(re)Setting the global migration and health agenda

Governments are faced with the challenge of integrating the health needs of migrants into national plans, policies and strategies across sectors, responding to the call to ‘leave no one behind’ and achieve Universal Health Coverage, stated by the 2030 Sustainable Development Goals. Coordinated efforts are needed to ensure that migrant health is addressed without discrimination throughout the migration cycle, as are efforts to adapt and strengthen the resilience of local health systems in light of more diverse population health profiles. Addressing the health needs of migrants and affected local populations reduces long-term health and social costs, facilitates integration and contributes to social and economic development.

Overview of the 2nd Global Consultation on Migration and Health
International Organization for Migration, 2017

I’m currently in Colombo, Sri Lanka, preparing for the 2nd Global Consultation on Migrant Health that starts tomorrow.  Co-organised by IOM, WHO and the Sri Lankan government, the Consultation will revisit the 2008 World Health Assembly Resolution on the Health of Migrants, and will explore if – and if so how – a focus on migration and health can support countries in achieving global health and development targets, such as Universal Health Coverage, and the Sustainable Development Goals.

But these are politically sensitive issues.

Alone, the topic of migration, health, or development can unsettle political leaders and public officials alike.  Together, they become even more difficult to manage productively in political and policy discussions, particularly within the increasingly xenophobic and anti-(im)migrant world we find ourselves in.

There is an acute need for rational discussion and action on the interconnected concerns of migration-health-development, and it’s hoped that the 2nd Global Consultation will be the start of a (re)new(ed) international framework for action.  To this end, the Consultation has three key objectives:

  1. To share lessons learned, good practices and research in addressing the health needs of migrants, and to identify gaps, opportunities and new challenges.

  2. To reach consensus on key policy strategies to reach a unified agenda across regions on the health of migrants, reconciling acute large scale displacement, as well as long-term economic and disparity-driven structural migration, and to pave the way towards a possible roadmap of key benchmarks.

  3. To engage multi-sectoral partners at policy level for a sustained international dialogue and an enabling policy environment for change.

These are ambitious objectives for a three-day Consultation but they do provide an important starting point for engagement in a politically-sensitive global conversation.  With three parallel focus areas – (1) global health; (2) vulnerability and resilience; and, (3) development – the 2nd Global Consultation will (hopefully) provide a platform for the development of a much needed global framework for action on migration and health.  The Consultation process has been designed with the aim of informing an implementation plan that will include: actionable policy objectives; a research agenda; and, a progress monitoring framework.

However, I have some concerns with the wording and framing of the meeting objectives, and how these may (inadvertently) fuel prevailing rhetoric that (incorrectly) associates migrants with poor health (particularly in relation to the language of vulnerability), the spread of diseases, and as a burden on the health and welfare systems of host nations.

With that said, I’m fully aware of the limitations – political and practical – associated with such a Global Consultation and acknowledge that we do need to (re)start somewhere.

But my concerns lie at the heart of the very politics that has resulted in the need for such an engagement in the first place.  A Global Consultation such as this is as much an opportunity for advocacy and fact-checking (in an increasingly post-factual world) – and for reminding the global community of the importance of good health, social justice and health equity – as it is for supporting action.

My key concern is that the focus on the health needs of migrants and the health of migrants could be interpreted to mean that migrants (who have not been defined) have a burden of health needs/poor health that is far greater than the rest of the world’s (non-migrant) population, therefore suggesting that migrants are in fact a social welfare and health burden.  But existing evidence shows that this is a problematic starting point.

It’s not about migrants always being sicker or more in need of healthcare.

It’s about improving our understanding of how migration (as a process) interacts with health.

It’s about unpacking the complex, bidrectional relationship between migration and health; it’s about exploring the ways that migration may determine health, and how health can determine migration.

It’s about understanding that migrants are not by definition vulnerable or sick but that the process of migration may impact health and wellbeing in negative – or positive – ways.

It’s about acknowledging the prevalence of diverse population movements, both within countries and across national borders, and recognising that these are experienced globally.

It’s about improving our understanding of the ways in which the positive selection of (most) migrants results in a healthy migrant effect, and in understanding how and why this health benefit often rapidly drops away.

It’s about emphasising and outlining the need for migration-aware health responses (including those needed beyond the health sector), n0t solely about migrant-sensitive health system planning (that’s a key failure of the 2008 Resolution and the 1st Consultation in my opinion).

It’s about applying existing frameworks – like a social determinants of health approach – to explore and understand interactions between migration and health.

It’s about returning to the basic premise of a primary healthcare approach for improving health for all.

It’s about health equity and social justice.

However, it’s a start.  And my cynicism associated with the state of world (health governance) affairs needs to be noted.  The Consultation has a Herculean task of working to attain political consensus on the need to (re)set a progressive and inclusive global agenda on migration and health.

 

(re)Setting a global agenda

I attended the first Global Consultation, held in Madrid, Spain in March 2010, almost seven years ago.  This first Consultation proposed a health-systems-focussed framework for implementing the 2008 WHA Resolution, consisting of four key pillars:

  1. Monitoring migrants’ health
  2. Policy and legal frameworks affecting migrants’ health
  3. Migrant sensitive health systems
  4. Networks, partnerships and multi country frameworks on migrant health

Whilst there has been some action in some contexts, progress has been pretty limited at a global level – and current world politics are eroding progress where it may have been made.  More importantly, the fact that the Resolution and the first Consultation were (are) very Euro-centric and health-systems focussed, and considered migration only in a context of cross-border migration, relevance in other contexts was (is) limited.  Hopefully there will be time over the coming days to work to address this as we hit the reset button.

First, it’s important to recognise how and why the 2008 Resolution came about, why the first Consultation was hosted by the Spanish government, and how these processes may have resulted in a less-than-globally-relevant agenda being formed and implemented.

In a nutshell:  the Resolution arose in response to a concern from southern European states (namely Portugal and Spain) that called on the rest of the EU to play their role in supporting the health of migrants.  At the time, Portugal and Spain were providing free healthcare to non-nationals, including an increasing number of both regular and irregular migrants travelling into central and Western Europe via Northern Africa and Southern Europe.  However, other EU members were not and Portugal and Spain felt that whilst they were doing the right thing, they were paying for it in ways that they couldn’t afford.  The European financial crisis impacted this, and led to some changes in these policy frameworks, with some restrictions in access to care for foreign nationals imposed in Portugal and Spain.  And, since the 2010, we’ve witnessed a global trend for further restricting and securitising the movement of people, accompanied by an erosion of the right to health(care) for non-nationals.  Increasingly, healthcare providers are being co-opted into the work of immigration officials (for example, the UK Border Agency has been accessing NHS patient files in order to identify non-nationals) and a renewed focus on the health status of migrants is featuring in discussions associated with the growing securitisation of migration management.  Scary times.

 

The current global health context

Whilst some of the global health terrain remains similar to that in 2008, much has changed.  (Political) Priorities and focus areas for some regions will continue to influence the setting of a global migration and health agenda and much work is needed to ensure that the outcomes of the Consultation are sufficiently global in their relevance.  Key debates in Europe and North America (namely those associated with the “European Refugee Crisis” and the global health concerns resulting from the election of Trump as President of the USA) are fuelling much of the current global migration and global health debates.  However, the relationship between migration and health is a long-standing concern elsewhere, particularly in regions associated with a high burden of communicable diseases (notably TB, increasingly MDR- and XDR-TB and HIV), and with high levels of internal mobility.  There’s a critical need to ensure that global realities are engaged with.

Since 2008, international focus has turned to the “Large Movements of Refugees and Migrants” with subsequent impacts on global health discussions.

The UN General Assembly Summit on Large Movements of Refugees and Migrants has created a unique opportunity for the global community to forge a greater consensus on managing the world’s movements of migrants and refugees. It also set in motion the development of a roadmap to a Global Compact for Safe, Orderly and Regular Migration and a Global Compact for Refugees.

The framing of the “European Refugee Crisis” has led to a renewed interest in the health of migrants. But not the progressive, inclusive, humanitarian kind of interest that’s needed. Rather, as Seth Holmes and Heide Castañeda highlight, the “crisis” has been presented in ways that allows for unsubstantiated rhetoric to strengthen popular perceptions, and fuel anti-foreigner sentiments.

These representations shift blame from historical, political-economic structures to the displaced people themselves. They demarcate the “deserving” refugee from the “undeserving” migrant and play into fear of cultural, religious, and ethnic difference in the midst of increasing anxiety and precarity for many in Europe.

The positioning of non-nationals in such a negative way, and the associated political actions resulting from uninformed and unsophisticated policy discussions, simply fuel efforts by EU member states to further securitise cross-border movements, and increasingly restrict access to government-funded healthcare for non EU-nationals.

Across the Atlantic, in the era of Trump, the (global) health community is acutely aware of the difficulties faced in working to achieve (good) health for all (for example, see here and here) – particularly in relation to migration.

 

Opportunities?

Hopefully it’s not all doom and gloom.

In 2016, the Institute for Global Health of University College London (UCL) and The Lancet initiated a Commission on Migration and Health. The Commissioners outline that

The Commission’s work will anticipate new policies arising from the changing political context and make evidence-based recommendations to improve such policies. It is our hope that the work of this Commission will provide the foundation for policy makers, advocates, international agencies, health-care systems, and communities to maximise the benefits and reduce the costs of migration on health locally and globally.

Hopefully the deliberations of the Global Consultation will feed into the work of the Lancet Commission.  These are currently separate(d) processes led by different institutions, and different people.

Hopefully the soon-to-be-appointed new Director General of the WHO will recognise that migration is central in both current and future global health action.  And perhaps they will boldly counter global rhetoric by calling for the implementation of – and accountability to – a comprehensive, evidence-informed migration and health agenda.

Maybe a migration lens will provide a much needed opportunity to reset the global health agenda in order to (re)engage in action to address social (in)justice and health (in)equity.

 

 


2nd Global Consultation on Migrant Health: Resetting the Agenda
Jointly Organized by IOM, WHO and the Government of the Democratic Socialist Republic of Sri Lanka
21-23 February 2017 | Colombo, Sri Lanka

Migration has been at the forefront of our digital screens and political discussions in recent years. The number of people who migrated across international borders surged by 41 percent in the last 15 years to reach 244 million in 2015, 21 million of which were refugees. Internal migration is estimated at 740 million people worldwide. Migration continues to evolve and to become more complex through increased mixed migration flows comprised of many categories of migrants, involving both traditional and new countries of origin, transit and destination. Additionally, the socio-economic, bio-environmental and political context within which modern migration takes place keeps changing, determining new challenges and areas of opportunity, including in the health sector, towards the realization of migration as an effective poverty-reduction and development-enabling factor.

Migration is a social determinant of health that can impact the well-being of an individual, as well as the community at large. Most migrants are healthy and young, and migration can improve the health status of migrants and their families through providing a safer haven or better education and purchasing power for ‘left behind’ family members, thanks to remittances. However, the migration process can also expose migrants to health risks and many migrants lack access to adequate, equitable health services and financial protection. Health systems may not have sufficient capacity to manage migrant health needs especially in the case of large movements. Furthermore, human mobility, whether resulting from migration or international travel can be a critical factor in the spread of disease and/or a challenge to controlling it. The Ebola crisis reminded us how a lack of preparedness, targeted health services and surveillance along mobility pathways undermines effective disease control measures.

Governments are faced with the challenge of integrating the health needs of migrants into national plans, policies and strategies across sectors, responding to the call to ‘leave no one behind’ and achieve Universal Health Coverage, stated by the 2030 Sustainable Development Goals. Coordinated efforts are needed to ensure that migrant health is addressed without discrimination throughout the migration cycle, as are efforts to adapt and strengthen the resilience of local health systems in light of more diverse population health profiles. Addressing the health needs of migrants and affected local populations reduces long-term health and social costs, facilitates integration and contributes to social and economic development.

The UN General Assembly Summit on Large Movements of Refugees and Migrants has created a unique opportunity for the global community to forge a greater consensus on managing the world’s movements of migrants and refugees. It also set in motion the development of a roadmap to a Global Compact for Safe, Orderly and Regular Migration and a Global Compact for Refugees.

THE 2nd GLOBAL CONSULTATION ON MIGRANT HEALTH

In response to the renewed international attention to the topic, IOM, WHO and the Government of the Democratic Socialist Republic of Sri Lanka jointly organize the 2nd Global Consultation on Migrant Health to offer Member States and partners a meaningful platform for multi-sectoral dialogue and political commitment to enhance the health of migrants.

Objectives

  1. To share lessons learned, good practices and research in addressing the health needs of migrants,  and to identify gaps, opportunities and new challenges;
  2. To reach consensus on key policy strategies to reach a unified agenda across regions on the health of migrants, reconciling acute large scale displacement, as well as long-term economic and disparity-driven structural migration, and to pave the way towards a possible roadmap of key benchmarks;
  3. To engage multi-sectoral partners at policy level for a sustained international dialogue and an enabling policy environment for change.

Expected outcomes

To facilitate a continuation of the political dialogue on the advancement of migrant health:

  1. A “Colombo Statement” expressing governments’ support to promote the health of migrants at multi-sector level;
  2. Experts’ and policy makers’ recommendations to lead the future advancement of migration health as a key global health agenda;
  3. Agreed ‘indicators and benchmarks’ to enhance the 2010 Madrid ‘Operational Framework’ with a progress-monitoring framework;
  4. A common roadmap of engagement, aligned with the implementation of WHA resolutions, SDGs, UNGA Global Compacts for migrants and refugees, and other relevant instruments;
  5. A research agenda and network for the production and sharing of evidence to enhance migrant-inclusive policy development.

Scope

Three thematic areas defining global agendas and paradigms are proposed, within a rights-based, people-centered, gender and equity approach:

  1. Global Health:  to reduce disease burden in migrants and host communities through universal health coverage (UHC) encompassing promotion, prevention, treatment, rehabilitation and palliation. This will be calibrated by concepts of quality of care, integrated people-centered health services, primary health care and health system strengthening.
  2. Vulnerability & Resilience: to reduce vulnerability and enhance resilience of migrants, communities and health systems, calibrated along the social and environmental determinants of health model and equity in migrant health concepts.
  3. Development: to ensure health of migrants is made an integral part of the 2030 Agenda for Sustainable Development, and key indicators to monitor progress of achievements are identified, calibrated along the Sustainable Development Goals.

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