Abstract
While the right to health is a basic human right recognised in international law, the COVID-19 pandemic painfully revealed that existing policies and regulations poorly protect many categories of migrant workers, not only during a pandemic, but beyond. This article draws on research data collected during the pandemic and examines the experiences of ‘essential’ EU migrant workers with Dutch health care and identifies structural barriers migrant workers face when attempting to realise fundamental health rights. We show how sedentarist biases in the configuration and delivery of the Dutch health-care system, but also in the legal-administrative residence system and the organisation of work, as well as a general lack of migrant awareness in central government regulation and communication prevent the full realisation of the right to health and undermine migrant workers’ rights.
Introduction
The right to health is a basic human right that is recognised in international law. The COVID-19 pandemic, however, painfully revealed that existing policies and regulations poorly protect migrant workers not only during a pandemic, but also beyond. Especially striking were the EU- and national-level emergency responses prioritising continued free movement of ‘essential’ workers, without due regard for their protection (Mantu, 2022; Rasnača, 2020). This led to higher COVID-19 infection and transmission rates among migrant workers (Fasani and Mazza, 2020). This is illustrative of what the mobilities literature refers to as one of ‘the fundamental premises on which our societies are built, namely constant and uneven mobility’ (Adey et al., 2021: 2; Lillie and Simola, 2016). The COVID-19 pandemic exacerbated the uneven mobility of ‘essential workers’ who remained mobile and at work, sometimes at the cost of their own health and protection. Major COVID-19 outbreaks among workers in the meat sector in 2020 started a public debate on their working and living conditions and prompted calls for government intervention in several EU countries.
By studying EU migrant workers who supposedly have secure legal status because of their EU citizenship and the EU right to labour migration, our contribution seeks to fill an important gap in the literature on the right to health and migrants. On the one hand, the migrant health literature has focused on migrants with insecure or less secure legal statuses, such as undocumented migrants, asylum-seekers, recognised refugees or victims of trafficking (Lebano et al., 2020). On the other hand, the literature on (low-waged) migrant EU workers has critically assessed their access to social rights (Lillie and Simola, 2016; Simola, 2018; Ulceluse and Bender, 2022) but has paid less attention to health (for exceptions see Perna, 2018, 2021; Stan, 2015). We argue that the ‘sedentary bias’ (Malkki, 1992) inherent in the operation of health-care systems, which are set up to serve settled populations, needs to be taken seriously by governmental, non-governmental and industrial relations actors because of its exclusionary effects on migrants, negative consequences for public health, and overall undermining effect on workers’ rights. Our argument is that the pandemic exposed how sedentarist biases in the design and operation of health-care systems (Follis et al., 2023; Gionco, 2019), together with similar biases in legal and administrative systems regulating residence, (re)produce migrant precarity and require targeted migrant-friendly interventions.
Drawing on research data collected during the COVID-19 pandemic, we discuss the experiences of EU migrant workers with health care in the Netherlands, and the structural barriers they face in realising fundamental health rights both during the pandemic and otherwise. Considered ‘essential’ during the COVID-crisis for the functioning of national economies and of the EU internal market, work in the migrant-dominated Dutch food and distribution sectors was sustained mainly by Polish and Romanian workers, putting them at heightened health risks. Their low reservation wage makes EU migrant workers a ‘cheap labour force’, frequently subjected to unhealthy and unfair working and living conditions. This concerns the type of work they perform (low-skilled and low-paid), the conditions of their employment (flexible) and their lack of social networks, leaving workers highly dependent on employers for, among other things, housing, health care and information (Berntsen and Skowronek, 2021; De Lange et al., 2023).
While occupational health and safety has always been a fundamental issue for the trade union movement (Johansson and Partanen, 2002), the right to and access to health care is not central to the trade union agenda. The COVID-19 pandemic, however, made visible problematic legal-administrative health-care arrangements and migrant workers’ dependency on temporary agency employers in accessing local health care. This shows that this is not simply a private matter, outside the remit of industrial relations. Rather, access to health care should be treated as part of a nexus that links precarious health-care status, precarious work and precarious administrative status, making it highly relevant for trade unions.
This article is structured as follows. Section 2 discusses the implications of health-care systems that reproduce ‘sedentary bias’ in their design and delivery. Section 3 presents data collection and methods. Section 4 illustrates how the sedentarist requirement of municipal registration in practice limits access to local health-care providers and care. Section 5 discusses the exclusionary effects of employer dependence on access to care. Section 6 zooms out and focuses on the general transformation of migrant health into public health during the pandemic. Section 7 concludes, stressing the importance of legal-administrative status for accessing health care and the need for migrant-friendly interventions to counter the sedentary bias of social protection systems.
Sedentarism and migrants’ access to health care in the EU
Migrants’ difficulties in realising the right to health are well documented (Lebano et al., 2020). The COVID-19 pandemic, nevertheless, further exposed and problematised the ‘sedentary bias’ (Malkki, 1992) in national health-care systems, which link rights and access to belonging to a given (national) territory (Gionco, 2019). Such sedentarist logic considers territorial disembeddedness to be exceptional and ‘outside the natural order of things’ rather than ‘a fact in socio-political contexts that institutions must be responsive to’ (Follis et al., 2023: 788). This excludes migrant workers from smooth access to health-care services in host countries, as they are regarded as exceptional, instead of an integral part of the population that national health-care providers are supposed to service. Sedentarist biases co-exist with the recognition in international law that the right to health is a basic human right that obliges states to ensure that health facilities, goods and services be available to everyone under their jurisdiction, and that they be accessible, acceptable and of good quality (Pace and Shapiro, 2009: 8). Healthy working conditions, as well as health-related education and information, are considered key aspects of the human right to health and of workers’ rights (OHCHR, 2008).
EU law, which applies equally to the Netherlands and all other EU states, is considered to have absorbed international and European human rights provisions on the right to health (Hervey and McHale, 2015). EU harmonised legal rules on the right to health – that is, individual rights for migrating persons – exist in a limited number of cases, such as cross-border health care for EU citizens (Directive 2011/24/EU), standards for refugees and asylum-seekers (Directive 2011/95/EU and Directive 2013/33/EU) and occupational health and safety (Directive 89/391/EEC). This legal framework has been criticised for failing ‘to create provisions designed to alleviate de facto barriers that inhibit the ability of migrating people to receive healthcare’ (Pace and Shapiro, 2009: 13).
EU citizens enjoy a right to cross-border health care that has been developed as part of the internal market and with the help of European Court of Justice jurisprudence on cross-border patient rights (Vollaard and Sindbjerg Martinsen, 2017). Bradby et al. (2020) describe this development as an adaptation of nationally configured European health-care systems to transnational EU mobility. Health care is seen as a national resource which is accessible through citizenship-based claims in the case of European migrants or human rights-based claims in the case of non-European and undocumented migrants (Bradby et al., 2020: 2). However, the existence of transnational health rights does not diminish the ‘sedentary bias’ that shapes national systems. The primary responsibility for health protection and health-care systems (including management, organisation, delivery and financing) remains with the individual EU Member States and national authorities retain significant power over health-care provision (Gionco, 2019). In theory, because of the existence of cross-border patient rights and of rights as EU citizens, EU migrants are perceived as ‘super citizens’ who can mobilise health rights across jurisdictions (Bradby et al., 2020). In practice, neither citizenship nor human rights claims are successful in dislodging practical barriers that migrants face in accessing health care. EU law links legal residence and social rights by requiring EU migrants to maintain work or have sufficient resources not to become an unreasonable burden when becoming unemployed and making claims on the social assistance system, including health-related claims (Mantu and Minderhoud, 2019; Simola, 2018).
Registration in the receiving country is a basic requirement within the European health and social insurance system that many migrant workers fail to meet, specifically in the first months of new employment in a receiving country. As testament to sedentarist logics in their design and delivery, EU health-care systems assume that patients can speak and understand the local language and share cultural assumptions with health-care providers (Bradby et al., 2020). Common barriers regarding migrants’ access to health care across the EU relate to lack of knowledge about existing health systems, services and benefits, administrative and financial barriers, health literacy, language, cultural differences, and exposure to discrimination, as well as to fear and distrust (Graetz et al., 2017; Lebano et al., 2020; Slootjes, 2021). To overcome these problems, migrants’ access to health care in receiving countries depends on special arrangements inside or outside standard frameworks (Follis et al., 2023). Migrants make less use of secondary specialist health care than the host population (Graetz et al., 2017) and tend to have a higher hospitalisation rate and make greater use of emergency care services. Studies in Italy, the United Kingdom and the Netherlands found that emergency services were often the main (and only) contact migrants had with the health-care system in the receiving country (Berntsen et al., 2022; Di Napoli et al., 2022; Harrison and Daker-White, 2019). This may be because hospitals are the first (or only) points of access to health care in countries of origin, but also to emergency services’ greater flexibility and accessibility. For migrants, it is a way to seek immediate remedy and circumvent linguistic, cultural and bureaucratic barriers (Follis et al., 2023: 790). But reliance on special arrangements to counter the sedentarism of the health-care system can be problematic. For example, Perna (2018) stresses the role of health workers as gatekeepers with discretionary decision-making capacity and the economic considerations that guide decisions about who should receive care regardless of (lack of) legal entitlement.
Research consistently highlights the gap between formal entitlements and the substantive reality of rights on the ground. The fact that social protection systems are increasingly shrinking in most EU states also plays a role (Dwyer 2001; Perna, 2018, 2021). Stan (2015) showed, for instance, that not only did Romanians in informal work settings lack health-care access in Ireland, but the lack of information excluded even legally employed Romanians from the free Irish health-care system and subjected them to ‘prohibitive out-of-pocket-payments for services’ (p. 3). The failure to organise health care in a way that guarantees migrant workers’ access legitimises discriminatory practices that exclude migrants from de facto accessing local health-care facilities. It can also affect transnational health-care practices. Different reasons motivate migrants to seek care back home: (i) a perceived lack of availability; (ii) fear of the high cost; (iii); perceived lower quality compared with health care in the country of origin; and (iv) feelings of unease about local health care due to perceived social, cultural, religious and linguistic differences (Goorts and Smal, 2022: 29; Migge and Gilmartin, 2011; Stan, 2015; Tiilikainen and Koehn, 2011). The transnational character of EU workers’ health-care practices is described by Stan (2015) as part of a ‘European healthcare assemblage’ and citizenship regime that is linked to diminishing and increasingly unequal access to public health services in both home country and host EU state and to privatisation. A recent more migrant-friendly development is telehealth care, which carries the potential to reach otherwise poorly covered populations, such as migrants (Follis et al., 2023).
Studies highlight how inequalities of access to health care are intricately linked to disparities in employment, socio-economic status, education and housing. This is sometimes referred to as the migrant health-integration nexus (Slootjes, 2021). Our analysis aligns with studies that stress the link between employment status and health risks, such as the higher risk of infection affecting subcontracted workers in the German meat industry during the pandemic (Finci et al., 2022) and the spillover effects of subcontracted workers’ health for the local community, creating public health risks (Ban et al., 2022). In addition, we draw attention to the implications of EU workers’ administrative status for their right to health and for public health, more generally.
Data and methods
This article draws on a research project examining the impact of COVID-related measures on ‘essential’ migrant workers in the Netherlands. Workers’ health-care arrangements and access was one of the focus themes, alongside (COVID-related) health and safety at work, living arrangements, employment conditions, workers’ mobility, social and labour rights, information and institutional knowledge, and social and family obligations and circumstances. We conducted a survey among 153 Polish and Romanian workers in the Dutch meat and distribution industries, in-depth interviews with 35 migrant workers (see Table 1 for an overview), and 56 expert interviews with health-care providers, local, regional and national civil servants, employer representatives, trade union officials and NGO workers. Fieldwork took place between October 2020 and May 2022, all the worker surveys and interviews being conducted in 2021, in the middle of the pandemic. While most expert interviews were conducted digitally, the migrant surveys and interviews were a mix of online and face-to-face encounters, depending on the relevant COVID restrictions. The workers were surveyed and interviewed in their native languages. The interviews were audio recorded and transcribed and translated into English by the interviewer who conducted the interview. The interview transcriptions were analysed thematically, using central themes such as work, living situation, health and health care, corona measures, social life, and future plans (see De Lange et al., 2023, for the full project report and data collection; Skowronek et al., 2022, for the interview material specifically; and Berntsen, 2022, for the full survey results).
Overview of migrant interviewees and survey respondents (in brackets).
The majority (85 per cent) of the Polish and Romanian workers we surveyed and interviewed worked on temporary agency contracts. Temporary agency work is a major employment channel for low-waged EU workers in the Netherlands, even after several years of Dutch residency (Heyma and Vervliet, 2022: 18). We spoke with migrants who arrived in the Netherlands during the COVID-19 pandemic, as well as migrants who had lived for multiple years in the Netherlands. Half of the migrant workers surveyed lived in employer-arranged housing, the others arranged their (own or shared) accommodation by themselves or via their social network. Many EU workers knew English at a basic conversational level, while Dutch language skills were far rarer.
Based on the survey and interview material collected, this article highlights EU migrant workers’ experiences with health-care access and arrangements, although it lays no claim to being representative for all EU workers. Rather, we present anonymised migrant experiences to illustrate fundamental barriers to health-care access in the Netherlands for EU migrant workers related to problematic sedentarist biases in the health-care and legal-administrative systems.
The Dutch health-care system: not designed for ‘temporary’ migrants
Filip (28-years-old) moved from Poland to the Netherlands in the middle of the pandemic and works as an order picker in a supermarket distribution centre via a temporary agency. He experiences a lot of stress trying to meet the picking targets at work. Filip endures this stressful work environment to pursue his plans of building a better future for his family. Soon after friends, who already lived in the Netherlands, helped him secure a private apartment in a small Dutch town, Filip’s wife and new-born daughter joined him. A Polish friend who speaks Dutch helped Filip register with the municipality in the small Dutch town. However, when Filip’s daughter fell ill, Filip called all the GPs in his town and the surrounding towns, but none of them would accept him as a patient. After Filip’s wife contacted their health insurer, the insurer intervened and arranged a consultation at a GP practice for them. This practice had previously told Filip they had a patient freeze.
Under the Dutch Health Insurance Act, everyone who lives or works in the Netherlands has a right to care from the so-called ‘basic health-care package’, but also an obligation to take out health insurance. Everyone is free to choose their own insurer, while insurers are obliged to accept anyone applying for basic insurance. Health insurance companies have a duty of care: care included in the basic package must be available to all their policyholders. Consequently, migrant workers must, even if they still have insurance in their home country, take out health insurance within four months of their first day of work in the Netherlands. This is a grace period for organising the paperwork because the insurance obligation applies from the moment work starts.
The configuration of Dutch social services is grounded on sedentarism. Registration with a local municipality defines access to many social services, including health care. While EU law abolished the obligation to register with the local authorities for EU citizens who reside in another EU state for up to three months (Directive 2004/38, Article 6), Dutch administrative law requires people who stay or intend to stay in the Netherlands for longer than four months to register as residents with the municipality where they live. A special register for ‘non-residents’ (Register Niet-Ingezetenen, RNI) exists for people who intend to stay fewer than four months. RNI registration is necessary to obtain a Dutch citizen service number, which is needed to work legally, pay taxes and sign up for health insurance. In practice, many migrant workers who stay longer than four months in the Netherlands do not register as residents in a municipality. Because of language barriers and unfamiliarity with the Dutch institutional system and requirements, migrants rely on help (from employers or friends/acquaintances) to arrange registration. Migrants’ frequent rotation between employer-arranged accommodation does not help with adherence to the registration process. Our data confirm this: 30 per cent of the migrants surveyed who resided longer than six months in the Netherlands were not registered with a Dutch municipality (Berntsen, 2022: 44).
The RNI is an adaptation of the Dutch administrative system aimed at fast-tracking the registration of ‘temporary’ migrant workers and facilitating legal economic entry into the Dutch institutional system. This administrative solution disregards the precarity it creates in other spheres of migrants’ lives. Being registered as ‘non-resident’ (that is, without a Dutch address) may block access to a general practitioner (GP). GPs are obliged only to accept patients with an address in the GP’s municipality and can refuse to register new patients if their capacity is full (Rijksoverheid, 2024). This explains why many migrant workers are not registered with a Dutch GP: 60 per cent of the workers we surveyed had no Dutch GP.
Migrants registered as non-residents also encountered difficulties in obtaining a DigiD code, which in the Netherlands is a necessary digital means of identifying oneself in online contacts with government organisations, educational and health-care institutions, or pension funds. At the height of the pandemic obtaining such codes was time-consuming. Migrants lacking a DigiD code could not register their vaccinations in the system, resulting in travel difficulties.
But even if migrant workers are registered with a municipality, their access to a GP may be hindered, as Filip’s case (cited above) exemplifies, due to discrimination on the part of health-care providers. Interviews with insurers and other stakeholders confirm a reluctance among GP practices to sign up migrants because they are more time-consuming patients: a lack of Dutch language skills and unfamiliarity with the Dutch health-care system and the role of GPs leads to mismatched expectations and, ultimately, a lack of trust in the system (interview consul, February 2021; see also Goorts and Smal, 2022). The need for someone (an insurer, employer, or friends) to mediate migrants’ access to a health-care provider, as in the case of Filip above, is not uncommon.
Our interviewees mentioned a lack of knowledge and information about access to and functioning of the Dutch health-care system and migrants’ insurance as important barriers to health care. Language and information barriers reinforce each other and exacerbate migrants’ isolation from official information and support channels. While information may be available in several languages (including Polish and Romanian), direct communication with health-care providers is generally possible only in Dutch or English (interview insurer, April 2021). We can speak of language segregation in the Dutch health-care system between migrants who speak Dutch or English or have assistance and the rest who, despite paying the same insurance premiums, face difficulties accessing the system.
The overburdened Dutch health-care system, with local GP shortages, also hinders migrants’ access. GP practices in locations with dense migrant populations have publicly opposed the opening of new housing locations for migrants because of the feared extra patient pressure on the local medical infrastructure (interview local civil servant, May 2021). For some municipalities sufficient local health-care arrangements are a prerequisite of issuing building permits for migrant housing (interviews local civil servant, April, May 2021). These tensions led to initiatives to counter the above-mentioned segregation through the digital provision of health care to migrant workers (via apps, without the need of a DigiD code) and the creation of GP practices for migrants with services delivered in their native language (a sort of a GP hub for migrants).
In short, the sedentarist requirements of municipal registration, digital codes and language knowledge to access local health-care providers in practice limit EU workers’ access to health care. The realisation of migrants’ health rights in practice depends on local initiatives, willing friends, NGOs, employers or insurers to mediate individual (or in some cases, local) access to health care.
Employer dependency and health care
Magdalena is a 35-year-old Polish woman who moved to the Netherlands in the middle of the pandemic. Since her arrival, she has switched jobs several times, working in agriculture, distribution and meat, always on temporary agency contracts. Magdalena developed a muscle inflammation from her repetitive work on a meat-cutting belt. When she visited a GP, she found that she was not insured, even though she had told her employer earlier that she needed insurance. In fact, her employer – a temporary work agency – fired her only a few days later, after which Magdalena was forced to leave the agency-arranged accommodation within a few hours. Due to her injury, Magdalena could not find another job immediately, and ended up sleeping on the streets for a few days.
Emil is a 38-year-old Romanian who worked in agriculture in the United Kingdom for six years, before moving to the Netherlands in 2021 in the middle of the pandemic. Emil works in a meat-processing plant via a temporary agency firm. He would like to exchange this cold work environment for another job, but he has found it difficult to find other job openings. While Emil pays for Dutch health-care insurance, he feels unable to take advantage of local health care because he does not know the Dutch system nor is he able to express himself well enough in English or Dutch. In his words: ‘The Netherlands is a free country. I don’t know it well, but I won’t get lost. Everybody says you’ve got rights, you’re European, you have rights. But where are your rights? If I’m sick, if my leg hurts, who will take me to the hospital? I work. I pay €113 a month for health insurance. But if I’m sick, will anyone take me to the hospital? I don’t know any hospital; I don’t know any doctor. But I’m paying that money. For what?’
Many EU workers, like Magdalena and Emil, work under precarious conditions in the Netherlands on temporary (zero-hours) contracts, with no income security. Temporary agency contracts with a so-called ‘agency clause’ allow for immediate dissolution if the user company terminates the placement or when the worker reports ill (Van den Braak and Woutersen, 2021a, 2021b). In 2020, the latter practice was declared illegal by a Dutch court because it contravenes general labour law (Court of Appeal of The Hague, ECLI:NL:GHDHA:2020:460), but it took until 1 July 2023 before the collective agreement for temporary agency workers was amended.
Flexible employment arrangements have negative implications for migrant workers’ effective access to health care. If the employer also organises health insurance, an employment contract termination equally terminates the health insurance. Our interviews showed that a few insurers informally covered the costs of a former worker for up to a maximum of one month after dismissal and the formal end of the insurance policy (interview insurer, April 2020). The Migrant Workers Protection Taskforce (from now on: Migrant Taskforce) set up by the Dutch government in 2020 to advise on improving the situation of EU workers following COVID-19 infections among migrants in meat-processing factories recommended formalising this informal arrangement to increase workers’ protection. The government rejected this advice, arguing that if an EU worker becomes uninsured, they can rely on a special fund set up by the central government from which GPs and hospitals can recover the costs of treatment for uninsured persons. 1 In practice, many doctors are either unaware of the existence of this fund or reluctant to use it, because it comes with ‘too much paper-work’, sometimes asking for up-front payment for their services instead (interview local civil servant, May 2022).
Temporary agency firms can, and in practice frequently do, arrange Dutch health insurance for their workers. Most migrant workers we surveyed indeed had their health insurance arranged by the employer, with the insurance fee deducted from their salary. Although this practice is legal, it renders workers dependent on employers. Some employers, like Magdalena’s in the excerpt above, fail to arrange health insurance for their workers. There may be a lack of knowledge among employers regarding the health insurance requirement, especially in the case of newly established agencies (interview insurer, April 2020), but there are also cases in which employers deducted premiums, without signing the workers up for insurance, leaving them uninsured (Van den Braak and Woutersen, 2021a). In one instance, a temporary work agency was sentenced in court to pay a fine of €30,000 for having withheld health insurance premiums from 98 meat workers’ wages without having finalised the insurance (Openbaar Ministerie, 2022). In June 2020, the Dutch trade union FNV reported that 60 per cent of the migrant workers they had surveyed did not have their own health insurance cards and that some employers keep the health insurance cards, to prevent migrants from going to a doctor without their prior consultation (FNV, 2020).
All in all, being insured is a precondition for accessing health care but not a guarantee. Our interviews reveal the interplay between access to medical care and respect for other health rights, such as sick leave, which is understood to have an important role in the realisation of public health (Scheil-Adlung and Sandner, 2010). Several workers mentioned not being granted sick leave by the temporary agency firm when they needed it, not even after having an accident at work. Instead, some were forced to take (mostly unpaid) holidays, which they used to seek self-paid treatment in their home countries, despite being insured in the Netherlands.
Besides taking an administrative role in organising health insurance, employers, as already mentioned, may also get involved in arranging doctors’ appointments or overcoming language barriers. This can be viewed positively, as part of an effort to help workers who speak only their native language, such as Emil, but migrants also reported negative experiences. When Zygmunt, a 50-year-old Polish meat worker, experienced coughing – a known COVID symptom – he asked a supervisor at work to help him get a doctor’s appointment but he was refused help. Other agencies take this role more seriously and employ specific ‘welfare officers’ who can help workers with medical issues (interview consul, February 2021). The presence of a ‘welfare officer’ as translator in a GP’s office can be problematic, however, because the officer represents the employer, thereby allowing ‘market’ considerations to enter medical practice, while raising questions about doctor-patient confidentiality. Under Dutch law, the employer is not allowed access to an employee’s medical file because confidentiality is legally guaranteed. Unless a GP happens to speak a worker’s language or translators (or reliable translation apps) are available, however, it is difficult to guarantee this right to confidentiality.
To sum up, although safeguarding the right to health (care) is first and foremost a state responsibility, in the Dutch context temporary agency firms, by contracting health insurance and mediating access and communication with health-care professionals, take on a critical role in migrants’ access to health care, sustaining a precarious loop of employer dependency among migrants, many of whom are already in precarious positions vis-à-vis their employers. It was the precarious position of subcontracted EU migrants in the German meat sector, critically exposed during the pandemic, that led Germany to ban subcontracting for the whole sector (Ban et al., 2022; Schmidt and Blauberger, 2023).
Migrant health as public health
When Magdalena had a confirmed COVID infection, her employer – a temporary agency firm – forced her to come to work, even though the Dutch public health services (GGD) had told her explicitly that she needed to remain in quarantine. The agency asked Magdalena not to say anything about her illness at the company where she worked. The agency even instructed Magdalena that, if the GGD called again, she should not tell them she was back at work.
The experiences of migrant workers such as Magdalena suggest that public health interests do not necessarily coincide with the economic interests of the employer. Our interviews revealed cases in which workers with a confirmed COVID infection were pressured by their agency to break quarantine or isolation rules and return to work. Some employers sent their workers home on ‘vacation’ instead of sick leave to save costs. Public health concerns during the pandemic did not seem to deter employers who routinely followed a market logic, putting work and profits first. Notwithstanding examples of employers who took good care of their workers, our interviews indicate that migrants who had experienced such practices in the past were hesitant to report ill while having COVID symptoms. The fear of job and income loss also kept workers from calling in sick and to continue working despite possible (unconfirmed) COVID symptoms. If migrant workers were afraid to report symptoms, this impacted their personal health negatively and caused spillover effects for public health by exposing others to transmission risks (Ban et al., 2022; Goorts and Smal, 2022).
When employment contracts and health insurance are terminated because a worker reports in sick, there is a risk that they will end up uninsured and on the street, thereby becoming a public health risk. The pandemic transformed the health of EU migrant workers from an individual and private issue into a public health one affecting the health of Dutch citizens, the Dutch health-care system and local administrations. Pre-existing employment relations and the reliance of the Dutch state on private actors, such as employers but also NGOs, to implement public policy influenced how public health objectives were met and the level of social protection extended to migrant workers. Although the Migrant Taskforce (set up in 2020) designated employers’ power over their workers’ health and health care problematic, employers remained important actors in implementing government policy. Employers were responsible for checking that newly arrived workers were insured in their country of origin for the duration of the quarantine, when no insurance in the Netherlands could be taken out. Furthermore, because many migrants live in employer-arranged housing, employers were also involved in the implementation of quarantine measures. Our interviews show that some agencies took good care of their workers, while others failed to do so, for example by putting workers in isolation in accommodation together with healthy and working migrants or by failing to provide quarantined workers with any groceries or medication. Workers who had just arrived and lacked a social network that might help had to go out to get their own groceries, possibly putting others at risk of contracting COVID-19.
The lack of accurate registration of EU workers in municipalities gave rise to additional challenges for testing and vaccination policies because Dutch public health services did not know where migrant workers lived. Consequently, employers (temporary work agencies) and user companies facilitated testing and vaccination at the company or housing locations. The survey and interviews suggest arbitrariness in testing practices. Some employers breached government standards by pretending to use testing sticks or by testing workers after a shift rather than before it. Besides being problematic from the perspective of migrants’ health and protection, such practices raise public health concerns. The implementation of public health policies depends on employers’ goodwill and arbitrariness, whereas state agencies’ failure to enforce existing rules allowed bad practices to flourish (Berntsen et al., 2023).
Language and information barriers kept migrants from obtaining reliable information on quarantine, testing and vaccination in the Netherlands. For some, it was a challenge not only to obtain relevant information in a language they understood but also to interpret official information on their specific situation. For instance, government announcements on quarantine rules would refer to ‘the household’ as the entity to consider in case of a COVID infection. When living with 150 other people and sharing facilities, such as bathrooms and kitchens, it was difficult to know who belonged to one’s ‘household’ and therefore when to quarantine and when not. Employers also complained about difficulties in translating official information and rules on the situation in the workplace. Frustrated by the lack of clarity in public communications and a lack of workable government solutions, the employer organisation for temporary employment agencies (ABU) developed its own standards (ABU, 2021).
During the pandemic, public health information became available in multiple languages, including those spoken by EU workers, but only at a later stage. Language remained an essential barrier to making appointments with the GGD (Dutch public health service) for testing or vaccination. NGOs received many questions from migrants about the vaccination process in the Netherlands (NGO interview, January 2021). When 62-year-old Czeslaw, for example, asked his employer to help him make a vaccination appointment, he was given the general GGD number. Because Czeslaw does not speak Dutch or English, he was unable to call and make an appointment himself and thus remained unvaccinated.
The transformation of migrant health into a public health issue nudged the Dutch public health authorities to rethink how messages of public importance are communicated and to adopt a more migrant-friendly approach, communicating official government statements directly in multiple languages. Likewise, there have been experiments with more migrant-friendly health-care delivery, such as the creation of GP practices for migrants where at least the nurses speak Polish or Romanian. There has been no evaluation of how effective these experiments are in countering the ‘sedentary bias’ in the design and delivery of health-care services, however.
Discussion and concluding remarks
In this article we highlight how sedentarism in the configuration and delivery of health care, as well as in the legal-administrative residence system, work organisation (temporary agency employment), and – during the pandemic – a general lack of awareness of migrants’ situation in central government regulation and communication prevented the full realisation of the right to health for EU migrant workers in the Dutch meat and distribution sectors. We especially flag the pervasive use of flexible forms of employment that categorise EU workers as ‘temporary’ migrants in terms of employment and social protection, including health care, as well as for the purpose of registration with local municipalities. Failure to register as a resident in a municipality impacts registration with a GP, who act as gatekeepers in the system. This functions as a legal-administrative barrier to accessing health care for many migrant workers. Our analysis confirms the role of cultural and language barriers linked to sedentarist biases in the delivery of health care that inform the perception of EU migrants as ‘anomalies’ or exceptional patients who demand adjustments and extra resources, despite their contributions to the Dutch insurance and tax system.
Employers play an important, and potentially problematic, role in facilitating or inhibiting health-care access for migrant workers. Dutch law allows the temporary work agency to contract health insurance, to organise registration with the Dutch authorities (but does not oblige it to do so, which can be just as problematic), and to arrange accommodation for EU workers, partly because it correctly assumes that such migrants are less knowledgeable about Dutch society and its social protection system. This assumption is linked to the temporary nature of their employment contracts, whereby temporariness functions as ‘justification’ for this legal-administrative set-up. In law, policy and government communications, however, there is no recognisable link between temporariness, precarity and vulnerability. Migrant workers end up footing the bill for the social costs of their employment, which has a negative impact on their reservation wage. This is the case when ill migrants are sent home on vacation to avoid paying them the required compensation. More generally, market logic rules the terms of migrant employment, allowing temporary work contracts to be dissolved immediately following client firm preferences, or if a migrant becomes ill. Migrant vulnerability is switched on and off depending on state and employer interests: the same migrant worker for whom the employer organises health care because of their unfamiliarity with the Dutch health-care system is expected to navigate the system alone upon becoming unemployed and uninsured.
The COVID-19 pandemic exacerbated the exclusionary and sedentarist effects of the Dutch social protection system, which only partially includes ‘temporary’ migrant residents. Furthermore, it clarified the need for the health-care system to change and accommodate migrants as a matter of public policy and public interest. Testing or vaccination campaigns that fail to reach migrant workers threaten public health and can have negative consequences for workers generally. We note a series of system adaptations with the potential to accommodate migrants and their specific needs. These include the roll out of campaigns in migrants’ languages and translation of important public information; deployment of telemedicine and apps, and the setting up of multilingual GP hubs. As Follis et al. (2023) rightly point out, however, their success depends on whether they incorporate a ‘mobile patient’ outlook or simply reproduce the existing ‘sedentary bias’, for example by assuming digital literacy or access to digital means. Other initiatives concern health insurance companies concluding an agreement with the government on protecting migrant workers, (proposed) state legislation on the better regulation of temporary work agencies and the duty to register, and the adoption of changes in collective agreements to better protect migrant workers, such as the cancelled termination option in temporary agency contracts (Berntsen et al., 2023). It remains to be seen whether these changes are sufficient to counter sedentarist biases and protect migrant workers, especially because some of the proposed legislation has still not been implemented.
Other Dutch adaptations, such as allowing employers to organise testing and vaccination, are more ambiguous when considering the overreliance, if not outright dependence, of many workers on their employers for work, health care, housing, transportation and information, combined with the lack of enforcement and supervision capacity of the Dutch state (Berntsen et al., 2023). The Dutch state delegates tasks to private actors, in this case employers, who do not necessarily have the same interests as the state or the migrant workers. Even if employers did have the best interests of their workers at heart, outsourcing the safeguarding of a fundamental right such as the right to health, with public health at stake, is questionable.
Our analysis shows the potential detrimental health effects for migrant workers stemming from private actors’ self-regulation, which undermines migrant workers’ rights in general. We argue that the Dutch state participates in sustaining the power imbalance between workers and employers through the legislative and administrative choices it makes in relation to labour and health (care), among other things. Trade unions have an important role to play to protect migrant workers’ rights, through active outreach about such rights, collective action, collective bargaining and enforcement, to break vicious cycles of precarious employment. As an increasing body of critical scholarship shows, trade unions’ fight against migrant worker precarity extends beyond the workplace into many different domains, and should not overlook the problematic link between migrants’ precarious health-care arrangements and precarious employment.
