Though it is recognised that migration and displacement can act as negative determinants of health for millions of people forced to move, and that migrants often face inequalities and inequities in accessing health services, the momentous global push towards achieving universal health coverage (UHC) risks leaving migrants behind. Dr Davide T Mosca recaps the challenging political and policy environment within which efforts are made to advance the migrant health agenda globally.
Migration is not a new or transient phenomenon, nor is it just a current problem that needs to be solved. Rather it represents a reality that is probably here to stay, and needs to be pragmatically, cooperatively, and compassionately managed, including with regards to its health aspects. Health systems must become more competent and inclusive in regards to human mobility and diversity, or face failure in achieving their health goals.
There are an estimated 277 million international migrants worldwide, out of whom 25.4 million are refugees, 164 million are workers, and many other are seeking international protection, or just a better life and safety in another country. If one adds migrants who remain within the boundaries of their own country and internally displaced people, the total reaches more than 1 billion people, or one in seven of the global population that has left home and is on the move.
Communities in many countries see a growing proportion of regular or irregular foreign-born residents, and that trend is growing. Yet health systems are designed around static and homogenous populations, and tend to treat mobility and diversity as a matter of exceptionalism.
[...] health systems are designed around static and homogenous populations, and tend to treat mobility and diversity as a matter of exceptionalism.
More than 10 years ago, when migration was possibly perceived with a less fierce sensitivity, member states of the United Nations came together in New York for the first High Level Dialogue on Migration and Development (2006). The event witnessed an unprecedented states’ commitment towards a multilateral dialogue on migration, and the will to identify together appropriate ways and means to maximise its development benefits, and minimise its negative impacts.
Riding that wave, in 2008 the 61th World Health Assembly approved the Resolution on the Health of Migrants (WHA 61.17) that urged member states to adopt policies and implement programmes to ensure that, in an era of globalised human mobility, the right to health of migrants was upheld – regardless of migrants’ race, gender, age or legal status. The resolution urged member states to ensure disparities in accessing healthcare were overcome for the public health good of all, and that negative health outcomes of migration were avoided. Several countries and supranational entities engaged in developing migrant-sensitive health policies, migrant-friendly services, and in forging partnership at multi-sector level to identify and tackle conditions of vulnerability to ill health along the migration journey, at origin, transit, destination, and return.
The health of people who migrate reflects the circumstances of migration. Yet progress was slow, and hampered at the national level by persisting differences in the ways societies value migration as a whole, as a structural factor of development, and its relation to health. A range of insurmountable obstacles included:
- a lack of common definitions and understanding around migration dynamics
- a lack of adequate data systems to support an evidence-based policy development
- difficulties in influencing laws
- restrictions and discriminations affecting health but beyond the control of the health sector
- and financial constraints and conflicting priorities.
At global level, the lack of clear mechanisms to monitor progress and assess impact weakened accountability, and a collective drive towards improvements. As a result, recommendations expressed by experts and considered action frameworks often remained deprived of much needed transformative leadership. Migration remained a marginal concern within health and health system debates, and health remained utterly absent within migration debates.
Migration has become one of the most critical and divisive geopolitical issues of our time, and has amplified social and political divisiveness in societies around the world.
The global financial crisis of 2007–08 made the situation even more difficult. The repercussions on public expenditures and on impoverished strata of societies in the global north coincided with the global migration push linked to persistent poverty in the global south, caused by multiple lasting and unresolved conflicts in North Africa, Middle-East and beyond, as well as the first migrants induced to move by environmental changes.
In the aftermath of the fall of the Gaddafi regime in Lybia and the war in Syria, and a large influx of migrants towards Europe, a toxic tone has dominated the migration debate. Concurrently, thousands of migrants have lost their life in a journey that became more dominated by desperation than aspiration.
Migration has become one of the most critical and divisive geopolitical issues of our time, and has amplified social and political divisiveness in societies around the world. At a time when the drivers of migration are stronger than ever, misperceptions, misinformation, political motivations, fear and anxieties in society have engendered, xenophobia, sovereignism, populistic rhetoric and more restrictive laws that eventually hinder the realisation of positive health outcomes for all. The political will to deliberately avoid potential controversies or disputes that could complicate or delay the approval of global strategies might have had a consequences in the health sector as well.
As an example, despite the pledge made by UN member states with the adoption of the 2030 Development Agenda and the Sustainable Development Goals (SDGs), to ensure ‘no one will be left behind’ and to ‘endeavour to reach the furthest behind first’ there is no evidence that a key health strategy such as realising Universal Health Coverage (UHC. SDG target 3.8) will include migrants. In many countries, citizenship and legal status dictate access to essential healthcare, and the fear of dismissal, stigmatisation, apprehension, deportation, just cultural, linguistic and economic barriers act as deterrent for migrants to access public services.
A critical aspect of the WHO and World Bank conceptual framework for UHC monitoring is an emphasis on using tracer indicators that reflect variations caused by factors in health systems, rather than factors outside the control of the health system. This is the key migration health challenge, since determinants of migrants’ ill health are more often set in laws, practices and dynamics outside the control of the health system.
The three dimensions of the UHC, ie population covered, services provided, and financial protection are assessed by means of indicators that are only focused on system capacity and financial aspects, and are not necessarily population-centered, so as to also monitor progress towards equity and inclusiveness.
Indicator tracers of the UHC monitoring framework evaluate access to services for disadvantaged populations through the lens of health system service capacity only, such as hospital beds per capita, or health workforce availability. Health security aspects, which are also part of the population tracer indicators, are only linked to the implementation of the International Health Regulations (IHR). This might not reflect the fact that global health security ultimately results from human security of every individual, the fundamental tenets of which are equity and the right to health for all.
Xenophobia, prejudice, indifference to human suffering and exclusion cannot be tolerated, particularly in health
Despite the fact that no systematic UHC monitoring report has so far captured the health status of 277 million migrants (and other marginalised groups), SDG indicator 3.8.1 is considered by the UN interagency expert group (IAEG) for a re-classification in Tier I of the SDG global monitoring system. This means that the indicator is conceptually clear, an international methodology and standards are available, and data are regularly produced by countries for at least 50% of the population; migrants seem to fall within the other 50%.
In view of this, the actual Tier for this indicator should be III: ‘no internationally established methodology or standards are yet available’. It is often said that ‘you can't manage what you can't measure, and what can be measured can be improved.’ It is therefore urgent that a metric system is in place within the SDGs to measure the health of migrants, if we really want to ‘leave no one behind’ and realise the old aspirational goal of ‘health for all’.
It is hoped that the WHO Global Action plan called by WHA Resolution 70.15 in 2017 and the forthcoming High Level Meeting on UHC in New York this year within the framework of Foreign Policy and Global Health (FPGH) will help strengthen political will and accountability for the health of refugees and other migrants within the SDGs. For this to happen and to cut the Gordian knot of migrant health, we need to forge a large alliance and convergence of intent across diplomacy, agencies, academia and civil society.
The health workforce should be more aware of its capacity to influence the global discourse and demand a seat at the table of discussion around migration and other global dynamics that are relevant for our present and our future. Xenophobia, prejudice, indifference to human suffering and exclusion cannot be tolerated, particularly in health.
Dr Davide T Mosca is a former director of Migration Health at the Institute of Migration (the UN Migration Agency).