Health insurance in Saint Helena, Ascension and Tristan da Cunha

The health system rests on public care provided island by island. On Saint Helena, the Health Directorate has about 250 staff, provides all the island’s health services and, for cases the island cannot treat, arranges referrals to medical services in South Africa and the United Kingdom. Jamestown General Hospital has an emergency department open 24 hours a day, inpatient wards, a maternity unit, a two-bed intensive care unit, a chemotherapy unit, surgery (general, gynaecological and obstetric, endoscopic) and radiology (X-ray, CT scan, ultrasound). District clinics, a pharmacy and a dental service complete the offer. France Diplomatie nevertheless specifies that the island’s medical facilities can only provide basic emergency services and that specialist care is not available there.

On Ascension, Georgetown hospital, run by the island government, relies on two doctors, a midwife and several nurses; it has X-ray and an operating theatre, and complex situations lead to a referral to the United Kingdom or South Africa. On Tristan da Cunha, Camogli hospital, opened on 7 June 2017, generally has two expatriate doctors ensuring continuous presence, expatriate and local nurses, two inpatient wards, X-ray, an operating theatre and a dental surgery; serious cases are evacuated to Cape Town by boat, and the FCDO (the British Foreign, Commonwealth and Development Office) indicates that the availability of a ship can take up to two months.

No contributory health insurance scheme was identified in the official sources read: care is charged for. On Saint Helena, the government distinguishes a resident rate and a scale applicable to visitors holding a short-term entry permit, who must be insured; access to the resident rate depends on the permit and on employment. On Ascension, medical and dental care is free for employees under contract and their accompanying family, and visitors must have comprehensive insurance. The cost of an evacuation falls under an assistance contract (see repatriation assistance). Health statistics appear in the “Key figures” block of this page where they exist.

• Saint Helena, stay of under 183 days: according to France Diplomatie, an entry permit is issued on arrival for a modest fee payable in pounds, euros, rand or dollars. You must present a return ticket (plane or boat), an insurance certificate written in English covering at least £175,000 of medical costs and air medical repatriation, booked accommodation and sufficient resources, with a passport valid for at least six months after the end of the stay. The final decision rests with the immigration officer on arrival.
• Saint Helena, longer stay: a long-term entry permit, which can run for up to five years, is applied for from the immigration service (form F), with proof of resources, health insurance covering evacuation, the ability to pay for the return journey and a criminal record certificate.
• Ascension: an electronic visa is compulsory before travel, to be applied for at least 14 days in advance, with a passport valid for six months. The visitor stays three months at most; the insurance must cover air evacuation for at least £500,000. There is no right of residence: anyone over 18 must hold a fixed-term employment contract or be the partner of a holder.
• Tristan da Cunha: prior authorisation from the Administrator and the Island Council is compulsory, applied for by email. The traveller shows a paid return passage, sufficient resources and insurance covering evacuation to Cape Town; a police certificate may be requested. Outsiders can neither buy land nor settle.
• Work: on Saint Helena, the employer obtains an immigrant employment certificate and the employee a long-term entry permit; self-employment of more than six months requires a work permit. On Ascension, employment goes through a contract with an employer on the island.
• Student: the European Health Insurance Card does not exist for these territories, which lie outside the European Union; student insurance or the CFE youth plan should be compared.
• Seconded employee : retention in the French scheme, according to CLEISS, for three years renewable once, with reimbursement up to what the French scheme provides on paid invoices (form S 3125c). Membership of the Caisse des Français de l’Étranger (CFE) remains a supplementary option.
• Retiree: CLEISS points to local institutions, voluntary CFE membership or private insurance; there is no form S1, as the territories are not in the European Union.
• Sea and terrain: the FCDO reports strong currents and sharks in the shallow waters of some beaches on Ascension, and boat transfers that can be dangerous in rough seas on Tristan da Cunha.

No text requiring a resident to hold private health insurance was read apart from the entry conditions above, which serve as an insurance obligation for the traveller. The cover amounts cited are those published by the local governments and by France Diplomatie; they should be confirmed before departure with the authority of each island.

The three islands are not in the European Union. CLEISS cites them neither in the list of social security agreements in force with France, nor in its list of foreign schemes, and its page on the British scheme mentions no overseas territory. For a temporary stay, they fall into the category “other countries or situations not covered”: on site, CLEISS indicates that no cover is possible unless an agreement applies. Without an agreement, no cover is arranged between the funds.

• Temporary stay: reimbursement on return to France of unforeseen care only is a possibility and not an obligation, medical repatriation is not covered by health insurance, and travel insurance suited to the real cost of care is advised by CLEISS.
• Secondment: the employee remains a member of the French scheme, three years renewable once; their contributions are paid in France, but they may also have to pay those of the host country. Care is covered up to what they would have received in France (form S 3125c with the paid invoices).
• Expatriation: the employee comes under the local scheme and is no longer covered by French social security; they may contribute voluntarily to the CFE in addition to their local membership. Without an agreement, local insurance periods are not taken into account in calculating the French pension.
• Retiree: CLEISS recommends checking local cover, choosing the CFE or private insurance, and points out that a retiree who is no longer a tax resident in France pays neither CSG nor CRDS.
• Taxation: the list of tax treaties published by the BOFiP includes neither Saint Helena, nor Ascension, nor Tristan da Cunha; the entry for the United Kingdom, which cites conventions of 21 June 1963 and 19 June 2008, mentions no extension to a territory. The list of tax information exchange agreements names other British territories (Anguilla, Bermuda, Cayman Islands, Gibraltar, British Virgin Islands, among others) but not these. Tax residence remains defined by article 4 B of the General Tax Code (home or main place of stay, professional activity, centre of economic interests); a single criterion is enough.

1. Before departure: notify the French agencies of your departure (CPAM, CAF, France Travail, pension funds) and choose your cover according to your status.
2. Choose the island and check its rules: each of the three islands sets its own entry conditions, which the FCDO invites you to confirm with each authority.
3. Saint Helena: passport valid for at least six months after the end of the stay, return ticket, accommodation, resources, and insurance whose certificate, written in English, covers at least £175,000 of medical costs and repatriation. For a stay of more than 183 days, apply for a long-term entry permit from the immigration service (appointment on +290 22287).
4. Ascension: apply for the electronic visa at least 14 days before departure, book the flight through the Ascension government (flight.bookings@ascension.gov.ac) once the visa is obtained, and check that the insurance covers air evacuation.
5. Tristan da Cunha: write to the Administrator’s office (tdcenquiries@tdc-gov.com) stating the purpose, dates, nationality and age; arrange a paid return passage and arrive in Cape Town at least two days before the ship leaves.
6. Employee: have the employer start the application for the immigrant employment certificate (Saint Helena) and complete the initial health assessment within four weeks of arrival.
7. Take out health insurance with evacuation before arrival; compare the CFE and international insurance according to age and profile.
8. Seconded employee: request retention in the French scheme from your employer and your fund; keep the paid invoices for form S 3125c.
9. Retiree: arrange health cover (CFE or private insurance) and find out about the right of residence from the Saint Helena immigration service before any project.
10. Register on the roll of French nationals living abroad on service-public; the France Diplomatie page names no competent post, and the French embassy in South Africa (Pretoria, +27 12 425 1600) is the first contact to confirm it.