Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Public Health (DPH)


Health Policy and Management



Committee Members




Subject Categories

Epidemiology | Health Policy | International Public Health | Public Health | Virus Diseases


Royal Decree Law 16/2012 and Royal Decree 1192/2012, Immigrants, Healthcare Access, HIV, Policy Implementation Analysis, Health Disparities, Late HIV Diagnosis, Mixed Methods, Spain, European Union


Background: The financial crisis of 2008 hit Spain hard. As a consequence, the government took multiple austerity measures, including reforms in the healthcare system in 2012. Specifically, the government reduced the budget for health and social services by 13.7% in 2012.The reduction was further followed with structural changes via the 2012 Royal Decree Law (RDL) and Royal Decree (RD).The 2012 RDL and RD entailed broad areas of action,but most importantly the Spanish National Health System (SNS) no longer covered undocumented immigrants. The 2012 RDL and RD excluded approximately 500,000 undocumented immigrants from SNS.

The number of immigrants in Spain has increased greatly since the 1990s; thus, ensuring that the health needs of this vulnerable population is addressed by the Spanish health system is of great importance. Immigrants in Spain and throughout much of Europe are often socio-economically disadvantaged and therefore especially vulnerable during economic crises. In addition, immigrants are disproportionally affected by infectious diseases and other health disparities. Spain has one of the highest prevalence rates of HIV cases among European Union countries. Yet, health disparity issues are much understudied in Spain and there is no comprehensive public health framework addressing the wellbeing of the immigrant population. This dissertation aimed to fill this gap by investigating the impact that the 2012 austerity measures have had on immigrants in order to inform future interventions.

Objective: To examine, in three separate papers: 1) the legal and regulatory actions taken at the regional level in 7 Autonomous Communities (ACs; Andalucía, Aragón, Basque Country, Castilla La-Mancha, Galicia, Madrid, and Valencia) after adoption of RDL 16/2012 and RD 1192/2012 (April and August 2012) until the enactment of RDL 7/2018 (July 2018) and their impact on access to both general healthcare and HIV services among undocumented immigrants; 2) the prevalence of late HIV diagnoses (LHD) among immigrants regardless of documentation status living in Spain versus native-born Spaniards from 2010 to 2015; and 3) systematic barriers encountered by HIV-positive immigrants while initially accessing healthcare services and their personal experiences as HIV-positive immigrants living in Spain.

Methods: In the first study, a policy implementation analysis of how 2012 RDL and RD was conducted by reviewing regional documents and supplementary interviews with 9 regional public health administrators/specialists in 7 ACs. Indicators were developed based on prescribed requirements to access free healthcare services among undocumented immigrants. ACs were categorized under 5 levels of access: High Access, Medium-High Access, Medium, Medium-Low Access, and Low Access.

In the second study, the prevalence of LHD among HIV-positive, antiretroviral therapy-naïve immigrants living in Spain compared with native-born Spaniards was estimated using data from the 2010-2015 Cohort of the Spanish AIDs Research Network (CoRIS; n=5943 in total, 1488 immigrants and 4445 native-born Spaniards). Multivariate logistic models were fitted to compare the prevalence of LHD between the two groups, adjusting for demographic and behavioral covariates.

The third study relied on key informant interviews (n=12) to investigate barriers encountered by HIV-positive immigrants while initially accessing healthcare services and their life experiences as HIV-positive individuals in Spain. Participants were recruited via a local nongovernmental organization (NGO). Thematic analysis was performed to identify common themes related to systematic barriers to accessing care and experiences of discrimination and distress in Spain.

Results: This research discovered huge variability in how the 2012 RDL and RD were implemented across 7 ACs. Andalucía provided the highest access to free health services to undocumented immigrants for both general care and HIV treatment, with few administrative barriers, including no requirement for identification or registration in the AC. Medium-high access was provided by the Basque Country and Medium access was provided by Aragón, Madrid, and Valencia. Medium-Low access was provided by Castilla-La Mancha. Galicia provided the lowest access. Compared with other ACs, Madrid and Galicia differentiated levels of access for undocumented migrants in terms of HIV care (less stringent) versus general healthcare (more stringent). Although regional specialists mostly agreed that access to free healthcare for undocumented immigrants was a human rights issue, 50% of the selected ACs required a minimum period of proven residency in a region.

In addition to the structural barriers and distress experienced by HIV-positive immigrants, this dissertation found that the prevalence of LHD was much higher among immigrants than native-born Spaniards (37.4% vs 45.7%, respectively; P

Finally, 4 primary themes were identified as a result of the qualitative analysis of key informant interviews among HIV-positive immigrants in Valencia. Specifically, participants identified experiencing emotional or physical (eg, side effects of medication) distress as they adapted to life as HIV-positive individuals. Participants also expressed experiencing discrimination while living as HIV-positive immigrants in Spain. The primary systematic barrier to accessing health care encountered by participants was the inability to fulfill the requirement of having proof of registration in an AC for the required time period, thus not being able to apply for a public health insurance card and utilize free care services. Participants identified a positive impact of third-party (NGO, social worker, friend/family member) guidance on their experience of applying for a public health insurance card.

Discussion: This dissertation found that undocumented immigrants are differentially affected by HIV in Spain. The 2012 healthcare reform restricted their access to free healthcare services in real and practical ways, but the level and types of restriction varied greatly across ACs. This research also revealed the importance of civil society for advocating for the human right to health care for all as well as providing instrumental support to immigrants on how to successfully navigate the Spanish health system. A larger role of NGOs in the Spanish health system to address the health needs of vulnerable population may be worthy of further research and consideration. Overall, this dissertation makes an important contribution to the knowledge base on the experience of healthcare among HIV-positive immigrants in Spain. Collectively, the body of work draws on and provides a mixed methods framework that can serve as the methodological basis for further research on immigrants and health disparities in Spain and elsewhere in Europe. Findings will inform future policies aimed at providing a comprehensive public health framework to enhance healthcare access among all populations, including both documented and undocumented immigrants.


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