Migrants and Health in Portugal

The aim of this research is to atain knowledge on immigrant´s health related problems and to identify their dificulties when acesing health care services. The article describes immigrant´s dificulties when acesing health care services that are visiting the health ofice at a National Immigrant Support Centre. Design: : A qualitative study was conducted, analysing available documentation and observing the health isues dealt with at the National Immigrant Support Centre’s (CNAI) Health Ofice. The 148 cases are mainly immigrants coming from Portuguese speaking African countries for health purposes. Immigrants from Brazil have more restricted aces, and feel discrimination on the part of the services. Immigrants from Eastern Europe come in search of information and have communication dificulties. Obstacles are related to the lack of knowledge of the law, but also to the failure of puting the law into practice. The ofice has had a great demand of users seeking information and in acesing the health care system. Results: The cases analysed are mainly nationals from Portuguese Speaking African Countries (PSAC), Brazil and countries in Eastern Europe. The majority of the immigrants coming from PSAC are patients receiving treatment under international Cooperation Agreements requesting financial and social support. Immigrants from Brazil have more restricted aces and feel greater discrimination on the part of the services. New Labour Migrants from Eastern Europe, on the other hand, come in search of information and are known to have communication dificulties. Conclusions: Legislation in Portugal provides aces to health care to al citizens, regardles of their legal condition and origin. However, some immigrants have had significant dificulties with aces to Portugal’s National Health Service. The obstacles are not only related to the lack of legal knowledge, but also to the failure of puting the law into practice, which requires atention by the institution responsible for efective and comprehensive coordination. The ofice has had a great demand of users seeking information, who, above al, wish to solve their problems and dificulties in acesing the health care system.


I. Introduction
This article is the result of a study which seeks to understand the problems that migrants face when accessing health care in Portugal (more specifically, in Lisbon), through the analysis of information collected at the National Immigrant Support Centre's (CNAI) Health Office.To this end, a qualitative study was conducted, based upon the analysis of existing documentation and the observation of migrants visiting the Health Office.A first analysis shows that there are problems at different levels in what concerns the use of health care services by immigrants.Some are connected to their own irregular situation and others owed to difficulties encountered during the process of family reunification.
There are also many cases of individuals coming to Portugal for treatment within the scope of health agreements with Portuguese Speaking African Countries, who need financial and social support in the absence of assistance from the responsible entities.
The results of this case study may lead to further intervention in the areas where the problems are identified, the improvement of health care services dealing with immigrants, the development of a better model of integration and increased articulation between the different institutions involved.
In Portugal, the right to health care is assured for all immigrants, regardless of their juridical situation, in accordance with Order 25360/2001.The Portuguese Law ruling the access of immigrants to health care services is clearly in favour of closing the gap between immigrants and the Portuguese National Health System.According to the report by the NGO Medicins du Monde (Chauvin et Parizot, 2007), the theoretical rights practically cover the entire population of Portugal and, in comparison with other European Union countries, a significant percentage benefits from these services.Despite this favourable policy, however, there are often difficulties in putting the law into practice due to lack of knowledge, not only by the immigrants, but also by the staff manning these services.
An improved understanding of the determinants of access and use of the health services by the immigrant population can prove useful in the development of more adequate policies and health programmes that might effectively contribute to reduce health problems.It is essential to recognize, both at the level of the users and the responsible political entities, that it is not enough to have an available system of services but, that this must be accessible.In order to help immigrants to have total access to what is put at their disposal by law in each country they choose to live in, it is equally important that they are fully informed of their rights.It is within this frame of analysis that we were interested in understanding the role of the Health Office working specifically with immigrants in order to then approach the migrant's health problems.
This study is thus the result of an analysis on the situation of migrant's access to health carried out during a period of observation at the Health Office of the National Immigrant Support Centre (CNAI) in Lisbon.This seemed to be the most suitable place to perceive the existing problems related to health and migration since it is the only structure of its kind assisting immigrants in Portugal.One of the objectives of the study is to understand why immigrants request the help of the Health Office, when in fact access to health care services is foreseen and assured by Portuguese law, since 2001.
Who then asks for support at the Health Office?Which are the main existing problems?What obstacles exist?Which solutions are provided?These are the questions I here attempt to answer.
The study aims at exploring a poorly studied reality, as well as achieving a better understanding of this problematic which involves the profile of the users and determining their health problems.Through a better comprehension of the ailments affecting the population, we may be able to identify the measures required to improve relations between immigrants and the National Health System.But can it be that these cases are "impossible" to solve in the public services sector and therefore ending up at the offices of CNAI "as a last resort"?Can it be that these specific and vulnerable cases concern just a small percentage of immigrants?
Our perception is that the access of immigrants to the health services has improved, although the difficulties concerning the lack of knowledge of the law remain and that the use of the National Health System by immigrants depends, largely on their period of permanence in Portugal, their legal status and their nationality.
We consider that this can be used as a contribution to other studies to be carried out within the same field because it examines problems of access to health care in a country (Portugal) where migrants have -in theoryremarkably comprehensive entitlement to care.In practice, however, there are many barriers to immigrants enjoying these entitlements.It seems that there are very big implementation gaps due to health care workers not knowing or respecting the law (which itself is rather complex).Migrants are also poorly informed about the law.The result of the study shows how the best legislation in the world can be of little use if not enough attention is paid to its implementation.

II. Immigration in Portugal
Portugal has evolved from a country predominantly of emigration to become also a country of immigration in the 1990s.The immigrant population increased in a very significant way until recently mainly due to the arrival of citizens from Brazil and the "New European Countries".
In twenty years , the number of foreigners with a residence permit increased more than sixfold.In general terms, however, this is an underestimated evolution, considering the existence of a significant but uncertain number of irregular migrants without residence permit.
Seven years ago, throughout 2007, for example, Portugal granted residence permits to a total of 146.636 labour migrants, 56% of whom coming from countries in Eastern Europe.Considering that Portugal does not have any historical connections with these countries, such a flow of migrants from Eastern Europe may be considered exceptional.Available empirical evidence shows that this population was very different from the migrant groups arriving in Portugal decades before.The reasons behind the first immigration movements are connected to Portugal's colonial past, while this new movement seems to be structured and nurtured from the regions of origin.These relatively "new" labour migrants are significant in number and are highly qualified when compared with the first flow of migrants and even when compared to the local population.Initially, these immigrants were mostly single active aged males and were scattered throughout the entire country.They arrived in Portugal in very poor conditions, mostly through human trafficking networks.After approximately one decade, a family reunification process was witnessed with well organized groups of migrants, through active associations and a positive level of integration.
We also observed not only the reunification of families, but also another type of immigration, in particular of a large number of women who arrive on their own in Portugal, leaving their family behind in the country of origin (Hellerman, 2005).The oldest immigrant communities originating from Portuguese Speaking African Countries corresponded, in 1997, to 60,1% of all foreign citizens in Portugal from outside the European Union countries.In 2006 they represented only 45,5%, taking into account the increase of new migration flows coming from Brazil and Eastern Europe.In 2007, the most represented groups of migrants in Portugal, were coming from Brazil and Cape Verde, followed by those from Ukraine, Angola, Guinea-Bissau, Moldova and Romania, and corresponding, in total, to nearly 72% of the foreign population with residence permit in Portugal (SEF 2007).
On 31 December 2010, the number of foreigners registered as living in Portugal on a permanent basis was 445.262, which represents a decrease of 1,97% as compared to the year before.This decrease puts an end to the earlier continued growth of the foreign community in Portugal which had been registered in the past years.The main nationality groups continue to be those originating from the following countries: Brazil, Ukraine, Cape Verde, Romania, Angola and Guinea-Bissau.Brazilians continue as the largest foreign community, with 119.363 persons registered as residents in Portugal by the end of year 2010, and maintaining the tendency for sustained growth of that community.This has been the trend since the beginning of the century.Ukrainians remain the second largest foreign community in Portugal with a total of 49.505 nationals, followed by Cape Verde with 43.979, Romania with 36.830,Angola with 23.494 and Guinea-Bissau with a total of 19.817 citizens registered as residents in Portugal by the end of year 2010.
Whilst the total number of foreigners with residence permits in Portugal by the end of 2010 had decreased, the consolidation of the Brazilian predominance can be registered when, at the same time, the traditional foreign communities in Portugal (originating from Cape Verde, Angola and Guinea-Bissau) and those from Eastern Europe consisting of the so called «new migratory flow» (mainly from Moldova and Ukraine) have drastically reduced their number.Romanians, meanwhile, stand out as the principal group of immigrants coming from a European Union country.
From a demographic perspective, the immigrants are primary contributors to an old population with very few births.The main characteristics, when it comes to profiling the new immigrants, are that the majority is well educated and highly skilled, young in age and predominantly female, and most likely to contribute to the benefit of the host country.Presently we are facing in Portugal a new type of immigration which raises new social questions and, consequently, requests for new policies and practices as happening in other European Union countries as well.
Nevertheless in Portugal, several indicators reveal an inequality in what concerns employment, housing, education and other aspects of immigrant's social life.Their unemployment rate is higher than that of the Portuguese themselves, with a professional profile where the lowest qualified activities and the lowest salaries predominate.They live under poor housing conditions and, consequently, present a higher risk for poverty and social exclusion (Baganha et al., 2002, Fonseca et al,.2002, Malheiros et al,. 2007).

III. Access of Immigrants to the Health Care System in Portugal
Despite the remarkable legislative progress made in Portugal, with the full inclusion of immigrants in accessing health care, many problems at the level of structural and institutional constraints still remain.
In terms of legislation, Portugal started allowing immigrants to have access to the National Health System following an important increase in arrivals at the end of the 20th century.Since 2001, the right of access to National Health System health centres and public hospitals is assured to all foreign citizens regardless of their nationality, economic status or legal situation (ACIME, 2007).Foreign citizens must obtain a health card from the NHS.
Immigrants "without papers" may get a temporary beneficiary card that can be obtained if they show a certificate attesting their place of residence.The fees that immigrants are expected to pay for health services correspond to the official rates in practice for Portuguese citizens.However, those who do not contribute to the Portuguese Social Security System, must pay a higher fee for medical treatments.Still, the existence of this possibility, in the European context, reveals great progress (Ingleby et al., 2005).
Between 1998 and 2009, non-documented immigrants in the Netherlands only had access to health care considered "medically necessary".Currently the costs of "medically necessary care" for undocumented migrants could be reimbursed if efforts are made by the patient which includes sending an invoice and a reminder and verification by the authorities of the patient's ability to pay.
The new scheme does not distinguish between 'primary' and 'secondary' care, but between 'directly accessible' and 'not directly accessible' services.However, a person must first obtain a referral, a prescription or an indication in order to use a 'not directly accessible service'; these services provide "planable care" .
Undocumented migrants who, because of their own ignorance or that of the health worker who refers them or writes a prescription, obtain hospital treatment or prescription medicines from non-contracted providers, will find themselves liable to pay the entire costs themselves.Only 80% of the normal fees for services can be reimbursed, except in the case of pregnancy and childbirth which have 100% coverage.(Cuadra C., 2010b).
In Greece, the provision of any type of healthcare service in the public sector for undocumented migrants is prohibited.Hospitals and clinics are exempted from this provision in the case of underage children or in case of emergency treatment (life threatening events) (Article 84/Ν.3386/2005)(Cuadra C., 2010a) Cuadra also shows that the variations observed do not seem to be associated with the system of financing (mainly tax based or insurance based).There is no relation between the financing system and the levels of care to which undocumented migrants are entitled.Intuitively it might also be expected that strong, well-established welfare states will grant more complete entitlements than newer ones.Comparing Sweden on one hand, with Portugal and Spain on the other, shows that the opposite is also found (Cuadra C., 2011).
In Portugal, foreign citizens are guaranteed the right to be attended to in a NHS health centre or hospital, regardless of their nationality, economic means or legal status.Their conditions of access are defined in accordance with order 25360/2001 of November the 16th, issued by the Ministry of Health.Documented foreign citizens are required to obtain a health card from their local health centre (Cuadra C., 2010c).Undocumented migrants' entitlements within the framework of the NHS in Portugal depend upon the length of time that they've been living in the country.Entitlement to universal healthcare involves obtaining the equivalent of a health card.The basic requirement for undocumented migrants is a 90 day stay.However, if the relevant authorities do not officially recognise that an undocumented migrant has been living in a specific district for more than 90 days then the migrant will only be entitled to access emergency care in public hospitals upon payment of the full cost of treatment.Those undocumented migrants able to prove that their residence in Portugal exceeds 90 days may obtain a document equivalent to the health card called "temporary registration".The document may be obtained upon presentation of two witness statements by locally registered residents, confirming the undocumented migrant resides in that neighbourhood.
In the United Kingdom, undocumented migrants have the right to receive emergency care free of charge at Accident and Emergency departments.Undocumented migrants may, in principle, access primary care and secondary care if they pay the full costs or are exempted (determined on a case by case basis).Despite this, the UK established a number of specific initiatives, with immigrants in mind, following the principle of respect for diversity and promotion of integration through the creation of culturally adapted services.
In Sweden, this philosophy is considered inappropriate because, in this country, the concept of equality works according to the needs and not in relation to other variables that may differentiate immigrants (Pillinger, 2003).
In Portugal, there are no national multicultural health programs exclusively targeting immigrants or minority ethnic groups.Such persons may use the same services which are available to all citizens (Fonseca et al. 2009).
Despite the existence of universal coverage and access to health care, we often observe that the immigrant communities in Portugal do not benefit from all available services and are not included in the existing systems of health promotion, prevention and treatment of diseases (Gautier et al., 1997;Luck et al., 1999;Mcmunn et al., 1998;IOM, 2004).
The access and the use of health services can become difficult at different levels due to legal, structural, organizational, economic, cultural and language barriers (Dias et al., 2004;Fennely, 2004).Even if the universal right to health is recognized, de jure, the limitations imposed, de facto, on immigrants, particularly in the case of those whose situation is irregular, may determine the access to health care.The unstable and precarious situation of immigrants, their difficulties in trying to obtain social protection and the cost of health care fees may become obstacles in the use of these services by the immigrant population.Financial constraints and the lack of sufficient resources in the health sector, in general, may also condition the efficiency and effectiveness of the response to the health needs of the immigrant population.The behaviour of both administrative and medical health care staff could, as well, be another decisive factor in the degree of use of the services.More often than not, health care professionals have a rather limited knowledge in what concerns the legal framework or on how to put this into practice.This often results in exclusion of the immigrant communities from the health care system.Moreover, discrimination and stigmatisation socially produced and associated to the immigrants' situation can also condition their access to information and, consequently, the use of health services (Wolffers et al., 2003).
Available bibliography on this subject points to the existence of multiple factors influencing the access to health care, namely, discrimination by institutions, lack of knowledge on rights, lack of information about the services available, limitations in communication, fear and mistrust (Ingleby et al., 2005).Cultural obstacles, such as gender differences, food habits and the absence or reduced levels of preventive health care in the country of origin are other possible constraints (Carillo et al., 1999;Carlsten, 2003).
At this stage it is important to mention the lack of studies on the effective access of immigrants to health care in Portugal.Much of the existing research on migrants, ethnic minorities and health concerns exclusively groups of migrants that settled in Portugal in the decades following the independence of Portuguese Speaking African Countries (PSAC) (years 1970s, 1980's) .
This report is restricted to a small number of cases studied and to a specific place, thus cannot be considered representative of all immigrants.CNAI sees people with many different types of access problems but we do not know if they are representative of the problems experienced by all migrants.
We must, therefore, emphasize the need to carry out a more extensive research in this area.The access to health care by immigrants in Portugal varies greatly depending, in large measure, on their legal situation and their nationality.Some data on foreign residents in Portugal show that those with their legal situation in order are very often registered in the health centre; on the other hand, those without documentation use mainly the emergency services in the Hospitals.This option is preferred as they do not wish to be identified and these services function in a more anonymous way (Freitas 2003).

IV. The Health Office at CNAI
The High Commission for Migration and Intercultural Dialogue (ACIDI) was set up as a public service with the mission of receiving migrants and promoting their integration.
Directly under the office of the Prime Minister, it is an interdepartmental support and advisory structure of the Government in what concerns immigration and ethnic minorities.Created in 1992, the High Commission for Migration and Ethnic Minorities (ACIME) was converted into a public body in 2002, being recently renamed as ACIDI and having its scope of intervention broadened.One of its priorities is to facilitate and ensure the contacts between the migrants and the public administration.The creation in 2004 of the National Immigrant Support Centre (CNAI) in Lisbon and in Porto consolidated the mission of the ACIDI.The CNAI has an Office where most of the public administrative services that migrants need to contact (Service for Foreigners and Borders, Social Security, Ministry of Education, Ministry of Health, Ministry of Justice) are represented under the same roof.The staff working in Lisbon come from 11 different countries and speaks over 12 different languages.It is within this organisation that the Health Office functions, having been set up as a joint venture between the ACIDI and the Ministry of Health (Horta e Carvalho, 2007).
The National Immigrant Support Centre (CNAI) is already well known and recognized internationally as an example to be followed and a structure that offers an integrated response in helping the immigrants by referring them to the different services they require, depending on their particular needs.Therefore, it is already considered a model for the integration of immigrants (Abranches, Alves, 2008;Oliveira, Abranches, Healy, 2009).
Considering that one of the main difficulties of immigrants is related to the lack of information concerning their rights and duties, as well as their lack of knowledge on how to establish relations with the National Health Service, this office was created mainly in order to ensure easy and swift access to health care services although not foreseeing the provision, as such, of health care.Its activities are mainly directed towards the dissemination of information to immigrants and to public health care staff on the existing legislation.Also to its interpretation and application so as to ensure immigrants´ access to health care services, by informing them clearly on their rights and duties.The mediators contribute to unblock situations of access together with health centres, hospitals and other health related institutions; counsel users and monitor situations of social deprivation.Mediators play a key role as they recognize the cultural codes of those involved in communicative relations so as to overcome barriers and facilitate exchanges between the various parties, anticipating and preventing possible misunderstandings.They also provide information and support to various health and social institutions on the rights and duties of foreign citizens in Portugal concerning access to health care and search for solutions using other offices of CNAI.
As mentioned by Horta and Carvalho (2007), the Health Office at CNAI functions in partnership with health centres, hospitals and religious entities, social institutions, Non-Governmental Organizations, related consulates, local centres for the integration of immigrants, the International Organization of Migration (IOM) and other offices of CNAI.

Methodology
As previously explained, the objective of the present research is to establish a sufficiently clear picture of the overall situation observed at the Health Office of CNAI with regards to immigrant problems and health needs, and to propose recommendations on more effective ways to better invest in the improvement of immigrants´ access to health care.
Based on the information collected and the observation done at the Health Office we were able to identify some of the health problems affecting immigrants, the main difficulties and obstacles they encounter when trying to use health services and the solutions found for each situation.
In terms of methodology, we undertook a qualitative study which included a thorough analysis of documentation available and the observation of problematic situations dealt with by the Health Office, with the summary of the narratives and the design of the profile of the users.We also transcribed the interviews made at the Health Office, with the objective of achieving a first diagnosis of the problems and constraints related to the immigrants' access to health care services, as well as of the action taken in each situation.We consider that a more comprehensive understanding of this problematic will result also in recommendations envisaging the improvement of the health services provided to immigrants.
By using the inductive method we enabled the problematic to emerge through the register of the observations of particular cases made in the field.This allowed us to perceive patterns, similarities or variations in the situations, to formulate preliminary hypothesis to be explored and, only thereafter, to develop general conclusions.
In this case study we have observed all the cases that were visiting the health office for migrants.We also undertook exhaustive analysis of all the processes that existed at the health office.
The criteria of inclusion of the cases were all the persons that were coming for any reason to contact the health office personally or through the local centres of immigrant support that were reporting the problems to the national centre.The criteria also included the barriers, obstacles and difficulties migrants faced in accessing health services and the solutions to solve those barriers.The study was a really small study and cannot be representative of all the universe of migrants and their relation to national health system in Portugal.
During the period between May 2008 and January 2009, I carried out an observation of the users of the Health Office with regular weekly visits.During these visits, all facts considered relevant to the observed cases were collected, registered and analysed.
The information gathered was used to identify the major barriers and difficulties concerning the access to health services and to acknowledge how each problematic situation was solved by the Health Office staff.Through this observation, I was able to recognize the key problems limiting the access of immigrants to the National Health Services as described in the results.The cases analysed relate to migrants coming from the Portuguese Speaking African Countries, Brazil and Europe.Between June and December 2008, 148 cases of immigrants of 18 different nationalities were followed.Table 1 shows their distribution by country of origin.

Table 1: Country of origin
In seeking to bring to light some of these problematic situations I will here report on the analysis undertaken at the Health Office by focusing on the observations found to be the most relevant, highlighting, at the same time, the differences between the groups of migrants.

V. Problems and Critical Factors Identified
According to the cases observed, it is evident that immigrants in irregular situations go through great difficulties in what concerns the access to health care and the cost of these services.It became clear that some of the problems are also associated with the lack of knowledge of Portuguese law, not only by the immigrants themselves, but also on the part of the health professionals.The undocumented migrants who request assistance to access health care are normally looking for a solution to pay only the minimum rates or, if possible, to benefit from the exemption of paying fees.In reality, however, in many of the cases, they should be charged the maximum fee, considering that they are in an irregular situation.Furthermore, immigrants also try to obtain a health card which will give them access to the public health services.These cases concern mainly African and Brazilian immigrants.
As an example, if migrants are in a regular situation and contribute to the Social Security System, the fee will be 2,25 € at the health centre and 4,60 € if they go to the central hospital (this will change as of January 2012: 5 € at the health centre and 20€ at the central hospital) .Without any payment to the Social Security, the maximum fee is 31 € in the first case and between 80€ and 150€ in the second case.Undocumented migrants can, theoretically, access the services but will have to pay the full cost without the benefit of moderating fees.Sometimes, certain services refuse to treat irregular migrants or (when they do) ask them to pay the highest available fees.This situation may happen even when dealing with children and pregnant women and it is usually justified by their irregular situation or because they never contributed to the social security system.There are also cases of pregnant women and mothers in an irregular situation who, upon having recently given birth, look for help to attain access to maternal (ante and postnatal) appointments.
The fact that they do not have a Social Security number nor ever having contributed to the system is a major obstacle when immigrants try to be assisted at the health centres.Immigrants who arrived in Portugal through the family reunification process come to the Health Office for the same reasons.They either ask for help to access the National Health Service or request assistance to pay the service fees, as they have been charged the maximum rate.
In cases of financial difficulties related to the payment of medical consultations, treatments, medicines and means of diagnosis, immigrants are advised by the Health Office to request a certificate of "financial deprivation" from the Social Security Services.Very often one is confronted with real social cases and in certain situations, the financial difficulties are not only connected with the payment of health care but related to many other levels of needs.Immigrants ask for assistance to purchase food, clothing, medicines or transport tickets.I identified numerous situations where the health problems bring to light social and economic shortcomings.Many immigrants due to their limited financial resources are neither able to access medical consultations, buy medicines nor to go through the necessary treatment to improve their health.In these situations, the relation with Non-Governmental Organizations, such as Social Solidarity Institutions, Religious Organizations and other agencies promoting health care who may also provide support in medicines, food, clothing, transportation and even housing becomes fundamental.
In the case of pregnant women, we observed situations where the health services have charged the maximum fees, even if these services should be free of charge as defined in order 25360/2001.Health care is exempt from payment of fees in cases of transmittable diseases and preventive health care, including mother and child care and family planning.
As with children, some health centres refuse their admittance because they are not registered in the Social Security System, even if their parents have a permanent residence permit, and despite the fact that the registration of children is not compulsory with the Social Security System.There are also cases of refusal of young students who are immigrant's children by the health centres, because they do not have a social security number.This is also the case with babies whose parents are in irregular situation.During the field research, for example, I observed parents complaining about the highest fees they are requested to pay for their young children, when these should be exempt of payment until the age of 12 and should enjoy all services free of charge.
It is here also important to highlight the difficulties met by citizens from Portuguese Speaking African Countries who come to Portugal for medical treatments, often defined as "evacuated patients".They apply to the Health Office each time they need financial or social support even if they should, in fact, be protected by the respective Bilateral Cooperation Agreement on Health.The law regulating such agreements is defined through a series of decrees.1About 50% of the cases of citizens from these countries who request for help at the Health Office are patients certified by a medical commission.They arrive in Portugal, either through the Cooperation Agreements on health or with a temporary visa for a specific medical treatment.The majority of these patients usually need an extension of the visa for the continuation of the medical treatment.African patients under the Cooperation Agreements often request financial and social aid given that their Embassies frequently do not fulfil their obligations as defined in the agreement.
In such situations, the Health Office in order to be able to respond to these cases, again articulates with partner organizations.The Embassies of the countries of origin are supposed to cover the expenses of the patients.However as they are not complying with their responsibility many immigrants are forced to work illegally or to search for help when they have no means of subsistence.
When we proceed to an analysis of the findings by nationality, we are also able to verify some differences depending on the citizens' origin.As with Brazilians, these individuals go through great difficulties in accessing health services.In certain cases, this is more limited and complicated due to a complex relation with the administrative staff working in the public health services.The Health Office staff at CNAI have reported that they perceive the existence of a hostile attitude involving some level of discrimination, certain prejudices and stereotypes when citizens of Brazil request the services of the NHS.Consequently, their right of access is obstructed more frequently than with other nationalities.There is, nevertheless, a bilateral social security agreement between Brazil and Portugal, the content of which, very often, is not applied in the health centres due to lack of information.
Concerning immigrants from Eastern European countries (Bulgaria, Georgia, Moldova, Romania, Ukraine), it seems evident, according to the results of the study, that their major concern is the search for concrete information and, thus, to learn about their rights and duties.Most of the Eastern European immigrants have their documents in order, in regards to work and social security.Nevertheless, even if the majority of them have their legal situation regularized, some still have social problems and are affected by financial difficulties.Others, who managed to obtain their residence permit through a family reunification process, still have difficulties in obtaining the health card and in paying the moderating fees.This group of immigrants also frequently mentioned their communication problems and the difficulties in understanding the Portuguese language (Sardinha, 2009: 252-256).
The immigrants' lack of knowledge of the law and, above all, the ignorance of the law and its application by the Portuguese staff are important factors that obstruct their access to the National Health Service.For many immigrants (mainly those with low level of instruction) it is not clear how the NHS functions.Even if the Portuguese Law provides access to health care to all residents regardless of their origin and legal condition, it shows that many immigrants have significant difficulties when trying to access Health Services.Due to these reasons, immigrants often choose to go to the emergency services at the hospitals.
Distinctions found the migrant groups (as already described above) are summarized in table 2. They are identified by the reasons that brought them to the Health Office of CNAI and classified by countries: x-few cases; xx-almost half of the cases; xxx-almost all the cases

VI. Conclusion
It is evident that the major problems met by immigrants are related to the lack of easily accessible documentation on their residence status and on the legal framework concerning the Social Security System in addition to the constraints faced in the access to and payment of health care provided by the National Health Service.Frequently, the financial difficulties dealt with by the Health Office are not related solely to health problems.

Table 2:Reasons to visit CNAI
Even if this study provides only a partial image of the reality, since these immigrants -the users of the Health Office at CNAI -are neither representative of the entire migrant population nor of those more excluded from the system who suffer higher levels of social deprivation, it still permits us to draw up a list of the obstacles as well as solutions.The results may contribute to a better management of available resources and, thus, help prevent similar situations in the future.The obstacles met by immigrants are not only related to their lack of knowledge of the law, but also due to the failure of the Health Services in putting this into practice.This requires attention from the institution responsible for its coordination.Health administrative staff and health professionals who deal with immigrants often need to update their knowledge about the relevant legal framework in order to be able to correctly address the situations.Procedures need to be standardized.These must be well understood by all concerned parts without room for different interpretations and practices concerning the existing law as were pointed out in the analysis of the difficulties met by immigrants.There are countless administrative barriers because health staff teams refuse to receive irregular immigrants under the false pretext of their own ignorance of the law.There are, however, significant differences from one health centre to another regarding the staff's knowledge on the right of access to the National Health Service by the irregular immigrants.In fact, the access of migrants in an irregular situation to these health centres depends in large measure of the good will and acceptance by the administrative and medical teams.As mentioned in the report on the operational plan for the integration of immigrants (ACIDI, 2008), the difficulties in access to the National Health Service should not be attributed exclusively to the immigrants' lack of information.
In view of the limited nature of existing information, we must emphasize the need to pursue and extend the research at other levels, focusing on the functioning of the health services provided to migrants in order to improve their accessibility.
Evidence says that knowledge about cultural diversity must be emphasized through training activities, as it was observed by us during training sessions given to health staff.The training of health services professional staff so as to enable them to deal with cultural diversity as well as the development of a philosophy of proximity to those communities are extremely important.ACIDI promotes training on Health, Migration and Cultural Diversity at no cost involved to any of the institutions asking for this service.
As Fonseca already concluded, in practice, access to healthcare varies greatly amongst the immigrant population in Portugal, and depends to some extent on the legal status, length of stay in the country and on the immigrant's nationality (Fonseca et al. 2009).
The barriers inhibiting access and use of health care are often a consequence of the lack of information on the part of health professionals, especially among administrative personnel, as well as of the multiple and different interpretations of the law on the part of service providers.

Recommendations
It is expected that the results of this study will enable intervention in the areas where the problems are identified, the improvement of the health care services provided to immigrants and the development of a better model of integration and coordination between the different institutions involved.It may also lead to further recommendations for the public health sector and on health policies with impact on the improvement of migrants' health and the resolution of some of their major related problems.
The CNAI offices have had great demand from users seeking information, who wish, above all, to solve their specific daily problems.In particular, they wish to solve their difficulties in accessing the health care system.The establishment of procedures for training of staff working in health centres, hospitals and other public health institutions is strongly recommended.