Review Article


International comparatives of healthcare options for undocumented immigrants

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1 VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA, 02132, USA

Address correspondence to:

Gentian Kristo

MD, MPH, FACS, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA, 02132,

USA

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Article ID: 100022P16JL2019

doi: 10.5348/100022P16JL2019RA

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Muñoz-Largacha J, Kristo G. International comparatives of healthcare options for undocumented immigrants. Edorium J Public Health 2019;6:100022P16JL2019.

ABSTRACT


There are many country-specific differences and deficiencies with regards to the healthcare access for the undocumented immigrants: while in the US even emergency care cannot be accessed for free, in the European Union countries the human right to adequate healthcare servicesis translated only to emergency care for life-threating conditions, and treatment of infectious diseases that would be hazardous for their national populations. Even more restrictive is the policy for the undocumented immigrant healthcare in Japan where they are not even granted access to emergency services. In Australia the human rights of the undocumented immigrants are ignored as they face mandatory and indefinite detention in centers with scarce healthcare resources that cannot meet their needs. Thailand is the only country in the world that provides all undocumented immigrants with full access to the national healthcare systemwithout any administrative discriminatory steps. Healthcare access for undocumented immigrants is at the intersection of many other challenges brought up by immigration. As such, a proper healthcare policy can only be achieved as part of an overall fair immigration system.

Keywords: Healthcare access, Human rights, Immigration policy, Undocumented immigrants

Introduction


Although getting the necessary medical care is generally accepted as a universal human right [1], the application of this principle is particularly complex when it comes to one of the most at-risk populations, undocumented immigrants and refugees.

Wars, conflicts, and persecution have continued to displace an ever- increasing number of people from their homes in search for refuge and safety elsewhere. Statistics reveal the staggering magnitude of this problem: 59.5 million people were forcibly displaced worldwide in 2014, compared to 37.5 million a decade ago [2]. Most alarmingly, one in every 122 humans is now either an undocumented immigrant or a refugee, with over half the world’s refugees being children [3].

Due to significant hardship, the undocumented immigrants and refugees have increased needs for emergent and ongoing medical care. Unfortunately, the undocumented immigrants convey difficult policy challenges for the host countries and their health-related issues are often politicized.

As a result, undocumented immigrants often find themselves in a legal and healthcare grey-zone, a “no man’s land” with continued lack of proper access to health care. As policies and practices vary greatly across countries, in this paper we reviewed the healthcare coverage for undocumented residents in the United States (US), Canada, European Union countries, Australia, Japan, and Thailand.

 

United States

There was an estimated of 11 million unauthorized immigrants in the US in 2015, with six states accounting for 59% of them: California, Texas, Florida, New York, New Jersey, and Illinois [3].

Although the illegal immigrants in the US are at a very high risk of health problems, they have limited options for a proper access to healthcare. The two main reasons for this situation are their undocumented legal status and their economic marginalization.

Thus, under the implemented Affordable Care Act, undocumented immigrants are excluded from participation in Medicare and Medicaid. Furthermore, they are not considered eligible to purchase insurance through health exchange programs [4]. From the domestic politics standpoint (despite lack of evidence), extending healthcare to those who are illegally in the country is thought to encourage more illegal migration (the “pull factor”) and thus undermine the country’s laws.

A notable exception is the state of California, which in 2015 passed the Health for All Act, allowing illegal immigrants to purchase health insurance through California’s health insurance exchange [5]. Furthermore, California subsidizes health care for illegal immigrant children [6].

Undocumented immigrants are socially and economically marginalized, and typically work low-wage jobs shunned by nationals in industries that are less likely to offer employment health benefits [4]. The high rates of poverty among undocumented families mean that they cannot afford to buy private health insurance when not offered by employers.

Furthermore, undocumented immigrants often are reluctant to seek medical care due fear of unequal treatment and deportation [7].

With limited access to health care, the undocumented immigrants in the US have the following options for medical care:

 

1. Emergency medical care

The Federal Emergency Medical Treatment and Labor Act (EMTALA) of 1986 requires all hospitals that participate in the Medicare program to provide the necessary emergency health services to stabilize the patients that present in their emergency departments, regardless of their legal immigration status or ability to pay [8].

The hospitals that provide uncompensated care are then reimbursed by the federal government through the Medicaid Disproportionate Share Hospital (DSH) program.

Unfortunately, under the Affordable Care Act, the DSH program will be gradually reduced, for an expected total decrease of $18.1 billion in DSH reimbursements by 2020 [9]. This change is estimated to increase the amount of uncompensated care shouldered by hospitals with undocumented immigrant patients seeking emergency care.

Although, not refusing emergency healthcare services is an important humane act, it is not enough as it does not provide continued optimal access to healthcare. Offering only emergency medical care without covering for preventive and non-emergency care is detrimental not only to the health of the illegal immigrants but also to the public healthcare system as a whole.

Given legal, cultural, and economical barriers, undocumented immigrants are more likely to seek emergent as opposed to preventive health care. Thus, emergency care acts in reality as insurance of last resort for the undocumented immigrants.

Potentially preventable diseases are left undetected and untreated until these are advanced to a severe stage when emergency, more expensive care is needed. This deteriorates the health of the immigrants and the wellbeing of their communities, while consequently overutilizing the emergency resources leading to increasing health care expenditures [10], ultimately forcing taxpayers to incur more costs.

In some states with higher numbers of immigrants, up to 99% of emergency Medicaid patients are undocumented [10].

 

2. State-funded Medicaid coverage for emergency care

States and local governments are required to provide education, public safety, and other public services to their residents regardless of legal status. However, the expenditures for all public services, (including healthcare) for undocumented immigrants are disproportionally small and insufficient, accounting for less than 5% of the funds used for their population as a whole [9].

 

3. Non-emergent care at safety-net providers

Primary care services for uninsured undocumented immigrants are provided through some safety net providers such as not-for-profit hospitals, federal community health centers, and migrant health centers.

Unfortunately, the federal funding for these health centers is suffering ongoing cuts [9]. Moreover, the quality of care provided in these centers is reduced. Often, diagnostic tests are not available and primary physicians working in these centers have great difficulty referring uninsured patients to specialty care or admit them to a hospital for treatment of their chronic conditions [11].

 

Canada

Although undocumented immigration in Canada is not as widespread as in the US, an estimate of 500.000 total undocumented migrants [12] is faced with similar challenges with regards to healthcare access.

The Canadian federal government supports a universal health insurance program covering all Canadian residents.

According to the Canada Health Act [13], “all residents must have access to insured health care services on uniform terms and conditions without direct or indirect financial charges, or discrimination based on age, health status or financial circumstances”.

However, the universality, accessibility, and comprehensiveness of the Canadian healthcare system do not apply to the undocumented immigrants – known as “immigrants with precarious legal status”. They include the following:

  • Denied refugee claimants
  • Individuals who stay in Canada beyond the duration of a legal permit
  • Individuals who enter the country illegally

A discrimination policy is applied to the undocumented immigrants. They are not covered in any federal or provincial program, although they can access limited, emergency care-only services.

Being denied access to publicly-funded health care, the undocumented immigrants are left with few options [14],[15]:

  • Pre-pay their medical expenses (unrealistic given the financial hardship of undocumented immigrants)
  • Use of the community health centers run by volunteer staff, which are faced with very long waiting lists leading to non-optimal care.

European union countries

The number of undocumented immigrants in the European Union is estimated to be between 1.8 and 3.9 million immigrants, representing approximately 1% of the entire EU population [16].

Although European Union countries have less undocumented immigrants than the United States, their immigrant healthcare policies face similar difficult challenges. The healthcare access for undocumented immigration varies among the EU countries [17],[18],[19], with a comparison of national policies being presented below.

 

Belgium

About 40,000 to 140,000 undocumented immigrants live in Belgium, a country with a population of about 11.3 million. The emergency care in Belgium is universal and tax-based (while non-emergency care is insurancebased) and the undocumented immigrants have the

right to access emergency care free of charge. Since 1997, undocumented immigrants can also access free of charge the Urgent Medical Assistance, which includes both preventive and curative care such as examinations, tests, medications, operations, childbirth, physiotherapy, and continued treatment of any infectious disease that poses risks to the public. However, a provider has to issue a document certifying the urgency of the medical assistance and social services have to conduct a spot investigation to verify that the undocumented immigrant is indeed, unable to pay. This creates a complicated, bureaucratic system.

As a notable exception, the unaccompanied children immigrants have full healthcare coverage without any discrimination.

 

Cyprus

A small island-country in the eastern Mediterranean with a population of 1.1 million, Cyprus hosts an estimated 3,000–5,000 undocumented immigrants. The national immigration policy in Cyprus is very restrictive and focuses on the voluntary and forced return of the undocumented immigrants to their countries of origin. Undocumented immigrants in Cyprus can access free of charge only emergency care. In addition, the diagnosis and treatment of HIV and other communicable infections with immediate public health risks are also covered.For any non-emergent care that are required to pay the full cost of services.

 

Czech republic

About 17,000 to 70,000 undocumented immigrants live in the Czech Republic, a country with a population of about 10.3 million.

The undocumented immigrants are required to pay in full for all healthcare services without any exceptions. Although the law requires the providers to treat all patients for emergency, life-threating conditions and infectious diseases, patients are charged for those services.

The only theoretical option they have is to buyprivate health insurance. However, in reality such private insurance is not taken by the undocumented immigrants as it is costly, has limited coverage, and requires the undocumented immigrants to be free of pre-existing conditions when they buy it. In addition, safety-net healthcare options such as services provided by nongovernmental organizations remain very limited.

 

France

About 300,000 to 400,000 undocumented immigrants live in France, a country with a total population of about 65.2 million. Undocumented immigrants have free access to emergency care, perinatal care, abortions,and treatment of communicable infections with immediate public health risks (such as HIV, tuberculosis).

Since 2000, the undocumented immigrants can also access health care for free through a social benefit system called State Medical Assistance. Access and is subject to prerequisites involving the period of stay and proof of financial difficulties.The undocumented immigrants have to present supporting documents proving that they have been living in France for over three months and have an annual income of less than 8,645 euro for singles and less than 12,967 euro for couples. Their dependents (children) can also benefit from the State Medical Assistance.

The required administrative process to determine eligibility for the State Medical Assistance can be too complex for many undocumented immigrants who live clandestine lives in France andrepresent an obstacle to accessing the healthcare system effectively.

 

Germany

About 800,000 to 1 million undocumented immigrants live in Germany, a country with a total population of about 83 million. Undocumented immigrants have free access for emergency care, perinatal care, and treatment of communicable infections with immediate public health risks (such as HIV, tuberculosis).

In Germany being an undocumented immigrant is considered as a criminaloffence and all public employees are obligated by the German legislation to denounce any undocumented immigrant encountered during the course of their work. This obligation includes also the social welfare centers that have competences on health administration issues.

Since 2000, the law allows the emergency care and treatment for communicable infectious diseases to be anonymous and exemptedfrom the duty to denounce. However, due to fear for deportation, undocumented immigrants avoid preventive, non-urgent care. This could lead to worsening of their medical condition until emergency care becomes necessary.

 

Greece

Undocumented immigrants use Greece both as a final destination and as a transit stop on their journey to other countries in the EU. About 500,000 to 600,000 undocumented immigrants live in Greece, a country with a total population of about 10.7 million.

Despite the fact that the work performed by undocumented immigrants accounts for 25% of the GDP, being an undocumented immigrant in Greece is considered a criminaloffence and all public health centers and hospitals can be punished for providing services to them.

Emergency care is an exception to this punitive and discriminatory law. Undocumented immigrants are provided emergency care free of charge until their health has stabilized. Only children of undocumented immigrants are allowed the right to access the nonemergency health care free of charge.

 

Italy

About 670,000 to 900,000 million undocumented immigrants live in Italy, a country with a total population of about 60.8 million.

Undocumented migrants can access a wide array of healthcare services for free (although they have to provide copayments), they have to go through an administrative process called Temporarily Present Foreigners.

First, they have to fill out forms declaring lack of financial mean and then they are issued a six-month (but renewable) health card that entitles them to emergent and urgent care, prenatal care, vaccinations, as well as essential care for diseases that could worsen (such as infectious diseases and drug dependencies).

The system provided full healthcare access for their dependents under the age of 18. However, in practice there are barriers to optimal healthcare access for the undocumented migrants, such as:

  • Copayments increase the financial burdens for a population that lack resources.
  • They are entitled to have a family physician, which constitutes a major barrier for access to specialists
  • The Temporarily Present Foreigners process is bureaucratic and decrease efficiency 
  • Knowledge, culture, and language barriers

 

Malta

Despite being the EU’s smallest country with a population of only 400,000 people, the number of undocumented immigrants is 17,000 -- disproportionately high when compared with all other EU countries.Malta makes all illegal immigrants stay in governmental detention centers, which have very limited medical resources. Although the undocumented immigrants are considered to be allowed to access “free state medical services”, currently there is no legal framework addressing their right to access the mainstream healthcare system.

Netherlands

About 100,000 undocumented immigrants live in the Netherlands, a country with a total population of about 17 million. Undocumented migrants can only access care for life threating conditions, treatment of communicable infectious diseases (HIV, TB), perinatal care, vaccinations, and compulsory psychiatric treatment.However, they are expected to pay for their medical expenses. When they are proven that they cannot pay, the providers can then apply for reimbursement from an uncompensated care fund – which typically only refunds up to 80% of the costs.

The most important obstacle to this system is the fact that prior to accessing care the undocumented immigrants have to be evaluated by a doctor. Only when the physician considers the anticipated care as medically necessary can the immigrants access the healthcare services.

Furthermore, given overwork and the incomplete reimbursement for uncompensated care, many physicians are dis-incentivized to grant healthcare access to undocumented immigrants.

 

Poland

Although many immigrants use Poland as a gateway to the Western Europe, about 45,000 to 50,000 undocumented immigrants actually live in Poland, a country with a total population of about 38 million. In terms of healthcare access, the undocumented migrants are faced with a very discriminatory policy.

They can access for free only the following:

  • Out-of-hospital emergency care provided by the emergency rescue teams
  • Treatment of contagious infectious diseases that could endanger the public (TB, HIV)

When the undocumented migrants present to the emergency department with life-threating conditions, they are not turned away. They are treated but are required to pay the full cost for their medical services provided.

 

Portugal

About 130,000 undocumented immigrants live in Portugal, a country with a total population of about 10.5 million. Undocumented immigrants have free access to emergency care, perinatal care, abortions, and treatment of communicable infections with immediate public health risks (such as HIV, tuberculosis). The undocumented immigrants can also access health care for free through temporary registrations at health centers. They have to register every time they require medical assistance and access is subject to prerequisites involving the period of stay (proving that they have been living in Portugal for more than 90 days) and proof of lack financial resources. This administrative process is a significant obstacle for the undocumented immigrants to effectively access healthcare and is further complicated by language and cultural barriers.

 

Romania

Although Romania is faced more with the problem of emigration of its citizens in Western Europe, about 13,000 undocumented immigrants live in Romania, a country with a total population of about 21.7 million. Undocumented immigrants can access for free emergency care for life threating conditions, perinatal care, family planning, and treatment of communicable infectious diseases (TB, HIV).

For other medical services, the undocumented immigrants have to pay in full – not a realistic prospect given their lack of financial resources. However, their dependent children younger than 18 have full access to the Romanian national healthcare system.

 

Slovenia

Although there are no clear estimates about the number of undocumented immigrants, it is considered that a few thousands of them are living in Slovenia, a country with a total population of about 2.1 million.The Slovenian legal framework allows the undocumented immigrants toaccess for free emergency care for life threating conditions, perinatal care, family planning, and treatment of communicable infectious diseases (TB, HIV). For more extensive healthcare access, they have to pay in full for the provided services.

 

Spain

About 800,000 to 1 million undocumented immigrants live in Spain, a country with a total population of about 46.5 million. Spain provides the most extensive healthcare coverage to undocumented immigrants in the European Union. Thus, the undocumented migrants can access for free the Spanish tax-funded universal national healthcare system. However, the healthcare access for the undocumented immigrants is conditional on them completing a local civil registration, basically registration as residents with a municipality.

This administrative process is a significant practical obstacle for the undocumented immigrants to effectively access healthcare. They have to provide valid identity documentation and a resident address which is an important barrier given the clandestine nature of their immigrant lives. This is further complicated fear of deportation as by law, the Spanish police can access to the municipality registers.

Children under the age of 18 and pregnant women are exempted from the registration requirement. Undocumented migrants who have not completed the local civil registration can access for free only emergency careand treatment of contagious infectious diseases (TB, HIV).

 

Sweden

About 80,000 to 120,000 undocumented immigrants live in Sweden, a country with a total population of about 9.9 million. In terms of healthcare access, the undocumented migrants are faced with a very discriminatory policy. For a longtime the undocumented immigrants, their dependent children, and pregnant women had no free access to any medical services. They could access only through a co-payment emergency care, perinatal care, family planning, and treatment of contagious infectious diseases (TB, HIV).

Legislation introduced in 2012 grants children under the age of 18 full and free access to the Swedish national healthcare system. It also provides free emergency care for adults with life-threatening conditions.For all other healthcare services, the adult undocumented immigrants have to pay in full, which is a tremendous financial barrier to them accessing adequate preventive and nonemergent medical care.

 

Switzerland

Switzerland, a country with a total population of about 9.3 million, is not part of the European Union. Undocumented immigrants represent about 1–1.3% of the total population.

Undocumented immigrants can access for free emergency care services, perinatal care, and treatment of contagious infections. They are also allowed access to more extensive healthcare services, but they are required to purchase mandatory insurance provided by private insurers. When unable to pay for the high insurance premiums, the undocumented migrants can apply for income-related financial assistance to subsidize the insurance premiums, after first providing documentation of their inability to pay.

The high insurance premiums, the administrative process for acquiring finance assistance, and cultural and language barriers, all represent important obstacles that in practice prevent adequate healthcare access for the undocumented immigrants.

 

United Kingdom

Undocumented immigrants represent about 1.2% of the UK total population of 65.1 million. They can access for free emergency care, family planning, care for severe mental health conditions, and treatment of contagiousinfectious diseases. Importantly, the HIV treatment is not covered. Undocumented migrants with HIV/AIDS may be admitted to the hospital for stabilization when critically ill, but they are not provided additional services after they are discharged from the hospital.

Since 2004, the undocumented migrants cannot access hospitalized perinatal care, preventive care, and HIV treatment if they cannot pay in advance for the anticipated medical services. Not being able to access preventive care through family physicians represents also a serious obstacle for specialist referrals for the undocumented migrants.

 

Australia

About 62,000 undocumented immigrants live in Australia, a country with a total population of about 23.8 million. Australia has an extremely restrictive immigration detention policy. All undocumented immigrants are detained mandatorily for undetermined periods of time without having the legal right to oppose detention. Those intercepted while trying to reach Australia by boat are detained in offshore centers. Theoretically, these offshore detention centers should be able to deliver comprehensive healthcare services for free to the detained immigrants [20]. In practice however, healthcare services in these centers are provided by contractors and the quality of the care is sub-optimal: significant delays to be seen by a physician, scarce childhood vaccinations, lack of transparency, and inadequate medical records [21].

Undocumented immigrants who arrive in Australia by air and people who overstay their visa are detained in onshore immigration centers [22]and are entitled to receive healthcare services in these centers.

Not only the healthcare provided in the offshore and onshore detentions centers is inferior to the Australian standards, but the detention itself has many negative effects on the health of such a vulnerable population as the undocumented immigrants. In particular, mandatory and prolonged detention has been shown to deteriorate the mental health of the immigrants leading to increase in self-harming behavior and suicides [20].

 

Japan

Japan has the smallest number of undocumented immigrants among developed countries. Thus, only about 60,000 undocumented immigrants live in Japan, a country with a total population of about 127 million. This is the result of an immigration policy that focuses strongly on border and migration control rather than on human rights of the immigrants [23]. Given the tight boarder control, most undocumented immigrants living in Japan are foreign visitors who overstay their temporary visa. As part of such a restrictive immigration policy, healthcare access for the undocumented immigrants is non-existent. They are not even allowed to acquire public health insurance. As a result, they delay seeking medical attention until their condition worsens to the point of emergency.

Emergency care is not denied to the undocumented immigrants when they present with life-threating conditions. However, they are expected to pay for the medical services they received. As they are unable to pay for such expensive services, hospitals are left with unpaid bills.

Furthermore, safety-net healthcare services by community groups are very limited and unable to provide adequate healthcare access for the vulnerable undocumented immigrants.

 

Thailand

About 500,000 undocumented immigrants live in Thailand, a country with a total population of about 68.8 million. Since 2013, Thailand is the only country in the world that provides all undocumented immigrants with full access to the national healthcare system with all the rights of the Thai citizens, without any administrative discriminatory steps [24]. Undocumented immigrants have to pay only about $58 annually for their universal health insurance card [25].

Despite financial pressures and some challenges in the governmental reimbursement scheme for the hospitals, the Thai government remains strongly committed to continue this generous and humane policy.

 

Comparative analysis

There are many country-specific differences and deficiencies with regards to the healthcare access for the undocumented immigrants: while in the US even emergency care cannot be accessed for free, in the European Union countries the human right to adequate healthcare servicesis unfortunately translated only to emergency care for life-threating conditions, and treatment of infectious diseases that would be hazardous for their national populations.

Furthermore, the European experience suggests that even when there is official support for more extensive healthcare for the undocumented immigrants, in reality they face significant legal, cultural, language, and bureaucratic obstacles that affect their access to an effective and equitable healthcare system.

Even more restrictive is the policy for the undocumented immigrant healthcare in Japan where they remain legally invisible and therefore not even granted access to emergency services.

In Australia the human rights of the undocumented immigrants are ignored as they face mandatory and indefinite detention in centers with scarce healthcare resources that cannot meet the needs of such a high-risk population as the suffering undocumented immigrants. The Australian treatment of the undocumented immigrants is basically an apartheid health care system.

What is common about all the countries reviewed in this paper (with the notable exception of Thailand, where every single resident can access the universal healthcare system regardless of their immigration legal status) is that at the core of their immigration debates is the concern about their national sovereignty -- the principle of being the “master of your house”.

In an era of globalization, people fear that their sovereignty is being attacked from the outside (free trade agreements, outsourcing, and increasing multi-laterality of the international decision-making) but also from the inside (illegal immigrants breaking their laws, stealing jobs for natives, and free-riding the public services). With this fear being exploited by opportunistic politicians, a divisive political climate is created and can be prohibitive ondeveloping a fair approach on the issue of illegal immigration in general and on the issue of undocumented immigrant healthcare access in particular.

Healthcare access for undocumented immigrants is at the intersection of many other challenges brought up by immigration. As such, a proper healthcare policy can only be achieved as part of an overall fair immigration system. In our opinion, the current approach on undocumented immigration in all countries reviewed in this paper is a narrow focus on finding national solutions to a transnational, global problem. As the immigration crisis in the European Unioncountries in 2015–2016 indicated, this approach is a set-up for failure. Barbed-wire fencing national borders is not a sustainable solution to largescale immigration.

As far as healthcare access for the undocumented immigrants, through United Nations, the international laws should be reformed to mandate application in practice of the basic right of all human beings to unrestricted healthcare coverage. In this matter, the international law should clearly override the national policies.

We cannot think of a better way to close ouranalysis than with this quote from the great Martin Luther King in 1966: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane” [26].

Conclusion


Immigration is a global problem requiring comprehensive global solutions that should address in the first place the conditions that force the immigrants to leave their homes and embark in a very dangerous journey across foreign lands and oceans. All host countries should provide adequate access to quality healthcare to all the people inside their borders, regardless of immigrations status.

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SUPPORTING INFORMATION


Author Contributions

Juan Muñoz-Largacha - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Gentian Kristo - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Guaranter of Submission

The corresponding author is the guarantor of submission.

Source of Support

None

Data Availability

All relevant data are within the paper and its Supporting Information files.

Conflict of Interest

Authors declare no conflict of interest.

Copyright

© 2019 Gentian Kristo et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.