Medecins du Monde’s (MdM) 2019 Observatory Report Left Behind: The State of Universal Healthcare Coverage

On University HealthCare Coverage day, Medecins du Monde’s (MdM) 2019 Observatory Report Left Behind: The State of Universal Healthcare Coverage in Europe is a timely reminder of the dismal health situation faced by many vulnerable groups in 7 EU countries; a region with a clear commitment to human solidarity and vast wealth.

This report presents a unique insight into the state of Universal Healthcare Coverage (UHC) in Europe and highlights those who are left behind in European health systems. The report gathers data and testimonies collected from 29,359 people (97.5% migrants) attending Médecins du Monde/Doctors of the World (MdM) programmes in seven countries in Europe (Belgium, France, Germany, Luxembourg, Sweden, Switzerland, and United Kingdom) between January 2017 and December 2018.

Find the report here: https://www.doctorsoftheworld.org.uk/wp-content/uploads/2018/11/DOTW_2019_lowress_alt.pdf

World Migration Report 2020

The International Organization for Migration has just published its 2020 World Migration Report. Read and download it here!

Chapter 7 of the report (“Migration and Health: Key issues, governance and current knowledge gaps”) was written by MHADRI steering committee members Jo Vearey (Vice Chair), Charles Hui (Chair) and Kolitha Wickramage (Secretariat).

“The World Migration Report 2020 presents key data and information on migration as well as analysis of complex and emerging migration issues. Some of the topics covered in the report include human mobility and environmental change, migrants’ contributions in an era of disinformation, children and unsafe migration, migration and health, among others.”

The Director General of the IOM addresses the goals of the report (and indeed of the IOM as an agency) in his foreword:

“As the United Nations’ migration agency, IOM has an obligation to demystify the complexity and diversity of human mobility. The report also acknowledges IOM’s continuing emphasis on fundamental rights and its mission to support those migrants who are most in need. This is particularly relevant in the areas in which IOM works to provide humanitarian assistance to people who have been displaced, including by weather events, conflict and persecution, or to those who have become stranded during crises.”

“Likewise, IOM remains committed to supporting Member States as they draw upon various forms of data, research and analysis during policy formulation and review processes. Indeed, this is reflected in IOM’s Constitution where the need for migration research is highlighted as an integral part of the Organization’s functions. The World Migration Report is a central component of this important function.

In this era of heightened interest and activity towards migration and migrants, we hope this 2020 edition of the World Migration Report becomes a key reference point for you. We hope it helps you to navigate this high-profile and dynamic topic during periods of uncertainty, and that it prompts reflection during quieter moments. But most importantly, we hope that you learn something new from the report that can inform your own work, be it in studies, research and analysis, policymaking, communication, or migration practice.”

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Policy Briefing: Migration and Universal Health Coverage in Southern Africa

Along with other partners, MHADRI participated in a high-level South African and regional policy roundtable held in Johannesburg, South Africa in July 2019. The following briefing outlines the key recommendations from the discussion.

Migration and universal health coverage roundtable


This policy briefing is based on a high-level South African and regional policy roundtable held on 31st July 2019 in Johannesburg, convened by the University of Witwatersrand, Chatham House, and the UCL-Lancet Commission on Migration and Health.  Thirty-five academics, policy makers and members of civil joined the roundtable which aimed to engage critical concerns regarding access to healthcare for internal and cross-border migrants as part of formulating an inclusive approach to the health of the South African population.

Key recommendations from the roundtable:

  • Migrant-inclusive universal health coverage policies need to be implemented by the South African government, including in the new National Health Insurance, to support wellbeing, livelihoods and sustainable development.
  • Cost effective early and preventative care for all migrant populations, regardless of legal status, is the most effective public health and development strategy.   Health goals including 90-90-90 targets and SDG goals cannot be met without inclusion of a largely mobile South African population and international migrants.
  • Regional and global partnerships should be built upon. Consideration of harmonisation and standardisation of policies, and action to realise interoperability of health policies,  systems and  programmes is encouraged.
  • There is a need to explore bilateral/tripartite solutions between countries.  There should be encouragement of sub regional entities such as SADC to have a greater role in supporting inclusion of migration and health.
  • An accountability framework  should be implemented  to support implementation of UHC and  encourage migration-aware planning and anti-xenophobic actions, this should include accountability to civil society.
  • Through inclusion of migrants in universal health coverage South Africa could be a leader in Africa in advancing the evolution of UHC and mobility.   

Migration and Health in South Africa

In 2019, the newly re-elected South African national government voiced its commitment to ensuring that quality health care be available to all citizens, with National Health Insurance (NHI) at the centre of policy development; strengthened by the constitution of South Africa (SA), which states: ‘Everyone has the right to have access to health care services’. NHI has great potential to address persisting health inequalities in SA, and in the process advance the UN and WHO goal of Universal Health Coverage (UHC).  However, as currently framed, the  NHI proposal means migrant and refugee communities will be left behind, with the rights of asylum seekers and undocumented migrants to access healthcare restricted. 

Labour migration has been central to the South African economy for decades. Today, around half of the national population is mobile (sometimes referred to as internal migrants), and failure to take account of such mobility and secure access to care has contributed to poorer health outcomes. An estimated 3-4% of the SA population – approximately 4 million people – are estimated to be cross-border (international) migrants, the majority of whom originate from elsewhere in the SADC region and include permanent residents, and those with work, study and spousal permits. International migrants have historically made, and continue to make, substantial contributions to the SA economy including the many branches of mining upon which national wealth was founded. UHC is dominating the global health agenda, particularly following the declaration at the high level meeting on UHC at the UN General Assembly in September 2019. SA is a focal point for discussing migration and health in the SADC region.  In order to effectively implement UHC, migrants must be explicitly included.

Universal Health Coverage and Migration in South Africa – Recommendations

The following policy recommendations were proposed during the roundtable in order to achieve Universal Health Coverage (UHC) in  South Africa (SA) which is inclusive of migrants:

1. Current practices in health service delivery and health policy

The current state of knowledge about migration is poor in South African policy and practice: migration has been framed as: a burden on healthcare resources, an affront to values, taking jobs from citizens, a challenge; rather than an opportunity.

Recommendations

R1. The multiple arguments supporting inclusion of migrants, including legal, public health, and  economic development should be highlighted, rather than relying solely on rights-based arguments.

R2. Recognition of the scale of internal mobility and the benefits is very important i.e. migrants are providers of healthcare services as well as consumers, therefore they are  integral  to the health system.

R3. There is a need for a national campaign on migration and the rights of migrants, including working with provinces and municipalities to support them in their mandate for health service planning for migrants.

R4. In order to integrate the goals of the constitution into health service delivery the values and ethics of health care provision need to be integral to health policy and part of health worker training.  To strengthen research and evaluation in migration health, training institutions should integrate the topic within their curriculum and training.

R5. Regional and global partnerships should be built upon. Consideration of harmonisation and standardisation of policies, and action to realise interoperability of migration health policies,  systems and  programmes is encouraged.

R6. There is a need to explore bilateral/tripartite solutions between countries in response to migration health challenges.  Good practice examples of regional responses exist and a renewed conversation is needed.

R7. Capturing population dynamics, particularly of internal mobility in SA,  should be a vital component of planning across all government departments, including local government , and can be supported by effective triangulation of data sources.

R8. There is a need for a multisectoral approach to gathering vital migration statistics, including cross-border referral systems. It is  critical that data is used to assist in planning and responding to both internal and cross-border migration; and  not used for surveillance.

2. Accountability and leadership to encourage inclusion of migrants in UHC

The SA state is taking an increasingly anti-immigrant position, with  a tension playing out between patriotism and pan-Africanism.  There  continues to be scapegoating of migrants for failures of state policy and the securitisation discourse portrays migrants as a threat to security.  Rising xenophobic rhetoric is rarely called out and therefore accountability structures fail.

Recommendations
R1. The UHC declaration on 23rd September 2019 at the UN General Assembly can help drive implementation towards UHC targets,  and inclusion of migrants, in SA.  Implementation of UHC within each regional context should be developed through strong collaboration between policy, academia and civil society.

R2. An accountability framework  should be implemented to support implementation of UHC and encourage migration-aware policy planning and anti-xenophobic action at all levels.  
R3. There should be more accountability to civil society and inclusion of varied sectors in discussions.  There is a need for political and societal champions to step forward with other key stakeholders and generate meaningful momentum to achieve truly universal health coverage in SA.  There should be encouragement of sub-regional entities such as SADC to have a greater role in supporting inclusion of migration and health.

3. Migration aware and mobility competent health care systems

In the region there is little detail or consensus on protocols for migration health; there is an urgent need for better cross-border coordination and interoperability of health services across the Southern African context.  Significant barriers to care and lack of information exist, even when there is a legal entitlement to access services. Likewise, there is daily  discrimination such as migrants being last in the row in a clinic or receiving verbal abuse.  Public health of migrants, and South Africans alike, requires that there be integration and access to care for all migrants.

Recommendations

R1. The development of migration aware and mobility competent systems is needed, including: addressing language barriers, providing translators, accessible information for both migrants and healthcare providers, ensuring health services respond to mobility of care both internally and across borders.

R2. There is a need to develop and implement effective strategies to support  providers in delivering their duty of care to all, including migrants.  This may include providing health services to mobile populations in transit points, or making use of outreach services. 

R3. Over half of South African citizens move internally, much of this work-related.  Recognition of this mobility needs to be integrated into the current health system and NHI reforms.  Inclusion of mobile and migrant groups into health care can lower public health costs, through opportunity for early intervention and increased immunisation rates. Available resources should support a NHI system that seeks to achieve inclusive UHC; however resource distribution is currently unequal.

R4. People should be able to access healthcare regardless of documentation to achieve health targets and to improve health for all populations. 

Policy briefing: Migration and Universal Health Coverage in SouthERN AfricaR5. There is a need to assess how best to use existing resources. Costing studies will help develop cost-sharing mechanisms and financing systems to enable effective regional responses to migration and health.

Migration and health in Southern Africa: regional symposium report

Regional Symposium on Gender, Migration, Health and Public Policy & South African Launch of the UCL-Lancet Commission Report on Migration and Health

This report captures a two-day programme of presentations, panel discussions and group discussions at the regional symposium on gender, migration, health and public policy. The aim of day one was to discuss a number of migration-related topics including: health and universal health care (UHC) in Southern Africa, researching migration and health, associated ethical and methodological challenges, and reflecting on the politics and practice of migration and health research. Day one also included the launch of the UCL-Lancet Commission on Migration and Health in South Africa.

Day 2 of the symposium focussed on ‘Gender, Migration, Health and Public Policy: Improving gendered responses to migration and health across the Southern African Development Community (SADC)’. The aim was to present feedback from a research report on gender, migration and health and to develop a joint plan of action amongst stakeholders and participants for improving gendered responses to migration and health in SADC.

[originally published by Sonke Gender Justice]

Towards inclusive migrant healthcare

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4256 (Published 16 September 2019)

Denise L Spitzer, Sara Torres, Anthony B Zwi, Ernest Nene Khalema and Erlinda Palaganas

“Although the underlying political, economic, social, and environmental factors that lead to migration must be dealt with, we have an obligation and opportunity to support the health and wellbeing of migrants.

Health is a human right that transcends borders and juridical categorisations. Improving the wellbeing of the world’s migrants requires an intersectional lens that focuses on the diverse circumstances and locations in which migrants are situated. Empirically informed, community centred, culturally adapted intervention models that involve migrants will advance their healthcare”
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Healthcare is not universal if undocumented migrants are excluded

Helena Legido-Quigley, Nicola Pocock, Sok Teng Tan, Leire Pajin, Repeepong Suphanchaimat, Kol Wickramage, Martin McKee and Kevin Pottie

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4160 (Published 16 September 2019)

“Although migration is high on the international policy agenda, there is scant research to inform policy. Research on migration and health is concentrated in high income countries that have been relatively unaffected by the large migration flows among countries in the global south. Migrants in different areas will have particular health needs, owing to previous experiences in their countries of origin and the journeys they have taken. To a greater extent than in other health research, it is necessary to take account of these differences. Migrants will differ in their willingness to become involved with researchers, reflecting their experiences, which may have affected their trust in others. Interventions should relate to the particular barriers to healthcare faced by migrants. These include health beliefs and cultural norms, such as gender roles, as well as legal, financial, and regulatory aspects of the health system.”

Building alliances for the global governance of migration and health

Jo Vearey, Miriam Orcutt, Larry Gostin, Christy Adeola Braham and Patrick Duigan

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4143 (Published 16 September 2019)

“A collective, alliance based programme of action on migration and health that brings together civil society, practitioners, policy makers, and researchers is needed. A central “point-person” to drive and coordinate this process would need to be identified within central government; in different contexts, different focal persons may exist. Sri Lanka is a rare example of a country with a dedicated—and well documented—national migration and health policy process that can provide helpful insight for other countries. To support innovation and context specific alliance building, research is required to document and evaluate existing migration and health interventions and policies.”

“Crucially, there is a need to develop ways to future proof the global governance of migration and health: this is a contemporary governance priority for both the global health and migration sectors. If migration and health governance continues to be sidelined, it jeopardises action towards major global health targets, including those associated with the sustainable development goals, most notably that of universal health coverage. Two global compacts (international principles for good practice) were adopted in December 2018: one focuses on international migration and the other on refugees. These compacts provide opportunities for nation states to implement good governance approaches to tackle migration and health. Whether nation states choose a governance approach based on increasingly nationalistic discourses or an evidence informed approach to healthy migration remains to be seen. Developing a national scorecard on Migration and Health in all Policies, similar to the established Health in All Policies approach, could be an important step in holding nation states to account on their commitments both to universal health coverage and the sustainable development goals. To truly “leave no one behind” there must be a concerted global effort to build alliances to include migration and health in all policies.”

Improving the health of migrants

Kolitha Wickramage, Paul J Simpson, and Kamran Abbasi

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5324 (Published 16 September 2019)

With this editorial we launch a new series from The BMJ. The series seeks to improve understanding of the complexities of delivering better health for migrants and communities affected by migration, tackle unhelpful stereotypes and prejudices aimed at migrants, and focus on the role of health in improving the societal response to migrants. Developed by The BMJ in collaboration with the UN Migration Agency (IOM) and the Migration Health and Development Research Network (MHADRI), the first three articles consider the migrant health system and political dimensions of navigating policy, politics, and diplomacy in this complex field.

Better health for migrants isn’t simply a moral imperative. It is an evidence informed, economically wise choice that will improve health for all. It is a choice that must be made in defiance of populism, prejudice, and political expediency.

BMJ series on migration and health

In partnership with the British Medical Journal (BMJ) and the International Organization for Migration (IOM), we are excited to launch a new series on migration and health. The first articles are now online.

Anti-immigrant rhetoric permeates today’s political discourse and soaks through much of society. In this highly politicized context, dominated by debates on immigration and border control, understanding and tackling what affects the health of migrants, their families, and communities is often overlooked and underserved. These gaps in understanding the relation between migration and health remain a challenge that policymakers, practitioners, civil society, and researchers must collectively embrace.

The BMJ’s migration health series aims to provide insights and perspectives by researchers, policymakers, practitioners, civil society, and migrants themselves on issues, challenges and complexities in advancing migration health. The series is being developed in collaboration with the UN’s Migration agency (IOM) and the Migration Health and Development Research Network (MHADRI) – a global network of migration health researchers.

Global Forum on Bioethics in Research – “Ethics of research with refugee and migrant populations, 2017” – Meeting Report

MHADRI members participated in the Global Forum on Bioethics in Research satellite meeting in Bangkok, Thailand in November 2017, to explore the “Ethics of research with refugee and migrant populations”. Over two days and with the use of case studies, 42 participants from 24 countries discussed their experience of conducting research with migrant and refugee populations and the associated ethical challenges. By identifying what is needed to advance ethical research in this field, the meeting aimed to stimulate an agenda to improve research practice and health outcomes for migrant and refugee populations.

Download the full GFBR Report 2017.