Growing in the shadows: health needs and access to care of undocumented children in Europe

Introduction: Europe hosts an unknown number of undocumented children mainly living in urban areas. The lack of evidence about their living conditions, health needs, and access to care prevents adapted health and social policymaking. This study aims to build and compare evidence across different cities in Europe. Methods: This qualitative multicenter cross-sectional study was conducted in Prague, Paris, Frankfurt and additional German cities, Milan, Copenhagen and Geneva. Semi-structured interviews were conducted among key local stakeholders involved in health or social provision for undocumented children. Data was then pooled into an analytical matrix and classified into three main categories: social determinant of health, health needs and barriers / enablers to access health care. Data was analyzed using a Rapid Qualitative Analysis approach. Results: 48 semi-structured interviews were conducted. Major social determinants of health were unstable housing, barriers to access to education, low family income, fear of being reported. In Geneva and German cities, adolescents were at risk of labor exploitation. The main identified health needs varied according to age. Screening, vaccination as well as congenital conditions and prematurity were identified for perinatal age. Acute and chronic general pediatric conditions, vaccination, developmental disorders and dental problems predominate among school age children, mental health, sexual and reproductive health predominates in adolescents. Differences in access to healthcare are shaped by national policies, their regional implementation and context-specific arrangements among local actors. In Milano, Geneva, and Paris children can access the public healthcare system, either through enrolment in subsidized health insurance or through specific health programs. In other sites, access relies on informal arrangements between NGOs, charitable organizations, public actors, and schools. In all sites, informal arrangements play a key role in bridging the access gap to specific services such as dental care. Discussion: While undocumented children present comparable health needs shaped by adverse social determinants in European cities, the local responses widely differ raising issues of equity, coordination and continuity of care. These evidences call for strengthening and harmonizing health policies to secure the inclusion of all undocumented children into the formal healthcare systems, in accordance with the Convention on the Rights of the Child.