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Key findings: MHADRI scoping exercise

Key findings from the MHADRI scoping exercise with established migration and health researchers

MHADRI intern Holly McCarthy shares the key findings from her research that involved undertaking a scoping exercise with established migration and health researchers.

This project aims to identify and map existing gaps in migration and health governance, research, and access to resources, in order to determine how MHADRI can play a role in addressing these gaps and to gain an understanding of the work and views of established migration and health researchers across different regions.

Download the MHADRI Scoping Exercise Summary.


MHADRI scoping exercise with established migration & health researchers

This project aims to identify and map existing gaps in migration and health governance, research, and access to resources, in order to determine how MHADRI can play a role in addressing these gaps and to gain an understanding of the work and views of established migration and health researchers across different regions.

Drawing on conversations with leading migration and health figures, a summary of the findings will be shared with members of the network and the MHADRI steering committee may seek to publish a short commentary piece.

Interviews were conducted with leading migration and health figures in order to better understand and draw attention to migration and health governance and research challenges in the global south. While a number of commonalities can be observed across the responses of interviewed migration and health researchers, the interviews also brought to light various opportunities and obstacles that are specific to different national and regional contexts.

Interviewed researchers were, on the whole, optimistic about the potential for the MHADRI network to address some of the gaps and challenges discussed and feel that the network has an essential role to play in furthering the migration and health agenda internationally.

This project was designed and carried out by MHADRI Research Assistant Holly McCarthy under the supervision of MHADRI Vice-Chair Jo Vearey, PhD during a two-month internship at the African Centre for Migration and Society (ACMS) at the University of the Witwatersrand in Johannesburg, South Africa in October-November 2018.


Objectives

  • to map what is accessible and available in terms of migration and health data and research
  • to identify gaps in migration and health research across different regions
  • to collate the views of leading researchers on pressing migration and health governance issues in their region
  • to identify how the MHADRI network can play a role in addressing the gaps and challenges mentioned

Discussion topics

Researchers* were asked questions relating to:

  • their current role and migration health research focus
  • migration and health research and gaps in their region of focus
    • how they access and share resources, data and research related to migration and health
  • migration and health governance challenges in their region of focus
    • the strengths and limitations of multilateral action on migration and health issues i.e. Global Compacts
  • their involvement in migration and health networks and forums
  • how they influence migration and health governance and participation in advocacy work
  • their reasons for joining MHADRI and their hopes for the future of the network

   *Migration and health researchers who were interviewed for this scoping exercise are referred to as researchers.


Interviewing established migration & health researchers

Taking the MHADRI membership list as a starting point, potential interview subjects were selected based on their research interests and position as established researchers in the migration and health field in different parts of the world. With the exception of an interview conducted with MHADRI Chair Dr Chuck Hui who is based in Ottawa, Canada, all researchers have a focus on migration and health issues in low-middle income countries – a portion of states and regions commonly referred to as the global south. Researchers based in, or focused on, global south contexts were targeted in order to capture much-needed reflections on the state of migration and health research and governance challenges in regions usually underrepresented in global discussions.

An invitation email and corresponding letter were sent out to each potential interview subject in early October, outlining the scoping exercise and inviting researchers to take part in a 30-minute interview. Several migration and health researchers who are not yet members of MHADRI were also sent a similar invitation email and letter which included additional information about the MHADRI network and how to become a member. A follow-up email was sent in mid-October encouraging researchers to participate. Of the 23 potential interview subjects contacted (including eight non-members), eight researchers agreed to participate and two declined due to personal reasons and scheduling conflicts. The remaining 13 did not respond.

As of the 30th of November, 2018, eight interviews had been conducted with seven MHADRI members and one non-member. Of the eight researchers interviewed, four are men and four are women.

The countries – and broader regions- represented by the interviewed researchers include: Bangladesh, Sri Lanka, Nepal & South Asia, Uganda & East Africa, Bosnia and Herzegovina, Vietnam, Canada and South Africa.

Interviews were conducted via Skype or Zoom and were recorded with the consent of researchers.


RESEARCHERS INTERVIEWED

Dr Kedar Baral
Professor of Public Health & Director of MA of Public Health (MPH), Patan Academy of Health Sciences, Kathmandu, Nepal

Dr Paul Bukuluki
Member of MHADRI steering committee
Associate Professor, Department of Social Work and Social Administration, School of Social Sciences,
Makerere University, Kampala, Uganda

Thea de Gruchy
Doctoral Researcher, African Centre for Migration and Society (ACMS),
University of the Witwatersrand, Johannesburg, South Africa

Dr Charles ‘Chuck’ Hui
Chair of MHADRI Steering Committee and founding member
Academic clinician, Chief of Infectious Diseases at the Children’s Hospital of Eastern Ontario, Assoc Prof. in the Faculty of Medicine, University of Ottawa, Canada

Hassan Imam
Managing Director of DEVCOM & independent migration and health consultant
Dhaka, Bangladesh

Dr Renuka Jayatissa
Head of the Department of Nutrition, Medical Research Institute of Sri Lanka
Colombo, Sri Lanka

Dr Khuat Thu Hong (non-member)
Founder and Director, Institute for Social Development Studies (ISDS),
Hanoi, Vietnam

Diana Ridic
Public Institute for Health Protection & Senior Psychologist in Mobile Team with the IOM
Sarajevo, Bosnia and Herzegovina


Migration and health research focus (Individual)

Researchers were asked about their past and present migration and health research interests. In many cases, researchers’ research focus has been significantly shaped by pressure and opportunities to study those issues connected to migration and health governance challenges in their region. Many researchers observed that state or regional interest in a particular aspect of migration and health governance determined the level of support and availability and funding for research, influencing their migration and health research activity.

Dr Chuck Hui, for instance, has only been active in the migration and health sphere for five years. As migration to Canada has steadily increased, Chuck has begun to see more and more migrants through his infectious disease work, encouraging him to change his focus to migration and health. His contributions to migration and health research and governance, however, fall into two main categories. Firstly, the shaping and building of guidelines for various countries and regions to improve migration and health responses, and secondly, research on immunisation and vaccine-preventable-diseases in migrants.

Dr Paul Bukuluki’s migration and health research has focused on access to health care and sexual and gender-based violence experienced by migrants in Uganda and neighbouring countries. However, he acknowledges that in recent years, with the presence of large number of internally displaced people (IDPs) and refugees in the East African region, his research focus has been increasingly directed towards studies concentrated on forced migration.

Similarly, psychologist Diana Ridic’s personal research interests involve studying the mental health of cross-border migrants in relation to post-migration factors. She is interested in unpacking

when we actually accept the migrants, how are they accommodated in our context and settings? And what kind of post-migration stressors are present in our society? And how can they deal with these kinds of issues and problems?

Diana Ridic

However, despite her interest in the post-migration phase, Diana is pressured to focus on the ‘humanitarian crisis’ at hand in Bosnia and Herzegovina, looking instead at the primary health needs of migrants arriving, and the mental health of those still in the ‘journey’ phase.

Other researchers’ initial interest in migration or health has evolved into a migration and health focus over time. Dr Kedar Baral began his interest in migration and health with a focus on internally displaced persons (IDPs) in Nepal but this focus later shifted to research focused on HIV/AIDS with relation to the movement of “India-going” migrants. In recent years, Kedar has been investigating the health risks and challenges for Nepali labour migrants moving to middle-income countries, especially in the Middle East and South Asia.

Doctoral researcher Thea de Gruchy has, until recently, focused exclusively on migration and has only recently begun looking at responses to the health of migrant farmworkers along the South African border with Zimbabwe, research which involves thinking through implications for migration and health governance, policy and programmatic responses.

While Dr Renuka Jayatissa has always conducted nutrition and public health-related research, her interest in migrant health began last decade when she studied the health of internally displaced populations in Sri Lanka after the tsunami disaster. While Renuka has primarily focused on the health of internal migrants – including those forced to move to due to the civil conflict in Sri Lanka- in recent years she has begun researching the health of external migrants too.

Migration and health consultant Hassan Imam has been working with migration and health issues for more than 20 years, with a particular focus on migrant workers and health as a human rights issue for those affected by migration. He has been involved in research, capacity-building and communications across the migration and health field and has collaborated with the IOM, the ILO and various UN agencies in addition to his ongoing work with local organisations and ministries in his home country of Bangladesh.

Despite her interest in the relationship between migration and health, Dr Khuat Thu Hong’s research focuses on migration in general with health being just one aspect. Hong’s past research has engaged with issues relating to gender, sexuality, marginalisation and social inclusion but she is interested in incorporating health to a greater extent in her future research. Hong started her focus on migration in 2005 on projects predominantly focused on rural-to-urban migration. Hong’s recent research has looked at the difficulties that internal migrants face in accessing health services once they have moved to urban centres from rural areas, especially those employed in the informal sector who are not covered by health insurance.


Migration and health research focus (regional)

Low-middle income countries, certainly the global south, are poorly represented in migration health research. A lot of people who migrate for labour-related reasons are [also] under represented. A bibliometric analysis that was done shows a disconnect between flows of people and the research… most of the research is done in high-income destination countries of the West, and does not reflect the sending countries, nor the global south and low-middle income countries.

Dr Chuck Hui

As explained by Dr Chuck Hui, there is an imbalance in the migration and health research being produced globally, and often the largest categories of migrants, such as labour migrants, in regions with the highest levels of migration, such as East Africa or South-Asia, are underrepresented in migration and health research. Researchers observed that the migration and health research focus in each country appears to be correlated with the level of attention the state is paying to regional migration and health challenges.

For example, Hassan Imam’s focus on migration and health was made possible by the availability of funding and opportunities relating to research relating to the sexual health of migrants at a time when the government of Bangladesh was concerned about HIV/AIDS. However, these days Hassan feels that the migration and health focus in the region is not reflective of major migration and health issues, and research on the occupational health and safety risks for labour migrants crossing borders is significantly lacking. When asked about why he was less able to focus on migration and health issues in recent years, Hassan explained that

the problem is that my work is related with existing opportunities. The organisations are mainly focusing on migration, human rights, recruitment … but few organisations are focusing on the health issues of migrant workers.

Hassan Imam

Diana Ridic explains that health research that does exist in Bosnia & Herzegovina is often profit-driven, aimed at finding ways to reduce costs for health care providers and health insurance firms. When it comes to migration and health research, Diana observes that, given the influx of migrants in recent years, very little research on is being completed as energy is being given to responding to the ‘humanitarian crisis’ of migrants entering Europe. Resources and personnel from various international agencies, government initiatives are non-government organisations are being allocated to help manage the ‘crisis’ and while research isn’t the main priority, Diana believes that many of these actors are also collecting data while they are delivering help. Diana feels that analysis of this data is essential to improving present and future management of migration and health challenges. However, at present, there is neither the funding, nor the interest, to enable this type of research. Diana explains that the lack of funding opportunities for research is not an issue unique to the migration and health field, and in fact, since the Bosnian war in the 1990s, there are few active research institutes in Bosnia &Herzegovina. Diana adds that any migration health research that is being conducted is often linked to international agencies or external institutions, and Bosnian researchers associated with these projects are often only responsible for the Bosnian component of large-scale studies and are not steering them.

In South Africa, as Thea de Gruchy describes, migration and health research is largely focused on expanding access to healthcare and understanding barriers that different groups experience in accessing this care. Thea feels that in South Africa, compared to other regions, there is a greater emphasis on, and awareness about, the link between migration and health. This, coupled with the fact that access to healthcare is a significant issue for not only migrants (cross-border and internal) but also for local South Africans, means that research is largely focused on questions of access which, while positive, means that other aspects of the relationship between migration and health are often overshadowed.

When it comes to cross-border migrants, Vietnam is a major sending country to destinations across Asia such as South Korea, Taiwan and Japan, however the majority of migration research in Vietnam is focused on the mobility and migration of Vietnamese internal labour migrants moving from rural areas to urban centres. Dr Khuat Thu Hong is, at this stage, unaware of anyone conducting research specifically focused on migration and health in Vietnam, and thinks the link between these two topics lacks much needed attention. While the United Nations (UN) has conducted some research on the challenges faced by internal migrants in Vietnam, this was not specifically focused on health.

Here we don’t have much research focused on migration, and that focused on migration and health is almost none. I think the link between migration and health needs to be further researcher in Vietnam. We would love to learn from other regions about how this topic can be explored and studied.

Dr Khuat Thu Hong

Dr Renuka Jayatissa feels that there is a need for research in Sri Lanka – and South Asia more broadly – that is specifically focused on the health of those affected by migration, as including migration as a variable in broader health studies is insufficient. She stresses the importance of not only looking at the health and wellbeing of those who migrate, but to monitor the health of children-left-behind and the grandparents who care for them.

As the number of internally displaced persons (IDPs) and refugees has increased in East Africa, Dr Paul Bukuluki observes that the major migration and health research focus has become refugee health and the challenges relating to health access for those forced to migrate. However, Paul is concerned about this narrow focus and the lack of data available on the health of adolescents (10 to 24 years old), for instance, across different migrant populations.  Paul expresses difficulty in finding data on adolescents across various groups such as mobile populations, refugees and internal migrants, particularly in relation to those living in urban environments and believes that migration and health research should cover a broad range of age groups, populations, and health issues.

Researchers’ responses also reveal an overall lack of recognition of the importance of investing in migration and health research, and point to a need to consider migration in public health planning, and the necessity of factoring health into migration management.

Taking this idea one step further, Dr Kedar Baral advocates for a much more “holistic” approach to migration and health research.

We need to look much more holistically rather than focusing on small areas. The vulnerability arises from different contextual factors, and exposure to different environments, people, language […] [which all] impact on health.

Dr Kedar Baral


Kedar also stresses the importance of understanding migration and health issues as connected to the different stages of the migration cycle – before departure, during travel, the destination and, possibly, return. There are numerous challenges in need of addressing but Kedar reasons that

if we really want to address the issue, we need to focus at the beginning, those source countries or source communities, and ensure that [we know] […] what are the prevalent diseases or conditions that regional area is having.

Dr Kedar Baral


How and where researchers find migration health data and research

I see very little [data and research on migration and health]. To be honest, up until now, my knowledge on research in relation to migration from source countries to destination countries is very, very little. We are taking human beings as a kind of object, to produce economic productivity, rather than considering them as human beings, treating them as human beings, considering their wellbeing. Including source countries … they are not preparing. [Source countries] have to prepare [migrants] and this is the area that we need to research – stakeholders, policy makers, agencies, [everyone]
Dr Kedar Baral

Researchers each used different methods, repositories and networks to access data and research about migration and health yet many researchers are frustrated by the fact that information relating to migration and information relating to health are studied, and stored, in siloes.

In Bosnia and Herzegovina, Diana Ridic visits the medical archives to access health data though, unfortunately, the statistics are often presented in their raw form and haven’t been summarised. However, since Diana focuses on psychological health – which is often based on qualitative data – she usually collects much of her own data. When looking for up-to-date numbers on migrant populations and the routes that people are taking, Diana visits the government bodies responsible for migration matters. The Public Institute for Statistics also keeps some basic data, and the Service for Foreigner Affairs collects demographic data on the gender, status, and movement patterns of migrant groups, though this data is not connected to anything medical. Diana often uses correlations she finds between migration data and public health data as a starting point due to the lack of data available on migration and health.

Hassan Imam also finds migration and health data, research and resources “sporadically” as there is no central system presently available. He turns to major agencies working with migrants in order to find information.

Though demographic and health (DHS) surveys in Sri Lanka collect useful data, for those studying migration and health this resource is relatively limited as the DHS doesn’t factor in migration or mobility. Dr Renuka Jayatissa feels that if the DHS surveys were to consider migration then it could be a valuable resource for scholars in this field.

Dr Kedar Baral is also frustrated with the data available in his context. “For Nepal, if I want to [find data] I have to go to Labour Ministry, they have very fundamental demographic data [with which] there is nothing much we can do, it is very basic.”

The International Organisation for Migration (IOM) and the United Nations High Commission for Refugees (UNHCR) have some data available on migration and health in East Africa, but Dr Paul Bukuluki admits these are mostly small-scale studies. For Paul, universities and independent organisations can be a useful source of data, as they commission and release research that is not linked to national or international agencies. Paul reviews content published in journals and on websites that focus on migration and health, and keeps an eye on publications from the UNHCR, the Ministry of Health in Uganda and the East African Community (EAC) relating to his research interests.

In order to find data and resources, Dr Khuat Thu Hong relies on United Nations Population Fund (UNFPA) and content collected by the research institute where she works. Hong explains that social media is an effective channel for communicating information and their research institute ISDS disseminates information and resources through its website and Facebook page for others who might be looking for migration data and research. However, she feels there is an urgent need for increased data and research sharing between regions.

A challenge in staying up to date with research published in the migration and health space relates to the fact this area of scholarship is incredibly diverse. Dr Chuck Hui explains that this is a strength but also a weakness, as work is often conducted in siloes. There are many different actors in this space – people who focus on diseases, those who embrace the social sciences perspective, others who consider the global health security point of view – but there is a lack of communication and understanding about other work being done. Chuck uses Scopus and other peer-reviewed literature databases to find the research he needs. He mentions that conferences and the sharing of resources between contacts can also be a valuable tool, however, these conferences can sometimes reflect certain biases and reify an imbalance in whose voices are heard when it comes to commentary on migration and health issues, and this has an impact of whose resources are being shared and where they are coming from.

Others, like Thea de Gruchy, simply search for relevant research via Google and Google Scholar instead of accessing established migration or health databases, supplementing these searches with content which has been forwarded to them by colleagues. Thea has set up Google Scholar alerts to notify her when research related to her topics of interest are published and uses Twitter, Facebook and mailing lists to stay up to date with relevant research. Statistics South Africa (STATSSA) do publish reports, and there are certain sites that host useful data, but Thea uses search engines to land on these pages, and doesn’t target specific repositories or data bases.


What is needed to overcome barriers to accessing data and research?

Researchers outlined the various barriers to accessing migration and health data and research and connected them to the siloed nature of migration health research, an imbalance in knowledge production between the global north and global south and the issue of pay walls and subscription fees.  Suggestions were put forward by researchers on how to overcome these barriers, to improve access to quality and relevant migration and health data and research. The possibility of a centralised database was raised by several researchers, with emphasis placed on the need for a home where data, resources and research – specifically focused on the intersection of migration and health – can live.

Dr Paul Bukuluki explains that for many migration and health scholars, access to journals and reports is often obstructed by a pay wall, meaning that access is determined by the wealth of universities who must pay subscription fees, something Paul believes affects global south institutions to a greater extent than their global north counterparts.

“This is a very big barrier. Most of our master’s and PhD students interested in the area of migration and health are doing studies on this, but getting peer reviewed literature, information on current debates is a real challenge because of this.”

Dr Paul Bukuluki


A major barrier to conducting the kind of research Diana Ridic feels is necessary is the lack of access to essential tools such as SPSS software – Statistical Package for the Social Sciences – which her current employer has failed to pay the subscription fee too, limiting the capacity of her team to engage in proper research. Diana and her team have pooled together to buy one subscription to share between five researchers, but she explains that this is just one example of the lack of investment in research in the Bosnian context.

Dr Chuck Hui points to a lack of partnerships between high-income and low-middle income countries, and a need for more north-south partnerships to encourage working together to consider all aspects of the migration journey as well as reinforce the framing of migration as a process cyclical in nature. Chuck states that the global south is underrepresented in research generally, not only in migration and health, and this is a key reason for the imbalance in the data and research that is available. Not only that, but often the data available is only linked to migration or health which is a major limitation for migration and health researchers.

“There’s lots and lots of data out there, but the question is ‘is it helpful data?’ Does it have the appropriate data variables we need to do a correct analysis? For example, many different countries have migration-related data, but within that they often don’t have health-related data. There are many big data repositories in many different countries that have health data, but they don’t have migration data in there. They can talk about all the people with TB in a country, but migration is not a variable so you don’t know how big or small that issue is.”

Dr Chuck Hui

Dr Renuka Jayatissa explains the current difficulty in finding, and gaining access to, relevant peer-reviewed literature on migration and health issues.

Sometimes when you are searching it is very hard to find [what you’re looking for]. I know I have a half paper sitting on my computer, which I have not been able to complete, but it is very difficult to find the literature. So sometimes you do the work but you get stuck with the discussion because you can’t really find much literature for that.

Dr Renuka Jayatissa


However, Renuka is confident that a central database could address some of these barriers.

It’s a very good idea to have a kind of central database, at least some abstracts or something, so it is easier for people doing migration-related research so they have more access, that would be a great idea actually.

Dr Renuka Jayatissa

Dr Kedar Baral, too, is eager to see a central database established, believing it could significantly improve access to quality migration and health resources.

I think we should have an identified database that should be utilised, and that will really help to generate knowledge […] so that those who are interested, with an academic background, can generate knowledge from that and that can be translated into a [database] to improve the health and wellbeing of migrant people.

Dr Kedar Baral

In order to improve access to data and resources and information sharing about ongoing research, Hassan Imam also recommends establishing a central repository under the mandate of the UN or the IOM so that it can be connected to international agencies who are not tied to specific national contexts and who have an established interest in migration and health issues.

Thea de Gruchy thinks that a content aggregator around migration and health data and research could be interesting, as a way to address the fact that migration content and health content are often kept in spaces that don’t overlap. She suggests the creation of a newsletter or blog space that actively searches for and shares research, projects and advocacy work from different regions, connecting them with a central theme, which could be more useful than what is currently available.

“Aggregating that type of content, bringing it together, and packaging it in a way that’s more consumable…that would be something I would follow more closely.”

Thea de Gruchy


How improved access to data, resources and research will help

Researchers were, on the whole, optimistic that improving access to data, resources and research will assist with addressing migration and health governance challenges and will ultimately strengthen the migration and health field, bring researchers from different parts of the world together.

In Sri Lanka, Dr Renuka Jayatissa explains,

it’s much easier to inform policy action and convince people when you have strong evidence, otherwise it can be dismissed as a ‘perceived’ issue.

Dr Renuka Jayatissa

In the 20 years Renuka has been working as a researcher, she has found that no one argues with the evidence and if migration and health challenges are to be taken seriously and acted upon, then compelling data needs be collected and shared. Improving access to existing data and research has a key role to play in this.

This aligns with Dr Kedar Baral’s belief that once there is a central migration health database, pressure can be placed on those in charge of migration and health governance to invest resources into labour migrants who are contributing to the economy of the destination country. Furthermore, through the use of the database, research supporting the need for improved health access for migrants living in other countries can be used to enhance advocacy around the health rights and needs of cross-border migrants. In this way, increased access will help to push for greater investment in the wellbeing of migrant populations.

Increased data, resource and research sharing can also assist in addressing the needs of internal labour migrants who have difficulty in accessing health care by improving research and understandings of the relationship between migration and health. Dr Khuat Thu Hong believes this could provide opportunities to learn from other migration and health researchers, to see how research is conducted and what kinds of issues are raised and to learn how to better advocate for the health rights of those affected by migration.

The immobile nature of health data and the fact that migration is rarely a consideration is, for Dr Chuck Hui, a key migration health management issue that needs to be addressed.

For example, the [European Union]. There are multiple publications which have said that the health sector does not look at migration data at all as a variable. Whether somebody moves from a country within the EU, or moves from a country outside of the EU, how long they have been in the country, what type of migrant they are… the fact that they don’t have [this information] is a huge problem.

Dr Chuck Hui


Diana Ridic, seconds this, problematising the management of public health as domestic policy rather than something which neighbouring countries should collaborate on. The containment of health data of mobile populations within national borders complicates continuation of care, especially when it comes to mental health.

For example, when [migrants] are arriving they are losing inoculation cards for vaccinations. You cannot [know if] they are vaccinated in Greece, Serbia or Bosnia, so we are often doing re-vaccination. It would be great if we could share that medical information, [though] it can be tricky because of the privacy issues. When I have [notes] from a doctor or psychiatrist in Greece, it can be help me in the field when I am [treating people] if I already know that they are dealing with some issues, and they have some particular medicines they are taking. I can be more efficient.

Diana Ridic

However, Dr Paul Bukuluki reminds us that improving access to research and data on migration and health will not alone be enough to address migration and health challenges. Paul suggests that exchange visits between different countries and institutions implementing effective migration and health governance, combined with the distribution of best practice examples of how migration and health challenges can be managed, is essential to improving health for all.

Knowledge alone is not enough. We need more than knowledge to shift the norms, because policy is influenced by social norms.

Dr Paul Bukuluki


Global compacts & multilateral cooperation

It’s such a political realm [when you talk about migration and health] at that kind of level. I have been at those meetings, behind the doors…in the end it really is a political venture that has little to do with the data or the evidence, it has to do with how you’re able to leverage this or that to move a certain agenda forward. It’s great to get certain things into these global documents, but how it is received and how it is executed is variable.

Dr Chuck Hui

While researchers pointed out varying strengths and weaknesses of the Global Compacts – on Refugees and on Safe, Orderly and Regular Migration – when it comes to improving international migration and health governance, a common concern related to the vagueness of the Compacts and the apparent absence of necessary tools for their practical application.

Dr Renuka Jayatissa feels that the Compacts are important for encouraging action on migration and health issues as they “refresh a focus” on migration as a topic in the government and promotes discussion. She explains that sometimes governments can be very monotonous and “go in a uniform direction, so it is good when [international collaborations] bring the new ideas to reimagine and restructure our programmes.”

However, for Renuka, the limitations include that the Compacts are “trying to influence countries unnecessarily,” sensing that the scenarios discussed in the Compacts might be happening in some countries, but not in countries like Sri Lanka. She argues that implementing action to address issues that are not experienced by all countries is unnecessary and that the one size fits all approach is a significant limitation.

Dr Paul Bukuluki, too, believes that the Global Compacts lack “tools for adaptation” and guidelines on how to apply them at the local level. He suggests the inclusion of case studies which illustrate how the statements made in the Compacts can be adapted and implemented into realisable policy, something he feels would improve their relevance and effectiveness.

“The issue [with the Compacts] is that they are Global, they suffer from [a lack of] context specificity, they need adaptation to [different] contexts. Yes, it is ok to think globally, but you need to act locally. The adaptability of the compacts is one issue, because there is no one-size-fits-all solution and not enough is being done to adapt them to the local contexts of different countries.”

Dr Paul Bukuluki

While Dr Kedar Baral acknowledges that “[multilateral forums] are extremely important to bring the migration issue up to the [international] level”, he observes that the Compacts seem more preoccupied with the interests of receiving contexts, and is concerned that the public health responsibilities of destination countries are not explicitly outlined.

When you talk about migrant rights, or health rights, it is not clearly articulated in the document what would be the role of destination countries. For example, Bangladesh is a low HIV prevalence country, but if you look at the data more than 70% of people living with HIV are either migrants or a member of their family is a migrant. How did this happen? Healthy migrant workers who migrate from Bangladesh are getting HIV in the destination country, but when they return home Bangladesh is taking responsibility for the health care of the migrant workers, but there is no responsibility of the country of destination. I expected that the responsibility of the countries of destination should be clearly reflected in the document, but I found that was missing.

Dr Kedar Baral

Hassan Imam identifies multilateral forums as essential tools for less influential countries like Bangladesh to raise their voice. He explains,

Bangladesh cannot depend on bilateral agreements only. For example, we have Memorandums of Understanding (MOUs) with countries like Saudi Arabia but they are powerful politically and Bangladesh is not so powerful. So, when the problem is happening at the country of destination, the Bangladesh government cannot strongly negotiate with governments like Saudi Arabia [in the way it’s more powerful Asian neighbours can]. When the GCM is there, Bangladesh is getting the opportunity to raise these points at the multilateral forum. That’s why the GCM is definitely very important for Bangladesh… but it has to be legally binding for all countries somehow. Otherwise it will not be effective.

Hassan Imam

While less familiar with the content of the Compacts themselves, Diana Ridic also holds high hopes for the potential for multilateral collaboration to improve government action on migration, and subsequently migration and health, issues.

I actually think that only multilateral cooperation can help us [to address migration and health challenges in Bosnia].” It was very useful for me to [learn], for example, from the doctors in Greece, in Cyprus, in Istanbul [about their work with migrants and the challenges they face and the methods they are using].

Diana Ridic

However, several researchers interviewed perceived that the Compacts were ultimately serving the interests of high-income receiving countries rather than the health and wellbeing of migrants. For example, Thea de Gruchy spoke about debates held with her colleagues at the African Centre for Migration and Society (ACMS) about whether the Compacts are in fact using health as a smokescreen, disguising a push towards securitisation and the tightening of borders.


Migration and health governance challenges

Conversations with researchers revealed that each region has their own migration and health governance challenges and responses, however there were some common issues raised. The way in which access to health services is organised appears to be a common barrier for migrants – both internal and external – across various contexts, and other common governance challenges related to a diffusion of responsibility – with neither the sending nor receiving countries addressing the needs of cross-border labour migrants. Most researchers also discussed the lack of acknowledgement by governments of the link between migration and health as a barrier in addressing migration health challenges.

When discussing the key migration and health challenges in his region of focus, Dr Paul Bukuluki named the porous nature of borders in East Africa as a significant challenge when it comes to migration and health governance. Cross-border issues were seen as the most critical, as the informality and lack of policing along borders complicates public health management. Discrimination experienced by migrants attempting to access health services in other areas is also a pressing issue and Paul explains that as a Ugandan, he would have difficulty accessing health services in, for example, Rwanda, as he does not have the health insurance that Rwandan citizens require to access health services. Paul believes that addressing the lack of portability of health insurance is essential in a region characterised by mobility and migration.The lack of mobility of health insurance is also a problem in Vietnam, Dr Khuat Thu Hong explains.

Health insurance is linked to residential registration, so those who migrate from one place to another cannot use their insurance – if they have it.

Dr Khuat Thu Hong

Hong believes that access to health services for internal rural-to-urban migrants is the most pressing migration and health governance issue in Vietnam since health services are very expensive, and, due to the way health insurance is organised, those migrants who have moved to urban areas for work often have to pay an increased cost to access care when outside of the regional area where they are registered. The high cost of accessing health services often leads people to purchase medicine for themselves without consultation with a doctor, and can deter them from taking action to address health concerns.

In Bosnia and Herzegovina, Diana identifies a “lack of money and resources for delivering proper help to migrants” as one of the most pressing migration and health governance issues to be solved. The convoluted health care delivery system further complicates public health management, with Bosnian citizens themselves experiencing significant barriers in accessing necessary health care, making the health access landscape even more difficult for migrants to navigate.

Dr Renuka Jayatissa, while optimistic about the state of migration and health governance in Sri Lanka, is concerned about the effectiveness of current migration and health policy and programmes, and thinks that monitoring and evaluation of existing programmes should be carried out. She feels that a monitoring and evaluation framework is the key aspect missing from migration health governance in Sri Lanka.

 I think, governance-wise, there are so many regulations, rules and facilitations and all these things are there but I really do not know to what extent these things are implemented and to what extent those people are receiving all these services. Centrally-wise, the government is very keen and they have developed all these regulations and facilitation process and everything, though there may be a lot of implementation lapses.

Dr Renuka Jayatissa

Hassan Imam observes that occupational health and safety of migrant workers is a major governance issue in need of addressing urgently. He explains that when people migrate from their Bangladesh – and other low-income countries – they are often unaware of the realities of working in the destination country and there is a lack of training and orientation available before people migrate. Hassan also feels that not enough is being done to manage the mental health of migrant workers returning to their country of origin. Despite the high rates of suicide linked to issues migrant workers experience in ‘re-integrating’ these issues have never been addressed by any service providers or government initiatives.

Dr Kedar Baral names the lack of information available for migrants at the destination as a concerning issue relating to the wellbeing of Nepali labour migrants working abroad. He argues that improved access to information about health risks at the destination, where to find hospitals, and how the health system works and so on, is essential for those who are newly arrived. He seconds Hassan in his belief that occupational health and safety at the destination country is a huge gap that needs to be looked into, especially since many popular destination countries prioritise provision of health care to citizens.

For Thea de Gruchy and many migration and health scholars working in the South African context, the most pressing migration and health governance issue in South Africa is simply about getting migration recognised as something that needs to be considered when we talk about health, especially with the continued push for national health insurance.


Advocacy and influencing migration and health governance

Researchers all felt that it was important to use their knowledge and awareness of migration and health issues to advocate for increased consideration of migration in public health policy and planning, and for an increased focus on health when managing migration. Many researchers used their position as experts to raise awareness about migration and health governance issues and call for a greater allocation of resources towards migration and health as a means to improve health and wellbeing for all.
Hassan Imam, as a migration analyst, runs training programmes and participates in numerous migration-related and health-related workshops, and he uses these platforms to raise migrant health issues. Hassan has been conducting training with different agencies and government ministries to draw attention to the health challenges of migrant workers.

For the last 20 years I have been working with migration, and definitely I have a responsibility as a student of public health, so I think that these are the areas I should always raise whenever I have the opportunity.

Hassan Imam

Similarly, by engaging with policy makers and improving understanding of the health needs of migrant populations, Diana Ridic hopes to influence budget plans and the allocation of resources, having some input into logistics relating to the management of migration in Bosnia and Herzegovina.

Dr Kedar Baral explains that while his advocacy work isn’t very organised, he and his team are working with government, academia and civil society on migration and health issues, and are encouraging the inclusion of migration “in the medical school and in the school of public health […] [which] has to be inbuilt if we really want to address the part of the system response.”

Kedar believes that the inclusion of migration into medical and development faculties, will not only positively affect health service provision, but will strengthen advocacy in the long-term by building cross-sectoral advocacy partnerships. He adds that those being taught now are the people who will hold leadership positions in the future, so factoring migration and health into different areas of study is really “an investment for the next generation.”

Dr Paul Bukuluki, and his colleagues at Makerere University in Uganda, regularly engage with policy makers to communicate the importance of viewing migration and health as interconnected, emphasising the importance of factoring public health issues into migration management and governance. They collaborate across borders with other institutions and agencies in the migration and health space, and ensure that when they engage in projects there are actors involved who can take these projects forward and use the research to inform effective action.

Dr Renuka Jayatissa makes use of her position in the Sri Lankan Ministry of Health to draw attention to migration and health concerns.

Because I am working for the Ministry of Health, and I have access to all the committees, I can always raise my voice, even up to the President level. But usually we write to newspapers, run workshops, try to start awareness programmes and we also appear on television. Sometimes we try to leverage policy makers and sometimes we try to raise awareness with the general public.

Dr Renuka Jayatissa

In Vietnam, Dr Khuat Thu Hong and her team are pushing for the removal of the household registration system for national medical insurance so that people can move more freely and use their insurance regardless of where they choose to live. Since there are many internal migrants working in the informal sector, who come from rural areas and cannot afford to access health services, Hong advocates for improved health access for this group and for affordable insurance options for the already vulnerable. Hong believes the government and other organisations should support internal migrants and those in the informal sector to buy health insurance so that they can access healthcare regardless of their registered residence and involvement in formal or informal economies.

Dr Chuck Hui has an international focus, and hopes to be part of pushing the area of migration and health forward through the development of a common research agenda and building a network of migration and health figures where global south and early-career researchers are represented alongside established and global north researchers.  Chuck believes that the recognition of migrants as a heterogenous group who have a variety of health needs is essential to optimising health care access and provision for all.


Networks

Networks are a key tool many researchers use to access data and resources, and appear crucial for staying up to date with research conducted by others in the migration and health field. While many of the networks discussed in the interviews were informal in nature, these networks seem to be one the most valuable sources of information on migration and health matters.
Dr Kedar Baral, for instance, is involved with a number of local networks, such as the National Network for Safe Migration which is made up of lawyers, NGO workers and other advocates. Through these networks, Kedar is regularly invited to consult with NGOs and he uses his other connections in various ministries of the Nepali government to communicate the needs of grass-roots organisations to those making policy. Kedar observes that these networks are quite “fragmented”, but acknowledges that they play a critical role in bringing together those advocating for migrant rights, of which health access is one.

Diana Ridic meets others with research interests similar to her own through her work in the field delivering support to those working with arriving migrants at the border. She is a member of the Migration Group in Cognitive Behaviour Therapy and she collaborates with a network of GPs interested in promoting the health of migrants and refugees called M4H (Migrants for Health). She has contacts in the police, border police, the army, local and federal government, international agencies and NGOs and identifies her networks as essential to sharing information. Through these contacts, Diana receives recommendations for reading and is able to share ideas with fellow mental health professionals.  The connection to other psychologists and psychiatrists with a migration focus is a useful tool for not only informing and inspiring her own research aspirations, but for motivating Diana to see if certain phenomena – observed in other contexts – might also be present in Bosnia.

Dr Renuka Jayatissa explains that while there are official networks connecting migration and health researchers in Sri Lanka – through the IOM and The National Science Foundation, for example – the unofficial networks are just as valuable. When it comes to staying up to date, Renuka explains that “within the Ministry of Health we have a very good networks, and if anyone is doing research within the Ministry we will get to know.”

For Renuka, her involvement with the IOM and MHADRI has played a major role in connecting migration and health figures outside of Sri Lanka.

It was very good exposure, it helps you realise you can do more, it’s nice to share knowledge and to see what research others are doing and see how you can do the same kind of research in your country. It’s very useful to learn from each other, and then we can compare and improve together.

Dr Renuka Jayatissa

Hassan Imam explained that his network of migration and health colleagues is largely thanks to his connection to the organisations CARAM Asia (Coordination of Action Research on AIDS and Mobility) and MFA (Migrants Forum in Asia). Hassan finds out about migration and health research through the individual contacts he knows through engagement with events organised by such organisations, enabling him to connect “with researchers from every country – Bangladesh, India, Philippines, Sri Lanka, everywhere you will find people– they have experience working on migration and health issues.”

Dr Khuat Thu Hong is part of MNET, the Migration Network, an independent Vietnamese network of groups working on gender and broader health challenges experienced by migrant groups. This network brings together NGOs, researchers and advocacy groups dedicated to implementing intervention activities that support migrants at a grass-roots level whilst advocating for human rights. However, Hong says she is not aware of any other migration researchers in Vietnam, let alone migration and health.

At the moment, Vietnamese researchers have little access to connect to the international network [of migration and health researchers]. It is a good idea to further establish the MHADRI network to share information… to be able to learn from [others], to exchange our experiences and our information and to enable us to be connected.

Dr Khuat Thu Hong


Opportunities for early career researchers

Several researchers raised concerns about the lack of adequate opportunities available for early-career researchers to enter into migration and health research. Thea de Gruchy explained that, as an early-career, global-south-based researcher, she feels there is still a long way to go with the balanced representation of early-career researchers and researchers from the global south when it comes to conferences, forums, and publications. While Thea acknowledges that conferences are increasingly including more people from the global south and those starting out, the structures of these conferences are still in need of revision.

A lack of funding is also a significant barrier for early-career researchers in low-middle income countries. Diana Ridic shares that

if [early-career migration and health researchers in Bosnia] want to do something they have to travel around because you can always have some scholarship or [support] of your studies if you are in some kind of European fund or network. But if you are [working individually] or staying in Bosnia, you cannot find anything because there is, I would say, zero means for that kind of research.

Diana Ridic

Dr Kedar Baral shares similar frustrations and when asked if there were many opportunities available for his master’s students in Nepal he answered

No, there is none. I’ll give you an example. I’m the Director of a master’s of Public Health programme, and one of my students actually wants to do a thesis on migration-related topics. She does not have funding, she has to travel, spend time, at least to have some level of support […] for stationary, food, travel, some accommodation. I have not been able to raise the money as yet. I’ve not been able to attract the resources that she needs.

Dr Kedar Baral

Dr Renuka Jayatissa is, however, optimistic about the symbiotic relationship that established and early-career researchers can engage in.

I think that for early-career researchers […] networks are really helpful. The can get involved, most of the time most [established researchers] are very busy with our work, so these early-career researchers can really start the activities then they can link all the busy people like us together.

Dr Renuka Jayatissa

Renuka believes that early-career researchers can, in this way, support migration and health research, and in return can receive mentoring from those with experience.


Why researchers joined MHADRI

Many researchers mentioned a desire to connect with, and learn from, other migration and heath researchers as the principle motivation for joining the MHADRI network.
Non-member Dr Khuat Thu Hong explained that she would like to become a member in order to learn more about how migration and health challenges are being researched, discussed and addressed in different parts of the world. Dr Renuka Jayatissa echoed this sentiment, and thought that networking and sharing knowledge is the necessary first step towards international collaboration on large-scale studies.

Diana Ridic hopes that by joining MHADRI she can meet peers who shared her focus on migration and mental health. Diana raises the importance of having colleagues to debrief and reflect with. For her, cooperation with other psychologists and psychiatrists, where questions can be asked and researchers can support each other, is something she is missing.

I am very eager to meet people who are dealing with [these issues] because I am actually feeling lonely sometimes here, and I have a lot of people who are younger, and they are using me as their supervisor on different issues of psychology. I want someone who I can share ideas with about trauma and issues with refugees, different techniques, and how we can implement them. Especially in the mental health context.

Diana Ridic

Others, like Hassan Imam, explained that the lack of opportunity and funding available for migration and health research in his region drove him to join the network in search of opportunities. Many were referred by others in their field, with several referrals coming through staff at the IOM.

Dr Chuck Hui, as a founding member of MHADRI, hopes to put people in contact with each other to facilitate the conducting of larger, international, multi-centred studies.


What members hope to see from MHADRI in the future

Dr Chuck Hui envisions that, in the future, MHADRI could be a

…community for people to network, to understand cross-platform, cross-discipline, to have people who are academics speak to civil society, to work with civil society, to work with policy makers in asking the appropriate questions, utilising the appropriate data, so that it actually affects change. Not research for the sake of research, but research for the sake of affecting policy.

Dr Chuck Hui


This sentiment was shared by Hassan Imam who believes that the most important function of a network like MHADRI, is to ensure that

…what we learn from the researchers and from the data base and other information sources can be brought to the migrants at the grass roots level.

Hassan Imam

Hassan also has high expectations for the MHADRI network to further migration and health research opportunities.

I’m optimistic that this network can definitely initiate some process to prioritise the issues for research work, that is one thing. Definitely this network can also initiate the process of research both region-based and country-based […] Not only is this about research… it’s about [equalising] the findings of researchers. There should be some sort of initiative from IOM or a network like MHADRI so that something like a central database can be established. We can connect it with government and stakeholders at country-level and regional-level.

Hassan Imam

Dr Kedar Baral thinks that the MHADRI network can play a pivotal role in advocating for greater resource allocation to global south contexts for research on migration and health. He would like to see more resources available on the site so that people can find material relating to their area of interest, which will increase people’s use of the network and hopefully foster collaboration and communication in the future. He envisions that with this increase in collaboration and communicate then more evidence will start to be generated which can influence policy dialogue at the international level.

Diana Ridic is hopeful that MHADRI can serve as a repository of work where suggestions for readings on certain topics can be listed and shared, and Thea de Gruchy thinks the network has a lot of potential to create a space where migration and health data and resources can come together.

MHADRI [could be] a resource, listing publications that you can search for by area or topic. It has great potential for circulating information. […] Because of the nature of migration and health research, you’re often plugged into migration networks and health networks, so it would be cool if MHADRI was a space that brought together migration and health.

Diana Ridic

Dr Renuka Jayatissa would like to see two things from MHADRI in the near future. Firstly, to make use of the knowledge and experience contained in the network

[members] could be very useful. We need to share technical advice and recommendations from the experts to mentor early-career researchers and inform more collaborative research between members.” Secondly, the instigation of at least one joint venture “to see the different aspects of [migration health challenges in] countries … to have some kind of comparison to see how we can improve migrant health.

Dr Renuka Jayatissa

Steering committee member Dr Paul Bukuluki would like to see MHADRI publish a review of key studies in migration and health; a compendium of different research ventures made up of abstracts. He suggests that the MHADRI website serve as a platform where migration and health scholars can find out about research, opportunities, projects and funding avenues. However, he advises that

MHADRI should not be too ambitious in terms of people joining. It should first of all have concrete products that can be shared with people outside, and then people can join based on that. Expanding membership without having products is the wrong way of going about it…We need to moderate our ambitions in terms of how many members we should have, and what we have to offer the members. I think that we are not yet ready to open up to a huge membership when we are still organising ourselves in terms of what to offer.

Dr Paul Bukuluki

Despite these reservations, Paul is optimistic about the potential for MHADRI to enhance representation of global south researchers.


In conclusion

This scoping exercise revealed a number of gaps in migration and health research, governance and access to resources and was successful in bringing to attention challenges that are specific to different national and regional contexts.

A number of common themes, however, can be observed across researchers’ responses, confirming a need to build and strengthen south-south partnerships to correct imbalances in knowledge production, barriers to accessing resources, and to improve the representation of global south researchers at international forums.

It is clear that MHADRI members are hopeful about the role such a network can play in addressing the challenges discussed, and are eager to participate in increased international collaboration.

 

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