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Social Science & Medicine xxx (2014) 1e10

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Social Science & Medicine

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Transnational healthcare practices of Romanian migrants in Ireland:Inequalities of access and the privatisation of healthcare services inEurope

Sabina Stan 1

School of Nursing and Human Sciences, Dublin City University, Dublin 9, Ireland

a r t i c l e i n f o

Article history:Available online xxx

Keywords:Transnational healthcareEasteWest migrationHealthcare privatisationSocial inequalitiesUneven developmentRomaniaIrelandEuropean Union

E-mail address: sabina.stan@dcu.ie.1 (2013eJune 2014) Visiting Fellow, Centre for

Academy of Science and Letters, Drammensveien 78,

http://dx.doi.org/10.1016/j.socscimed.2014.04.0130277-9536/� 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Stan, S., Tprivatisation of healthcare services in Europ

a b s t r a c t

This article deals with the transnational healthcare practices of Central and Eastern European migrants inEurope, taking the case of Romanian migrants in Ireland. It explores the implications of migrants’transnational healthcare practices for the transformation of citizenship in Europe, more particularly interms of access to free public healthcare. The article places these practices in the larger perspective ofglobal care chains, seen as including transnational flows of healthcare seekers and healthcare workersthat link distant healthcare systems in an emerging European healthcare assemblage.

The study adopted a holistic perspective, taking into account both formal and informal practices, aswell as the use of healthcare services in both the host and the origin countries of migrants. These wereexplored during multi-sited fieldwork in Romania and Ireland, conducted between 2012 and 2013, andcombining a variety of sources and methods (semi-structured interviews, informal conversations,documentary analysis, etc.).

The article explores the links between migrants’ transnational healthcare practices and two otherimportant processes: 1) inequalities in access to healthcare services in migrants’ countries of origin andof destination; and 2) the contribution of healthcare privatisation to these inequalities. It shows thatRomanian migrants’ transnational healthcare practices function as strategies of social mobility for mi-grants, while also reflecting the increasing privatisation of healthcare services in Ireland and Romania.The article argues that these processes are far from specific to Ireland, Romania, and the migration flowsuniting them. Rather, they draw our attention to the rise of an unevenly developed European healthcareassemblage and citizenship regime in which patients’ movements across borders are closely interlinkedwith diminishing and increasingly unequal access to public healthcare services.

� 2014 Elsevier Ltd. All rights reserved.

1. Introduction

This article deals with the transnational healthcare practices ofCentral and Eastern European (CEE) migrants in Europe, taking thecase of Romanian migrants in Ireland. After the Second World War,access to healthcare has been an integral part of social citizenship inbothWestern and Eastern Europe (Marshall, 1950). Thus, in Europe,citizenship is central to the development of national healthcaresystems, but also to migration in general (Loyal, 2011) and totransnational healthcare practices in particular (Carrera and Lunt,2010). The article explores the implications of migrants’

Advanced Study, NorwegianNO-0271 Olso, Norway.

ransnational healthcare prace, Social Science & Medicine

transnational healthcare practices for the transformation of citi-zenship in contemporary Europe, more particularly in terms ofaccess to free public healthcare. It argues that social inequalitiesmore generally, and inequalities of access to healthcare servicesresulting from healthcare privatisation in home and host countriesmore particularly, contribute to generate Romanian migrants’transnational healthcare practices. Moreover, by contributing to thereproduction of these inequalities, these practices also serve toreproduce an uneven citizenship regime across Europe.

Research on the global assemblages of healthcare brought aboutby patients’ cross-border mobility and their implications for healthsystems is only at its beginnings (Whittaker et al., 2010, pp. 341e342). Most research to date has concentrated on NortheSouthhealthcare mobility, namely, that of middle-class nationals frommore developed countries seeking cheaper access to healthcare inless developed countries. Much less research has dealt with intra-

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S. Stan / Social Science & Medicine xxx (2014) 1e102

European movements (Carrera and Lunt, 2010), and, among thelatter, with the transnational healthcare practices of migrantsreturning home to access healthcare services (Macfarlane and deBrun, 2010; Migge and Gilmartin, 2011; Glinos et al., 2012). Theflow of migrants returning to their countries of origin to accesshealthcare was, however, identified as an important feature ofcontemporary global patient flows (Glinos et al., 2010, p. 1153).

I will use the term transnational healthcare practices to avoidboth the supply-side and consumer connotations ofmedical tourismand the demand-side and medicalisation assumptions of crossborder patient mobility. It focuses on concrete health-seeking be-haviours, seen as practices embedded in a larger social context thatcannot be reduced to the individual level of patient motivations(Glinos et al., 2010). It thus starts from the actors of these practices,seen as transnational migrants (Schiller et al., 1995) rather thansimply “patients.” Indeed, not only is migrants’ cross-bordermovement a process usually involving more than just health-seeking behaviours, their transnational use of healthcare servicesmay or may not lead to them being defined as patients. Finally, thisalso allows for an encompassing view on health-seeking behav-iours, as, especially for migrants, the latter may involve not onlyformal, but often also informal practices of access to healthcareservices (such as informal payments).

The first part of the article maps Romanian migration in Irelandand documents Romanian migrants’ patterns of access to Irishhealthcare services in the context of the larger inequalities of accesspresent in Ireland’s healthcare system. The second part depicts thetransnational healthcare practices of several Romanian migrants,most specifically their use of Romanian healthcare services. Theseare understood in the context of the larger social inequalities andinequalities of access present in Romania’s society and healthcaresystem. The unequal configuration of access in both Romania andIreland is then traced back to the increasing privatisation of theirhealthcare systems. The article closes by drawing attention to therise of an unevenly developed European healthcare assemblage andcitizenship regime in which patients’ movements across bordersare closely interlinked with diminishing and increasingly unequalaccess to public healthcare services.

2. Methods

The article is based on “intermittent” (Buchowski, 2004) multi-sited ethnographic fieldwork (Marcus, 1995) conducted since 2009on the topic of Romanian migration in Europe more generally, andof migrants’ transnational healthcare practices more particularly. Itcombines several distinct periods of intensive study, ranging fromone or two weeks to several months, that included interviews,participant observation, collection of secondary data, and docu-mentary analysis. The present article drawsmore particularly on 20semi-structured interviews and dozens of informal conversationsconducted with Romanian migrants between spring 2012 andautumn 2013. The interviews dealt with migrants’ migration his-tory and transnational healthcare practices, and took place inDublin, Ireland. Participants were selected through the snowballmethod, while also trying to insure that migrants with variousmigration histories (long or short, more settled or more temporary)and various educational (low, middle, and high level) andemployment backgrounds (low-skilled and high-skilled) wereincluded.

In order to capture the multi-faceted character of migrants’healthcare practices as well as the transformations affecting theIrish and Romanian healthcare system, the study also included in-terviews and informal conversations with other key informants.These were conducted a) in Ireland (7 interviews), with Romaniandoctors, as well as representatives of a migrants’ association (the

Please cite this article in press as: Stan, S., Transnational healthcare pracprivatisation of healthcare services in Europe, Social Science & Medicine

Romanian Community of Ireland), and various NGOs dealing withmigrants’ access to healthcare services (CAIRDE, New CommunitiesPartnership); and b) in Romania (15 interviews), with returningRomanian migrants, resident Romanian patients, and healthcarepersonnel working in Romanian hospitals, clinics, and surgeries.

3. The actors: Romanian migration in Ireland

In 2010, Romanian migration in Europe was estimated at morethan two million people (Stanculescu and Stoiciu, 2012, p. 23),forming thus the biggest intra-European migrant group (evenahead of Polish migration). Romanian migration in Europe took offin the 1990s, and in the second part of the decade already displayedwhat proved to be its lasting profile as a mainly temporarymigration for work, concentrated towards southern Europe, espe-cially Italy and Spain (Sandu, 2006). This migration is almost evenlybalanced between men and women, drawing on young personswith mid-level educational levels that are mainly employed in thedestination country in construction (men) and services (women)(Sandu, 2006). Despite the 2000e2008 economic boom, Romania’seconomic development, still importantly based on low-skilled andlow-paid employment in light industry, agriculture, and services,has not offered the local population viable alternatives to migration(Stan and Erne, 2014). Building onmigration networks developed inthe 1990s, Romanian migration considerably intensified in the2000s (Sandu, 2006). This was helped by several measures thatfacilitated Romanians’movement across European borders, namelythe 2002 lift of visa requirements for Romanians travelling toSchengen countries, and the 2007 accession of Romania to the EU.Free movement did not, however, mean free access to labourmarkets in the EU, and especially to the much coveted EU-15 des-tinations. Indeed, even after 2007, most EU-15 countries imposedtransitional restrictions on Romanian migrants’ access to their la-bour markets (EC, 2013).

In the mid-1990s, the UK and Ireland quickly became Romanianmigrants’ destinations of choice in the EU, as these countries wereseen to offer better wages and work conditions than southern Eu-ropean countries. Romanian migration to Ireland usually involvedmigrants attracted by the increasingly glittering image of the CelticTiger, but with previous migration experience in other Europeancountries. It quickly built on informal migration networks of family,neighbours, and friends, and was boosted by Romanians’ increasedfacility of movement across European borders after 2002 and 2007.In 2006, the Irish national census documented almost 7700Romanian nationals in Ireland (CSO, 2006), whereas by 2011 thenumber had risen to around 17,300 (CSO, 2011a). However, thesefigures only very partly reflect the numbers of Romanians actuallypresent in Ireland in this period. Even after employment prospectsin Ireland (and particularly in the construction sector) becamegrimmer following the 2008 financial crisis, some estimates stillput the total number of Romanian migrants present in Ireland ataround 40,000 people (Ziare.com, 2013).

The discrepancy between official and actual migrant numbers islinked to the status of Romanian migrants in the Irish labourmarket. Like in other parts of Europe, Romanian migration toIreland overwhelmingly involves young people and is evenlydivided among men and women (CSO, 2011a, 2013, p. 14). Up to2012, Romanian migrants did not have free access to the Irish la-bour market but saw their access to Irish jobs conditioned by theacquisition of an employment permit. Again like in other parts ofEurope, this pushed many Romanian migrants into informal, un-declared work, mainly in construction (men) and domestic work(women). The 2013 estimate of 40.000 Romanian migrants, alreadyvoiced after 2007 by Romanian officials in Dublin, means that, inthe second part of 2000s, between two thirds and a half of

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Romanian migrants in Ireland may have operated in the informallabour market. Interestingly, informal work affected higher pro-portions of newer migrants than those who had migrated earlier,indicating possible routes to formal integration in the labour mar-ket dependent on seniority in migration (CSO, 2013, pp. 7, 9).However, even those formally employed were also concentrated inlow-paid, low-skilled employment in construction and variousservices (CSO, 2013, p. 11), with only a thin layer of better-paid,high-skilled employment, mainly in the IT sector.

Romanian migration in Ireland is thus a patchwork of groupsdivided by various migration temporalities, employment statuses,and integration trajectories. It seems that, to the always importantcontingent of temporary migrants engaged in informal employ-ment, the last decade added a growing group of more stable mi-grants formally employed in low-skilled, low-paid jobs as well as aless numerous one of those formally employed in better-paid, high-skilled jobs. The two latter groups have thus also built during thisperiod the basis of a more thorough integration in Ireland, andtherefore have probably moved further away from the temporarywork migration of the first group. Do these differences impact ontheir respective engagement in transnational healthcare practices?

4. Accessing Irish healthcare services

Before trying to answer this question, wemust address themoreobvious issue of the access of Romanian migrants to the Irishhealthcare system. In fact, working and residing, more or lesspermanently, in Ireland make this use an obvious solution to themigrants’ health-seeking concerns.

Access to services in the Irish healthcare system is anything butuniversal, being heavily dependent on means. The 1970 Health Actused means-testing to distinguish between Medical Card holders,entitled to access free GP and in-patient healthcare services, andthe rest of the population who have to pay for healthcare serviceswhether out-of-pocket or through private insurance (DHC, 2010,pp. 43, 44). In 2005, an additional means-tested group was formedthrough the granting of GP Visit Cards that gave their holders freeaccess to GP consultations, but not to hospital services (EOHSP,2009, p. 20). In 2009, around 35% of the population had either aMedical or a GP Visit Card, 50% had private insurance, and 19% hadneither Medical Card nor private health insurance (DHC, 2010, p.44).

For non-Medical or GP Visit Cards holders, costs of GP care varybetween V45 and V60 per visit (DHC, 2010, 44). These are mainlypaid out of pocket as they are only sometimes and only partiallycovered by private insurance schemes. Access to free hospital ser-vices is restricted toMedical Card holders. Since 2009, non-MedicalCard holders have to pay daily in-patient charges of V75, up to anannual maximum of V750. They are theoretically entitled to freeaccess to Emergency and out-patient services if referred by their GP,but sometimes extremely long waiting times in Emergency de-partments and waiting lists for out-patient care effectively limittheir access to free public care in these areas. If they do not have areferral from their GP, they have to pay a V100 fee for eitherEmergency or out-patient visits (DHC, 2010, p. 44). For the 19% ofthe population who do not have either a Medical Card or privateinsurance and are also on relatively low incomes (see below), thecosts and waiting times involved in accessing public healthcareservices may constitute considerable barriers to access.

The notable inequalities in Ireland’s multiple-tiered system arethose between, on the one hand, the privileged private insuranceholders (who have, in addition, their private insurance premiumssubsidised, through tax reliefs, by the state), and, on the other,Medical Card holders and the low-income fringe of those who haveneither private insurance nor Medical Cards. Medical Card holders

Please cite this article in press as: Stan, S., Transnational healthcare pracprivatisation of healthcare services in Europe, Social Science & Medicine

are more likely to find themselves on waiting lists than privatelyinsured patients in 2010, the ratio between the two categories wasof 3:1 for in-patient care and of 4.5:1 for out-patient care) (CSO,2011b, p. 18; DHC, 2010, p. xi). Access barriers become even moredaunting for those who, although poor, do not hold a Medical Card,as almost 22% of people living in consistent poverty and 30% ofpeople at risk of poverty did not have a Medical Card in 2006(Keilthy, 2006, p. 3).

These inequalities of access are exacerbated even more amongmigrants. Having been hit more hardly by the financial crisis andthe consequent loss of jobs and income, migrants are now less oftento be found among the privileged category of private insuranceholders than Irish nationals. Thus, in 2010, only 24% of non-Irishnationals had private insurance as compared to 51% of Irish na-tionals (CSO, 2011b, p. 10). In contrast, in the same year, non-Irishnationals relied in proportion of 34% solely on Medical Card cover(as compared to 29% of Irish nationals), while 42% of them hadneither Medical Card nor private insurance coverage (as comparedto 20% for Irish nationals). This distribution of migrants’ amongIreland’s healthcare eligibility groups lead to a lower engagementof migrants with the Irish healthcare system than that of Irish na-tionals. In 2010, non-Irish nationals were almost twice as many asIrish nationals to abstain from GP consultations (40% as comparedto 24%) or from any health consultation (22% of as compared to 11%)during the previous year (CSO, 2011b, p. 14).

These inequalities of access are probably affecting even morestrongly CEE migrants, as data presented above concern all ‘non-Irish nationals’, a category which includes an important contingentof better qualified and better paid migrants from EU-15 (andespecially the UK). EU states’ response to migration in the last de-cades has included the adoption of selective restrictions to welfareentitlements for various categories of migrants. The resulting newwelfare stratifications (Fanning, 2011) have, however, to be seen asincluding not only social but also healthcare services and affectingnot only non-EU migrants, but also CEE migrants both before andafter the accession of their countries to the EU. Several studies havehighlighted a multiplicity of barriers for migrants, and especiallyfemale migrants, accessing Irish healthcare services, includingentitlement to free services (ICI, 2010; EUAFR, 2011), the mostimportant being undocumented status and employment in low-income jobs. These barriers also apply to Romanian migrants,given that, as we have seen above, they are mostly concentrated inlow-paid employment, and that their lack of free access to the Irishlabour market until 2012 pushed many of them into informalemployment and a grey zone as to the status of their stay in Ireland.This lead to a situation where Romanian migration to Ireland hasbeen divided among a thin strata of high-paid and better qualifiedworkers relying relatively more on private insurance; a group ofmore settled migrants in formal but low-paid employmentbenefiting relatively more from Medical Card coverage; a group ofmore recent low-waged migrants often lacking information ontheir rights to access free healthcare through the Medical or GPCards (Harkin, 2001, p. 24e26); and an important pool of migrantsengaged in informal work who may have found it impossible toprove that they met the “ordinary residence” condition foraccessing free healthcare services in Ireland (ICI, 2010, p. 5). Thetwo last groups lacked thus access to free healthcare coverage andhad to face prohibitive out-of-pocket payments for services.

Given the transnational character of both settled and temporaryRomanian migration, one would expect a creative use of EU regu-lations that are deemed to address EU temporary migrants’ accessto host country’s healthcare services. These are EU Regulation 883/2004 on the coordination of social security systems in Europe(regulating access to unplanned care during travel in another EUmember country through the European Health Insurance Card,

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EHIC) and the Directive on the Application of Patients’ Rights inCross-Border Healthcare (2011/24/EU) (regulating access to plan-ned care through reimbursement) (Mainil, 2012, pp. 153, 154).Apart from the fact that Romanian citizens were able to availthemselves of the EHIC only after Romania’s accession to the EU in2007 and of the Directive 24/2011 only after its 2013 imple-mentation in Romania, even after that, very few Romanian mi-grants were informed about them, or, if informed, chose to usethese means of accessing care when working abroad. In 2012, onlyaround 100.000 Romanians out of a population of 20million had anEHIC (Spiridon, 2013).

In addition, access to healthcare in destination countries facili-tated by EU regulations is dependent on the continuous participa-tion of migrants in the social insurance schemes of the country oforigin (in the Romanian case for a period of five years, see Rat,2011). As we shall see, longer-term, more settled, Romanian mi-grants may choose to stop their contributions to the Romanianhealthcare insurance fund, leaving mostly the more recent tem-porary Romanian migrants as possible active contributors. How-ever, the latter are also usually the least informed about their rights,and so the least prone to use these options. The result is a differ-entiated access to Irish healthcare services, echoing inside theRomanian migrant group the gradation of rights and hierarchicalsocial citizenship enjoyed by other migrants in Ireland (Loyal,2011).

5. Alternative pathways: Romanian migrants’ transnationalhealthcare practices

Romanian migrants compensate their low engagement with theIrish healthcare system by a relatively more vigorous use of theRomanian healthcare system. We look now at Romanian migrants’transnational healthcare practices, taking three concrete cases.These cases also try to match Romanian migrants’ varied engage-ment in temporary versus longer-term migration as well as in low-skilled versus high-skilled employment in Ireland.

Ever since she came to Ireland in 2007, Victoriaworked as a low-skilled, informal domestic worker cleaning the houses of uppermiddle-class Dubliners. Her husband, Ilie, worked in the boomingconstruction sector that built houses for the mounting middleclasses of the Celtic Tiger. Victoria and her family thus offer thetypical portrait of Romanian migration in Europe: temporary,working in unskilled jobs in the destination country, but alsoswinging between their country of destination and their country oforigin. Indeed, since 1996 when he first left Romania, Ilie engagedin more or less lengthy work sojourns in Belgium, France, England,and, since 2001, Ireland. Ireland looked like the summit of hismigration career and a possible settlement destination, but, at thestart of the crisis in 2008, Ilie went back to Romania, and later onreturned to Ireland only for relatively short work stints. Likewise,their two daughters were brought for one year to Ireland in 2007,but later sent back to Romania where they were left once again inthe care of Ilie’s mother.

Victoria and Ilie had thus only a partial, and unsuccessful,attempt at a longer-term, settled approach to their stay in Ireland.For most of the time, they engaged in a draconic regime of lowconsumption and high savings that they used in Romania torenovate and extend their house, buy more land, build a largestable, and invest in expensive equipment for processing timber inanticipation of their future return to the country. By contrast, evenafter Romania’s accession to the EU in 2007, Victoria and Ilie hadsemi-legal status in Ireland, as they were allowed to visit it astourists for three months at a time, but not to work legally, giventhat they did not manage to secure employment permits. Thismeant that when, in winter 2010, Ilie twisted his knee at work, he

Please cite this article in press as: Stan, S., Transnational healthcare pracprivatisation of healthcare services in Europe, Social Science & Medicine

chose to refrain from trying to access the Irish healthcare systemand to postpone seeing a doctor until he could go back home toRomania. In fact, as Victoria and Ilie returned home at least threetimes a year (for Christmas, Easter, and during their summer holi-day), they also regularly included in these visits medical consulta-tions and tests for themselves and their daughters.

Adina’s family offers another example of the apparently“typical” Romanian migrant. Adina works in a restaurant in inner-city Dublin, and her husband, Ion, works in the constructionsector. Adina and Ion both came at the beginning of the 2000s andmanaged to obtain residence and employment permits in Ireland.Although this predisposes them towards a more “settled” approachto their stay in Ireland than Victoria and Ilie, Adina and Ion alsodisplay similar attachments to their country of origin. Like Victoriaand Ilie, Adina and Ion return home at least three times a year. Likethem, they also concentrate all their efforts and their savings(which constitute a large percentage of their income) towardsRomania, where they have already bought an apartment and star-ted to build a big house. Like Victoria and Ilie, they hope that, oneday soon, they will go back to Romania for good; but, unlike them,their plans are vaguer, as they have not invested in possible gainfulemployment opportunities in the country.

Born in Ireland in 2005, their daughter has already been sentback home in the care of Adina’s mother for two one-year periods,and afterwards during her summer holidays. Moreover, althoughAdina and Ion enjoy legal status in Ireland and access its healthcaresystem through their private insurance scheme, they also usuallycombine their visits to Romania with medical investigations andtreatments. Actually, their daughter’s longer sojourns in Romaniawere directly linked to their search for a diagnosis and cure for herrepeated flu-like infections after unsuccessful results in Ireland.

Interestingly, both Victoria and Adina illustrate the wider de-skilling process undergone by CEE workers as a result of migra-tion. Victoria has high-school level education in pedagogy and wastrained as a primary school teacher. Adina left Romania just afterfinishing her university degree in law. Neither of them ever prac-ticed their profession, and both now seem to be in that respectirreversibly de-skilled, having worked for too many years in un-skilled jobs.

However, Romanian migration also includes highly skilledworkers that managed to maintain or even improve their qualifi-cations as well as integrate into the host country’s work force at alevel appropriate to their qualifications. Monica offers an exampleof such a highly skilled worker. Monica started her universitytraining in management and had a first child in Romania, but,before finishing her degree, she divorced and finally left the countryin 1996. After six months in England, she decided to go to Ireland.Three years later, she had a second child, and then obtained herIrish residence permit. After she finished a degree in electricalengineering, Monica had a rather convoluted work trajectory: shefirst worked at Intel and HP, then had her own cleaning company,and after the start of the financial crisis went back to university topursue a management degree. In contrast to the first two casesabove, Monica is a well-settled migrant who sees herself as havingleft Romania for good.

Again, however, similarities with the first two cases are many.Indeed, although she loathes almost everything in Romanian so-ciety, Monica spends her annual holiday in Romania, where she hasbought several pieces of land and several apartments “as an in-vestment for my pension.” As she has been a single mother formany years, she has left her daughters in the care of her mother inRomania for longer or shorter periods of time (the elder until shewas ten, the younger for one year when she was two). Finally,although she is critical of Romanian healthcare professionals, andhas alternated between private insurance and Medical Card

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coverage in Ireland, she also uses her annual holidays in Romania toengage in medical investigations and interventions.

These cases do not exhaust the diversity of Romanian migrantsin Ireland, but they do show somemain threads, especially in termsof divisions between low-skilled and high-skilled employment inthe destination country, or between more temporary and moresettled approaches to migrants’ stay in the host country. They offer,of course, a partial view on Romanian migration, as they paint thepicture of migration mostly from a young working migrants’perspective (all migrants in the above cases are between 35 and 45years of age), and more particularly from a young women’sperspective; but maybe this is a valid perspective from which tocapture the shape of transnational healthcare practices amongRomanian migrants. As already mentioned, Romanian migration inIreland is gender balanced and overwhelmingly involves youngpeople. Most importantly, in Romanian families, adult women areresponsible for insuring their own, their children’s, and often theirhusbands’ and parents’ access to healthcare services in addition totheir care at home.

Migrants’ healthcare practices have been understood inresearch and popular discourse as being part not so much ofmedical tourism as of the much abhorred benefit orwelfare tourism.In contrast to medical tourism, mainly seen as the economicallyprofitable movement of responsible middle-class consumers fromdeveloped countries, benefit tourism is mainly seen as the illegit-imate drain (and abuse) of developed countries’ public resources bymigrants from less developed countries. This is so even if CEEmigrant workers’ social security contributions in their host coun-tries exceed the benefits they draw in the latter. However, whereasin western Europe CEE migrants have been demonised as unfairlyprofiteering from their host countries’ social and healthcare ser-vices (Nowaczek, 2010), as we saw in the cases presented abovemigrants have been quick to use their feet to defy any simplifiedimage of a stable, and encroaching, migrant population. Indeed,these conspicuously swinging migrants have been going back totheir country of origin not only for regular visits to their parents,relatives, and friends, or to build and buy newer and bigger housesback home, but also to avail themselves of its healthcare services.Like Victoria, Ilie, Adina, Ion, and Monica, Romanian migrants, andespecially women, have actively spun the threads linking them tothe Romanian healthcare system. As seen earlier, they have usedtheir visits back home to consult with doctors, to have medicaltests, or to receive treatment. They have also bought medicines inRomania and then either brought them to Ireland themselves orhad them sent via friends and relatives. They have contactedfriends, relatives, and acquaintances in Romania to receive adviceon folk remedies, or to get medical advice or advice on how toaccess healthcare back home. The same people were contacted forsessions of informal therapy when psychological distress relating tothe difficulties of moving into a new society or of accessing ac-commodation, work, or education were taking a toll on their peaceof mind and stamina.

Similar practices have been observed for other migrants inIreland, including those from Central and Eastern Europe(Macfarlane and de Brun, 2010; Migge and Gilmartin, 2011).Following the framework proposed by Glinos et al. (2010), Miggeand Gilmartin explored migrants’ motivations to return to theircountry of origin for medical treatment. They found that migrants’perceptions of Irish healthcare services were paramount in thedecision to return for care in their country of origin, and concernedin particular the perceived lack of availability (a distorted percep-tion resultingmainly frommigrants’ lack of information), perceivedproblems with affordability (such as high costs of healthcare inIreland), and perceived lower quality of care in Ireland than in theircountry of origin (including long waiting lists, deficient hygiene,

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etc.). Studying refugees and asylum seekers from the former Sovietbloc, Macfarlane and de Brun (2010) also noticed that migrantsdevalued Irish healthcare services by asserting the superiority ofCEE biomedicine over that of the host country. This assertion wasnot only a symbolic affirmation of status on the part of migrantsfinding themselves in a vulnerable position in the host country, butalso a result of the way in which biomedicines grounded indifferent socio-cultural settings were brought together throughmigration.

These studies are valuable in that they point our attention to-wards migrants’ individual motivations (Migge and Gilmartin,2011) or their medical pluralistic practices combining various bio-medicines (Macfarlane and de Brun, 2010) as an importantgrounding for migrants’ return for medical treatment in their homecountry. This article explores another possible dimension of mi-grants’ transnational healthcare practices, namely, their participa-tion in an increasingly unevenly developed citizenship in Europe asa result, in particular, of increasingly unequal and sometimesrestricted access to healthcare services in both sending and desti-nation countries. We have seen that Romanian migrants’ access tohealthcare in Ireland is restricted by a highly unequal healthcaresystem as well as by differences inmigration status.We turn now tothese migrants’ access to, and use of, Romanian healthcare services,the main destination of their transnational healthcare practices.

6. Accessing Romanian healthcare services

Although, as stressed above, the engagement of Romanian mi-grants with the Romanian healthcare system displays similar in-tensities despite their various migration statuses, it does not,however, take the same forms and meanings for all of them. This isbecause the healthcare system became another playing field for theincreased social differentiation apparent in Romanian society after1989 (Popescu et al., 2006). Indeed, although the system is stillbased on the premise of free and universal access to healthcare, theconcrete ways in which access to healthcare is obtained are verymuch dependent on patients’ social position and serve in turn toreproduce the social inequalities between these positions.

Contrary to Ireland, in Romania the right to healthcare is stip-ulated in the constitution (Vladescu et al., 2008, p. 23), and access topublicly funded healthcare is in theory universal. Nevertheless,even during socialism, universality of access was fragmentedamong various socio-economic categories (e.g. among variouscategories of workers, between workers and inactive people, etc.).The reform of the Romanian healthcare system at the end of the1990s from state funded to one based on social insurance, withcontributions from employers and employees, only institutional-ised fragmentation in new ways. Following the reform, access tohealthcare services covered by national health insurance becameconditional on employment, with the state covering access to theseservices for the non-active and unemployed population.

Moreover, access to healthcare is strongly differentiated at thelevel of quality of medical and interpersonal treatment given byhealthcare personnel. Thus, on the one hand, the continuous lowwages of healthcare personnel resulting from the prolonged andsevere underfunding of the Romanian healthcare system has led toa situation where access to better care has increasingly becomedependent on giving sums of money or in-kind gifts to healthcarepersonnel (spaga in local parlance). This means that access to betterhealthcare depends on one’s material means, social position, andskills in making informal payments and gifts. On the other hand,better-off patients have recourse to what is seen as better care inprivate clinics and hospitals covered by private insurance (8% of thepopulation in 2008 [CP, 2008, p. 65]) or out-of-pocket payments.

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Moreover, despite Romanian healthcare system’s objective ofuniversality, important percentages of the population (6.5% in2002) and particularly of its rural population (16% in 2007) are notregistered with a GP (Armean, 2008, pp. 68, 88). Given the gate-keeper role of GPs in accessing services, these numbers may alsoserve as proxy for the proportions of people not covered by nationalhealth insurance. Even when covered, recourse to spaga in order toaccess better treatment leads to the reproduction of social in-equalities. A 2007 study on healthcare access in the relatively richnorth-western region of Romania found that the frequency ofinformal payments to doctors or nurses during hospitalisationconcerned 59% of respondents in the highest (richest) quintile butonly 37% of those in the first (poorest) quintile (Rat, 2008, p. 24),confirming the class bias inbuilt into the practice of spaga. Theseinequalities are also reflected in the use of private healthcare ser-vices. The same study found that only 21% of respondents in thefirst quintile availed themselves of private healthcare, whereas 49%of those in the highest quintile did so (Rat, 2008, p. 25).

Not only do poorer people not have the means to engage inout-of-pocket payments for private healthcare or in spaga foraccessing better publicly funded care, but when they do, thesepayments may contribute to increase social inequalities. A 2004study estimated that the total number of poor people in Romaniaincreased by 2% and the number of those in extreme poverty by 8%due to out-of-pocket payments for healthcare services (Vladescuet al., 2008, p. 17; ECHSD, 2007, p. 12). This leaves the mostvulnerable sections of the Romanian population increasinglyengaging in health-seeking behaviours that circumvent the officialhealthcare system by having recourse to popular and folkhealthcare (Kleinman, 1980), a phenomenon also reflected in thelarge readership of health advice columns in popular magazines(Bazac, 2012). By contrast, not only has Romania’s post-socialistmiddle-class the means to access private care or better publiccare through out-of-pocket payments, but also has developedrising expectations as to its health status. The dominant trendsamong this class reflect its strong demand for medicalisation, as itsmembers increasingly expect and engage in regular medical tests,or caesarean rather than natural births (Pop, 2012). Finally, tothese social class inequalities, we should also add importanturban-rural disparities (Vladescu et al., 2008, pp. 46e47) andgender and ethnic inequalities (Rat, 2008; Armean, 2008) inaccessing healthcare in Romania.

7. Transnational healthcare practices and social inequalities

Social inequalities are also reflected in the way Romanian mi-grants access Romanian healthcare services. The health insurancesystem that resulted from the end-of-the 1990s reforms put apremium on employment as a way to access public healthcareservices, thus instantly placing Romanians engaged in out-migration in the dilemma of either continuing personal paymentsto the health fund or being barred from formal access to publichealthcare services in Romania. Monica, for example, continued herpayments for Romanian national health insurance for several years,but two years ago finally decided to stop because already her accessto the Romanian healthcare system was no longer passing throughthis formal channel.

Like many other educated Romanians, Monica used her eco-nomic, cultural, and social capital to access not just healthcare butalso better healthcare in Romania. In the post-socialist landscape,she had two avenues open to her. One involved using healthcareprovided by private practices, clinics, and laboratories. The otherwas to try to get access to better healthcare services available inpublic healthcare units by recourse to informal connections (relatii)and payments (spaga) to their healthcare personnel (Stan, 2007,

Please cite this article in press as: Stan, S., Transnational healthcare pracprivatisation of healthcare services in Europe, Social Science & Medicine

2012). Interrupting her membership of the national health insur-ance scheme would not, therefore, have made a big difference tohow she accessed healthcare services in Romania.

This type of access cannot, however, be afforded by all Roma-nians living either inside or outside the country. Indeed, inRomania, the masses of low, un-, or de-skilled workers, of unem-ployed people, or of low-skilled retirees have neither the money toaccess private healthcare services, nor the social connections andincome for the spaga payments that would allow them to accessbetter healthcare in the public system. Victoria, for example, had tocontinue her payments to the national fund as her sole guarantee ofminimal access to care. However, although she also timidly tried tobuild up social connections with healthcare personnel in her homevillage and the nearby town’s hospital, the rather low levels of herspaga payments and her still unsure mastery of the language ofsocial distinction (Bourdieu, 1979) made them still treat her as a“peasant” unworthy of their full consideration.

In Romania, income is twinned with education as criteria forsocial distinction (Sampson, 1994). Indeed, many Romanians withthird level education see their social world as being divided be-tween the educated ones (that is, those like them, also called “in-tellectuals”) and the un-educated ones (all the others). For them,legitimate access to economic, cultural, and social rewards has to bebased on these differentiated education levels. This meritocraticvision of society was very much fuelled by developments duringthe last decades of socialism (when social reproduction based oneducation levels largely replaced the social mobility based on socialorigins of the first two socialist decades), and post-socialist neo-liberal transformations very much comforted intellectuals in theirdivisive vision of society (while also challenging their formerlysuperior positionwith the ascent of “newmoney” and new forms ofsocial differentiation, see Sampson, 1994). Thus, although theRomanian migrants in our cases engage in apparently similar usesof healthcare services back home, the actual forms these uses takediffer in important ways.

For Romanian “intellectual” migrants, a factor of distinction be-tween them and the other migrants is the presence, in their case, of“choice.” Indeed, their mention of the use they make of Romanianhealth services is always carefullycomplementedby theobservationthat they “have a choice,” because theycan afford to, and also do, useIrish healthcare services. When they use Romanian healthcare ser-vices, it is not because this is their only option, as, they are ready tostress, is the case for the masses of “poor peasants working in con-struction and cleaning” who “have no choice.” In contrast to thelatter, “intellectuals” present their engagement with Romania’shealthcare services as either conjectural e because they happenedto need medical advice or interventions during their trips toRomania, or as a sign of their privileged social statuse because theyare sowell connected at home that theywere almostpushedby theirrelatives and friends to indulge in the best care provided by Roma-nian specialist doctors. Like Veblen’s leisure class (1994/1899),Romanian “intellectual” migrants try to distance themselves fromthe grimworld of necessity and pecuniary calculus.

In trying to respond to these exclusionary tactics, many ordinaryRomanian migrants with low or middle levels of education try toclimb the social ladder by building bigger and larger houses backhome, but also by using their savings to access Romanian privatehealthcare services and thus counter a public system where accessto better care reproduces social inequalities of income, socialprestige, and control of subtle codes of social distinction. The resultof this increased use of Romanian private healthcare services is amassive “lift-off” (Sampson, 2002) of existent or aspiring, residentor out-migrant, middle-class Romanians from the country’s publichealthcare sector. In other words, healthcare leaves the domain ofuniversal social rights and un-differentiated social citizenship to

tices of Romanian migrants in Ireland: Inequalities of access and the(2014), http://dx.doi.org/10.1016/j.socscimed.2014.04.013

S. Stan / Social Science & Medicine xxx (2014) 1e10 7

enter the arena of struggles to construct a differentiated citizenry inmigrants’ countries of destination and of origin.

8. Privatisation and healthcare access inequalities

When we look at Romanian migrants’ uses of Irish and Roma-nian healthcare services, we see that they are, in both cases, deeplyembedded in highly unequal configurations of access to publichealthcare services. Our last question is what really lies behindthese configurations, what processes have brought them about andare reproducing them in time.

Critical strands in anthropology, tourism, and health studieshave highlighted the links between medical tourism, on the onehand, and the privatisation, commercialisation, and unevendevelopment of healthcare, on the other (Connell, 2006; Ormond,2013; Bochaton, 2013). Increasing constraints in accessingbudget-tight public healthcare services and reliance on privatesources for funding healthcare have pushed patients in developedcountries to look for cheaper alternatives in developing countries(Glinos et al., 2010, p. 1153). Given the considerable importance ofout-of-pocket payments for medical tourism, the healthcare sys-tems of its destination countries have become increasingly unequalas a result. Medical tourism’s contribution to draining financial andhuman resources from public to private healthcare units has led tothe development of two-tier healthcare systems that combine eliteprivate healthcare facilities reserved for medical tourists andwealthy local patients with increasingly neglected public facilitiesfor the local poorer population (Whittaker et al., 2010).

The more diffuse and informal transnational healthcare prac-tices of Romanian migrants in Europe are part of similar processesof increased inequalities of access fuelled by the privatisation andcommercialisation of healthcare. What is interesting in their case,however, is that they point in a more fundamental, albeit lessvisible, manner thanmedical tourism to healthcare inequalities andprivatisation in migrants’ countries of origin and of destination.Moreover, these processes have now been brought to bear not onlyon the more global and geographically and culturally distantmovements classically involved in medical tourism, but also onintra-European movements resulting from EU enlargement.

I adopt an encompassing view of healthcare privatisation andcommercialisation, as including not only the rise of private fundingand provision of healthcare (as illustrated by increases in privateinsurance, and private clinics and hospitals), but also the com-mercialisation of publicly funded healthcare through new publicmanagement (NPM) measures, as well as the progressive disen-gagement of state responsibility from the provision of services(through the outsourcing of ancillary services, restrictions in pub-licly provided care through the definition of minimum servicebaskets, or allowing private facilities to contract services with na-tional health funds).

As we have seen, Romanian migrants’ use of Irish healthcareservices is embedded in a highly unequal configuration of access tocare in which private provision and funding play an important role.The Irish healthcare system has never been truly universal, and wecan discern trends towards its increasing privatisation and com-mercialisation in the last decades (Burke, 2009; INMO, 2010, pp. 6e7). During the 2000s, successive governments introduced into thepublicly funded hospital sector NPM measures (targets, bench-marks, but also the Diagnostic Related Groups [DRG] method forhospital funding), contracted out cleaning and catering services ofpublicly funded hospitals, encouraged the private provision ofhealthcare through tax reliefs for private insurance premiums andthe construction of private hospitals co-located on public hospitalgrounds, permitted consultants to care for private patients even ifthey had contracts with publicly funded hospitals, and required the

Please cite this article in press as: Stan, S., Transnational healthcare pracprivatisation of healthcare services in Europe, Social Science & Medicine

latter to have 20% of their beds reserved for private patients (DHC,2001, p. 100). State disengagement from its responsibility for theprovision of healthcare can be seen in the introduction of caps onhealthcare personnel employment (and particularly nurses) inpublicly funded hospitals, as well as fees for medicines for MedicalCard holders, and increased fees for non-Medical Card holdersaccessing non-referred Emergency and out-patient services. Allthese measures have directly contributed to putting considerablestrains on publicly provided care (in terms not somuch of quality asof waiting times) and thus to encouraging recourse to privateprovision by better-off patients. The austerity measures adoptedunder the Troika after 2009 only exacerbated these tendencies, asthe numbers and wages of healthcare personnel, and particularlynurses, were significantly reduced (Burke, 2010; Erne, 2013).

In Romania also, Romanianmigrants had to face a highly unequalconfiguration of access to healthcare services, in which out-of-pocket payments for care in both private and public healthcare fa-cilities play an important role. The transformation of the Romanianhealthcare system into a social health insurance one at the endof the1990s also brought in the same package the introduction of NMPmeasures, such as contracts between purchasers and providers, orthe DRG hospital financing method (Stan, 2007). The private provi-sion of healthcare has been encouraged by allowing private clinics,hospitals, and medical laboratories to contract services with theNationalHealth Fund (Benezic, 2013), but alsobyprivatisingmedicalservices such as dialysis (Paveliu, 2011). In 2010,15% of hospitals and42% of secondary care out-patient units were private (INS, 2011).Most important, however, has been state’s disengagement from theprovision of healthcare through the continuous underfunding ofhealthcare services, caps on healthcare personnel employment,continuously low wages of healthcare personnel, and the loweringof employer and employee contributions to the National HealthFund (Paveliu, 2012). All these measures contributed to the declineof employment, working, and care conditions in public healthcarefacilities. In turn, these bred the ground for the development andinstitutionalisation of spaga payments as a means to access quickerand better care, but also for the defection of better-off patients andbetter qualified healthcare personnel to private healthcare facilitiessituated either in Romania or abroad (Galan et al., 2011; Toma andCiuhuta, 2012). The austerity measures adopted in the aftermathof thefinancial crisis under theguidanceof theTroikaonlyworsenedthese tendencies, as small local hospitals were closed, and thenumber and wages of healthcare personnel dropped even further(Trif, 2013).

Healthcare privatisation and commercialisation in Ireland andRomania have other curious similarities. Indeed, the two healthcaresystems combine the continuous importance of public fundingwith a rising importance of private provision of healthcare services.In both countries, the share of public funding is above 70% of totalhealth expenditure (WHO, 2013). However, a 2012 study onRomania found that 43% of its mainly urban respondents availedthemselves of private healthcare (Newsroom, 2012). In Ireland, 50%of the population have private health insurance, although privateinsurance contributes only 11% towards total healthcare expendi-ture (Thomson et al., 2012, p. 9). Healthcare services are thus usedto direct public money into private purses, echoing the develop-ment of recombinant property in CEE countries during the 1990s(Stark, 1996) but also the more general rise of the “predator state”during neo-liberal times (Galbraith, 2009).

9. Conclusion

This analysis offers awindow into two larger social contexts thatcan help us understand Romanian migrants’ transnational health-care practices.

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First, we may envision healthcare access as it is used byRomanian citizens and migrants as a sign of social mobility. As wehave seen, post-socialist Romania is aworld of renewed hierarchies,where education is still used, albeit not guaranteeing anymore, toaccess better paid and more prestigious jobs in industry or publicand private services. In this context, access to healthcare is a meansto claim a middle-class position. In the case of migrants, this claimis manifested in their feverish building of houses back in Romania,but also in their healthcare practices. House building is a prettyconspicuous practice that helps them signal to their family, friends,and neighbours back home their aspirations to a better status.Although, by contrast, healthcare practices are more intimate, andnot visible as such, they are, however, often public in that theyconstitute a favourite conversation topic. In Romania, health is oneof the main concerns shared in tightly knit groups of family, friends,neighbours, and colleagues (Geana, 2002; Weber, 2009; Kideckel,2008).

Thus, access to private healthcare can be seen as a strategywhereby ascendant middle- and upper-classes “lift-off’ (Sampson,2002) from wider society, and its apparently un-differentiatedpublic healthcare system is left to the masses of subsistence agri-cultural villagers and low-skilled, precarious, or unemployed ur-banites. Of course, for migrants, the majority of whom have mostlyonly aspirations to the lower ranks of the middle-class, access toprivate healthcare in Romania is also entering into a larger calculusof economic and social costs. Accessing private healthcare inRomania is more expedient than accessing the time-consumingand socially costly Romanian public healthcare system, as well asbeing less expensive than the Irish healthcare. Last but not least,migrants’ use of private services in Romania also answers theirincreased expectations of medical consultations and tests ondemand.

Second, migrants’ recourse to healthcare services in their homecountry has also to be placed in thewider perspective of what someanalysts called global care chains (GCC) (Yeates, 2009; Erel, 2012;Perrons et al., 2010; Hochschild, 2000). Their transnationalhealthcare practices direct our attention not so much, as in classicalGCC studies, to care providers’movements, as, alternatively, to careseekers’movements across borders. Like medical tourists, migrantsreturning for treatment in their home countries can be seen as thefluid that connects various healthcare systems, and thus variousregimes of social citizenship, in a larger transnational space. Theferment that makes the fluid flow and is in turn nourished by it isthe ongoing privatisation of healthcare systems around Europe.

Migrants’ transnational healthcare practices have been seenfrom the perspective of medical pluralism as building new linksamong various socio-cultural enactments of biomedicine(Macfarlane and de Brun, 2010). By engaging with their hostcountry’s healthcare system, migrants enact a critique of a histor-ically specific form of biomedicine from the point of view of theirexperience of the healthcare system in their country of origin. Two“ethno-medicines” become thus connected. This paper has tried topoint to other connections brought about by migrants’ trans-national healthcare practices: 1) the embeddedness of these prac-tices in class inequalities in both host and home countries; and 2)their participation, along with larger e global and European e

forces, in the privatisation of healthcare services around Europe.The story of Romanian migrants’ transnational healthcare

practices is thus not simply a market tale of patients’ rationalsanctioning of market deficiencies in the various healthcare sys-tems they encounter, or a cultural tale of patients choosing whatthey see as better healthcare systems in the name of their nationalattachments and experiences. It is also, most importantly, the storyof the embeddedness of these practices in healthcare inequalitiesresulting from healthcare privatisation in migrants’ sending and

Please cite this article in press as: Stan, S., Transnational healthcare pracprivatisation of healthcare services in Europe, Social Science & Medicine

receiving countries. Therefore, inasmuch as access to publichealthcare services is one of the core dimensions of social citizen-ship (Marshall, 1950), this is also a story of restricted and unevencitizenship across Europe.

There is, however, a need to go beyond even the imperative ofjoining in our analyses the transformations affecting healthcaresystems in migrants’ sending and receiving countries. Some maydismiss the above Irish and Romanian cases as concerning health-care systems of a very particular character because situated inwhatis now seen as the EU’s peripheral fringe, but the contrary argu-ment could also be made: these countries are not the exception toneo-liberal capitalism but its most pregnant instantiation. Since themid-1990s, Ireland has been at the top of most globalised countriesin the world rankings (EY, 2013). Both Romania and Ireland havebeen known as economic “tigers” during the 2000s’ boom, and bothhave been stark illustrations of a debt-driven model of economicdevelopment (Stan and Erne, 2014; McDonough, 2010).

The neo-liberal turn taken by the EU and its eastern enlarge-ment in the last decades led to a European citizenship configurationincreasingly differentiated across gender, class, and ethnic lines. Onthe one hand, accession resulted in unequal openings of EU-15countries’ labour markets and public services to new memberstates’ migrants (Favell, 2008; Loyal, 2011). On the other hand,European enlargement was concomitant with increased gender,class, and ethnic inequalities in CEE countries (Smith, 2010; Pickles,2010). This resulted in pockets of exclusion where social and eco-nomic marginalisation diminished the access of local populationsto citizen rights. In turn, migration has also been increasingly usedpolitically to restrict migrants’ access to citizen rights in bothsending and receiving countries (De Haas, 2010). This importantlyquestions CEE migrants’ integration in a common European citi-zenry (Likic-Brboric, 2011; Hansen and Hager, 2010), as they cometo avail themselves of rather precarious citizenship (Munk et al.,2011).

Moreover, in healthcare in particular, NMP measures, thedisengagement of state responsibility for healthcare provision, andthe active encouragement of private endeavours in healthcare havebeen observed in all European countries (Clarke et al., 2000;Maarse, 2006; Andre and Hermann, 2009; Schmid et al., 2010).Future research should try to further map the links between, on theone hand, European healthcare-seeker and healthcare-workermovements, and, on the other, the definitely uneven but surelycontinuing privatisation of healthcare around Europe. These pro-cesses draw our attention to the rise of an unevenly developedEuropean healthcare assemblage and citizenship regime in whichpatients’ movements across borders are closely interlinked withdiminishing and increasingly unequal access to public healthcareservices.

Acknowledgements

The study was generously funded by the SoN-DCU ResearchFunding for Postdoctoral Staff Grant and the DCU Research CareerStart Grant. My gratitude goes to all Romanian migrants whoshared their experience of accessing healthcare services in Irelandand Romania. I would also like to thank Roland Erne for hiscontinuous encouragement and stimulating intellectual support.The usual disclaimer applies.

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