Effects of restrictive asylum-seeker healthcare policies: systematic review of evidence from Germany

BACKGROUND: Asylum-seekers’ entitlements to healthcare vary within and across European countries, over time, and between different nationalities. Within Germany, healthcare policies for asylum-seekers range from restrictions of both scope and access to healthcare to full health entitlements, depending on a person's legal status, duration of stay, country of origin, and place of residence. We seized these variations to study the effects of restrictive vs. inclusive healthcare policies on health status, health system outcomes (incl. health equity), healthcare provision, healthcare utilization, and efficiency. METHODS: We conducted a systematic review in five databases (PubMed, Web of Science, SCOPUS, LIVIVO, Google Scholar) to identify and analyse empirical studies on the effects of healthcare policies for asylum-seekers in Germany. Out of 1159 initial hits, 66 records were assessed for quality and included in the narrative synthesis. RESULTS: The synthesised evidence shows that more inclusive policies facilitate needs-based health care utilization, incl. broader utilization of ambulatory services and lower use of emergency services. They reduce complexity, fragmentation and bureaucracy for healthcare users and providers by simplifying authorisation and reimbursement. Evidence suggests that inclusive policies contribute to better subjective and mental health among asylum-seekers. We found no evidence for access restrictions being associated with cost savings or other health system benefits. CONCLUSIONS: Restrictive healthcare policies are often justified with the need to protect fiscal resources and health systems. Yet, evidence from Germany shows that more inclusive healthcare policies for asylum-seekers hold benefits in terms of health system outcomes, while not entailing higher costs. Inclusive policies are thus not only normatively preferable to restrictive policy options; they also yield better performance from a health systems perspective. KEY MESSAGES: • Germany is a pertinent test-case for analyzing the effects of restrictive vs. inclusive healthcare policies for asylum-seekers. • Inclusive healthcare policies hold benefits in terms of health outcomes and health system performance, while restrictions fail to show advantages in fiscal or other domains of performance.