength for the public health system, which supports the ever-increasing burden of an aging population. If we add to this the low birth rate in Spain, increasing immigration represents a clear opportunity to recover the balance between the demand for health services and contributions to the system.6 In this connection, facilitating the process to obtain a personal health card, which would represent an undeniable step toward access to health care for immigrants, should lead to the incorporation of these persons within the social security regimen and help normalize a situation which otherwise, depending on the number of immigrants, could lead to an imbalance between the demand for health care and the resources available.
One of the settings in which immigration has had, and continues to have, particular repercussions is in health care, particularly in primary care services located in areas with large immigrant populations. In these settings--and despite the fact that the need to endow these centers with complementary resources (ie, training for primary care practitioners,7 cultural mediators, and administrative back-up) has been recognized for years--the current situation, although somewhat improved, still fails to meet real demands and needs as they currently stand. With regard to training, it should be emphasized that apart from enhancing knowledge and management skills for specific parasitic diseases or other health problems of normally low prevalence in Spain, it is essential to improve practitioners' knowledge of the social, cultural and anthropological characteristics of different collectives of immigrants residing in Spain.
Although immigration and its repercussions have become part of some leaders´ political agenda, concerns have yet to be reflected as concrete actions such as the provision of necessary resources to cover the new needs. As a result, in some primary care centers the work overload generated by the new situation has meant that such basic goals as the scheduling of appointments have suffered setbacks.
Moreover, various issues have yet to be dealt with regarding immigration and primary health care. Questions remain in relation with the characteristics of accessibility to the public health care system and its services, and in connection with immigrants´ expectations and interpretations. Some studies have noted that immigrants tend to use primary care services more than members of the autochthonous population, whereas they use specialized and complementary services less often. This can not be explained exclusively by the lower socioeconomic level of immigrants.2 Rather, this pattern of use may reflect barriers to access, but it may also represent immigrants' interpretation or knowledge of the health system. Their health characteristics and sociodemographic profiles may make them more likely to seek primary services rather than other types of care. Another issue to keep in mind is that when they have a health problem, irregular economic immigrants turn to health services less often.8 Recalling that most immigrants are irregular, this situation reveals the existence of barriers to access which clearly violate the principle of equality of access for equality of need.
A further issue related with the article published in this issue centers on the sources of information available, and the variables that each source covers. In this connection, to respond appropriately to the health priorities of the immigrant population and to anticipate resources and services, it is necessary to strike a balance between data confidentiality and information needed on the country of origin or nationality. This information should be included routinely in the clinical records of public health centers.
It is worth emphasizing once again that inasmuch as patterns of morbidity and mortality among foreign immigrants do not differ substantially from those of the autochthonous population, the main health needs of immigrants can be satisfied by improving their awareness of primary care services and of how the heath system functions, and by adapting existing resources to new needs. Considering the different social and cultural patterns that often characterize immigrant populations, and the needs with regard to health promotion and disease prevention, one useful approach may be to enhance and adapt community health programs associated with local health care strategies.
In the extent to which we are able to understand, orient and plan primary care resources as a new challenge rather than simply as a means to reduce work overloads will parallel our ability to achieve positive results towards ensuring equal health for all groups within the population.
