7. Population Mobility and Health

Question 1

Overview Summary

Answer 1

Welcome to the session on population mobility and health. In past sessions, you have learned about how the world has become increasingly interconnected. With these connections and the growing ease and frequency of transport, more people are moving between and within countries. In this session you will learn about the different stages of migration, international agreements that have sought to address migration, the politicization of migration, and recent issues in the study of migration.

Question 2

Overview Aims

Answer 2

To increase your knowledge of migration, its influence on individual and public health and implications for policy.

Question 3

Overview Learning outcomes

Answer 3

By the end of this session, you should be able to: Identify migration trends, forms, and migrant groups; Demonstrate an understanding of the different stages of migration, and health risks and opportunities at each stage; Identify key policy instruments addressing health and migration and assess their effectiveness in particular country contexts; and Critically evaluate current policy gaps and options for migration health at global and national levels.

Question 4

Key terms Migrant

Answer 4

any person who is moving or has moved across an international border (international migrant) or within a State (internal migrant) away from his/her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involuntary; (3) what the causes for the movement are; or (4) what the length of the stay is. Migrant is not a legal term, rather a broad category. At the international level, there is no universally accepted definition for “migrant” (IOM 2018).

Question 5

Key terms Population mobility

Answer 5

Population mobility refers to the movement of people across regions or areas, regardless of the specific characteristics of the individuals or groups that migrate, or their motives or mode of movement (Hanefeld 2017).

Question 6

Key terms Migration process

Answer 6

The migration process is a multi-staged trajectory of human movement, which may include some or all of the following stages: pre-departure, travel and transit, destination, interception and return (Zimmerman et al 2011).

Question 7

Key terms Migration health

Answer 7

Migration health addresses the physical, mental and social needs of migrants and the public health needs of host and home communities (IOM, 2008).

Question 8

Key terms Labour migration

Answer 8

is defined as the movement of persons from their home State to another State for the purpose of employment (IOM 2018).

Question 9

Key terms Irregular migration

Answer 9

Movement that takes place outside the regulatory norms of the sending, transit and receiving countries, for example without the necessary authorization or documents required under immigration regulations. (IOM 2018)

Question 10

Key terms Circular migration

Answer 10

Temporary, recurrent movement of people between two or more countries mainly for purposes of work or study. Circular migration is less linear or static than permanent or temporary migration (IOM 2018). Many migrants move easily from their place of origin directly to their destination location, like international students or a highly skilled worker resettling for professional purposes who take a plane or a train. Others, such as irregular or undocumented workers or persons fleeing persecution across borders, may be intercepted before arrival or while entering a destination. Each phase of the migration process may pose health risks and opportunities, and we will now explore these in detail.

Question 11

Key terms Forced migration

Answer 11

A migratory movement which, although the drivers can be diverse, involves force, compulsion, or coercion, for example due to humanitarian crisis. This contrasts with voluntary types of migration, for example labour migration where people move voluntarily in search of employment.

Question 12

Key terms Refugee

Answer 12

A person who, “owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country. (Art. 1(A)(2), Convention relating to the Status of Refugees, Art. 1A(2), 1951 as modified by the 1967 Protocol).

Question 13

Key terms Asylum seeker

Answer 13

A person who is requesting asylum due to fear of prosecution or coercion from a State, but this protection has not yet been granted. Importantly the status of asylum seeker differs from that of refugee, whose status has been recognised by a State or the United Nations High Commissioner for Refugees (IOM 2018).

Question 14

1 Background

Answer 14

According to the 2022 IOM report, in 2020 there were around 281 million international migrants in the world, which is about 3.6% of the world population (IOM 2022). Most migrants leave their countries of origin voluntarily, in search of better economic, social and educational opportunities. But the world is also witnessing high levels of forced displacement due to insecurity and conflicts, with over 21 million refugees and 3 million asylum seekers worldwide, in addition to 763 million internal migrants (around 11% of the world’s population), of whom over 40 million were internally displaced persons (IOM 2018).

Question 15

1.1 International migration

Answer 15

Who is an international migrant? Definitions vary with many based on administrative measures, such as the duration of stay. For example, a long-stay migrant would be those who maintain residence in a country other than their usual place of residence for more than 12 months, whereas short-term migrants would be those who remain for a period of more than 3 months but less than 1 year. Often this short-term migration is circular with migrants going back and forth, for example around seasonal work, and that such migration is often within a region. For example, in Southern Africa circular migration is common (Vearey et al 2018). In general, the category of international migrants does not include individuals travelling for tourism, business or to visit friends or relatives for short periods. International migrants might include international migrant workers, refugees, international students, and irregular migrants, such as undocumented workers or trafficked persons. There are profound differences between migrant populations, this can be problematic for understanding the health needs of different groups.

Question 16

1.2 Internal migration

Answer 16

Internal migration occurs within national borders, often across regional, district or municipal boundaries, and commonly from rural to urban settings. This movement is particularly responsive to economic expansion and contraction. Internal migrants may include: migrant workers, such as seasonal labourers, and people who are internally displaced, such as those who are fleeing conflict, natural disasters or leaving their homes because of land confiscation.

Question 17

Activity 1 Research current data on migration in the country in which you live. What are the trends? Thinking about the categories set out above, what type of migration do you observe? Is migration increasing? If yes from where, and what types of migration are occurring?

Answer 17

Please post your answers in the discussion forum.

Question 18

2 Health and the migration process

Answer 18

In this section, we discuss the different stages of migration, and health-related risks and opportunities at each stage.

Question 19

2.1 Migratory Process Framework

Answer 19

Traditionally, migration and population mobility have been viewed as permanent, one-directional movement from Location A to B. Contemporary migration is more accurately viewed as a multi-stage process that may include some or all of the stages in figure 1 below: pre-departure, travel, interception, destination, and return. People may enter this process multiple times and in various ways.

Question 20

2.1 Migratory Process Framework Pre-departure stage

Answer 20

The first stage of the framework – the pre-departure stage - is the period before individuals leave from their place of origin (Zimmerman et al. 2011). A person’s health prior to leaving his/her country of origin is influenced by both their biological make-up and the conditions in which they live, including the accessibility and quality of the health sector. Individuals living in poverty where there is endemic disease, inadequate water and sanitation and food insecurity are likely to leave home in worse health than wealthy individuals from areas of low endemicity (Gushalak et al. 2011).

Question 21

2.1 Migratory Process Framework Pre-departure stage

Answer 21

Sometimes, it is precisely the dangerous conditions at home, such as family violence or conflict, that pose serious health risks and cause individuals or entire populations to leave. Labour migrants, however, are commonly younger, healthier members of the community, leading to the so-called “healthy migrant effect” (Castañeda et al 2015). This refers to a situation where migrants have a better health status than the population in the destination country. This has been described, for example, in the Southern African region, where many migrants in search of work are seen to be healthier than the general population of the country they are joining (Veary 2014). Access to, and individual experience of, health services in the home country are key determinants of health and how individuals will use—or not use—health services after migration. Preventive programs such as immunisation and cancer screening may be unavailable or disrupted in the country of origin, making migrants more susceptible to disease or being diagnosed with advanced illness (Gushalak 2006, IOM 2017). Traditional medicine may be preferred but unavailable in the new residence. Migrants may also have expectations about public health services (e.g. that they would be officially free at the point of use, but actually require private payment) leading to scepticism or inhibition to seek care in new locations (e.g. which actually provide free public services).

Question 22

2.1 Migratory Process Framework Travel and interception stages

Answer 22

The second and third stages of the framework – the travel and interception phases - encompass the period after individuals leave their place of origin but before they arrive at a destination (travel); or when they are intercepted –for helpful (refugee or asylum-seeker support) or harmful reasons (prison, immigration detention)– en route to a destination (interception) (Zimmerman et al 2011). Among the most important distinctions for individual health during the travel phase are whether individuals are: a) Voluntary versus forced migrants or b) Documented versus undocumented or ‘irregular’ migrants.

Question 23

2.1 Migratory Process Framework Travel and interception stages

Answer 23

Forced or ‘irregular’ migrants are more likely to use dangerous modes and/or routes of transportation, as they often must leave their home without the required legal documentation.

Question 24

2.1 Migratory Process Framework Travel and interception stages

Answer 24

Transportation can include, for example, unseaworthy vessels or long, hazardous treks to arrive at their intended destination. In recent years the many tragic experiences and deaths of people seeking to travel by boat to Europe have put this stage into firm focus and at the forefront of much political debate. The travel stage is also when human mobility begins to bridge different zones of disease prevalence, with people transmitting or being exposed to new pathogens. Transmission of pathogens can occur during travel, including air travel (Brownstein et al 2006) or once a person has reached their destination, including where people move from low to high-risk areas, for example from non-Malaria endemic countries to those where it is endemic (Lynch et al 2011).

Question 25

2.1 Migratory Process Framework Travel and interception stages

Answer 25

The link between people’s mobility and disease came into sharp focus during the COVID19 pandemic, both with transmission during flights and with travel bans and entry measures by countries to slow the spread of new variants of the virus (Russel TW et al 2021) (Bou Karroum L et al 2021). Evidence on the effectiveness of these measures remains contested. Human mobility or migrants and others who travelled were associated with ‘bringing in’ the disease. To summarise, mobility, including migration, can expose individuals and groups to new pathogens and they may also become transmission agents.

Question 26

2.1 Migratory Process Framework Travel and interception stages

Answer 26

Migrants already affected by conditions such as HIV can experience treatment disruptions, with negative effects on individual health and ongoing transmission of disease.

Question 27

2.1 Migratory Process Framework Travel and interception stages

Answer 27

The interception stage usually affects only a minority of migrants, depending on the route, but often involves the most vulnerable migrants and poses the most extreme health risks. Refugee camps are a common interception strategy in response to humanitarian emergencies. Mortality rates can be high in these settings, as lack of adequate water and sanitation leads to diarrheal disease; and crowded conditions and being under-vaccinated can also make infectious disease outbreaks common. Please visit this interactive site where you can also find in the links section based on the Domiz Camp in Syria, to get a sense of life inside a refugee camp.

Question 28

2.1 Migratory Process Framework Travel and interception stages

Answer 28

Many refugees can remain in exile for many years without being offered long-term resettlement. The United Nations High Commissioner for Refugees estimates two-thirds of the over 16 million refugees worldwide at the end of 2016 were in “protracted situations” i.e. in exile for five years or more (UNHCR 2017). At the end of 2020, a total of 49 protracted refugee situations were registered, characterized by at least 25,000 refugees hosted for five consecutive years in the same host country. One example is the Afghan refugee situation, now in its fifth decade (UNHCR 2020). States may also use asylum reception centres for refugee claimants, or immigration detention centres for irregular migrants. These interception strategies often result in physical and mental health hazards, human rights violations and poor availability of health services (Steele et al 2011). Conditions in Australia’s Nauru and Manus Island detention centres, for example, have resulted in outbreaks of infectious diseases (Procter et al 2014).

Question 29

2.1 Migratory Process Framework Destination stage

Answer 29

The third stage of the framework – the Destination stage – is when individuals settle either temporarily or longer-term in their intended or accepted location (Zimmerman et al 2011). Here we begin to see some of the cumulative effects of health influences during prior stages, including past vaccinations, health knowledge, and health-related behavior, plus access to services in their new location.

Question 30

2.1 Migratory Process Framework Destination stage

Answer 30

Many migrant workers, especially irregular migrants, work in jobs in sectors such as in mining, construction, manufacturing and agriculture, where they are exposed to occupational risks such as injury and toxic agents (Moyce 2018). Studies indicate that migrant workers are generally at higher risk of injury and illness than native-born workers (Hargreaves et al 2019), (Rustage et al 2021). Migrant workers are also at greater risk of various forms of labour exploitation, which can have substantial implications for their work terms and conditions, especially long work hours, work-related stress and poor mental health (Hargreaves et al 2019), (Pega et al 2023).

Question 31

2.1 Migratory Process Framework Destination stage

Answer 31

Migrants often have difficulty learning about and navigating local health systems, and challenges identifying and reaching service providers or affording health services depending on their legal status and entitlements. As a result, they may delay or avoid medical care, increasing the likelihood of exacerbating treatable conditions. Migrant populations living in dense urban slums may be at particular risk of communicable diseases, malnutrition, and poor sanitation (IOM 2017).

Question 32

2.1 Migratory Process Framework Destination stage

Answer 32

Practitioners treating migrants may encounter challenges such as language differences which make communication difficult, or unfamiliarity with pathogens in the country of origin. Training for ‘cultural competency’ has emerged in a number of medical schools, as elsewhere, to help providers meet the needs of diverse groups and migrants’ varying interpretations of and responses to health and illness (Berger et al 2021).

Question 33

2.1 Migratory Process Framework Destination stage

Answer 33

Formulating migrant-friendly health service is needed to achieve universal health coverage and the Sustainable Development Goals (SDGs) (Mosca et al 2020).

Question 34

2.1 Migratory Process Framework Return stage

Answer 34

The final stage of the framework – the return stage – is when individuals go back to their place of origin either temporarily or to resettle (Zimmerman et al 2011). A person’s health at this stage will reflect the risks and opportunities they encountered throughout their journey. Most migrants make one or many return visits between a destination location and their place of origin. Seasonal labourers, such as agricultural workers, are very likely to go back and forth multiple times related to harvest times. This is known as ‘circular’ migration (Davies et al 2011).

Question 35

2.1 Migratory Process Framework Return stage

Answer 35

Migrants previously living in destination countries with a higher standard of health care may have difficulty maintaining a continuity of care at the same level. They may even face eligibility barriers after not working at home for many years. Migrant workers might also return to their former residence with occupational health problems, psychological disorders or chronic or potentially fatal diseases. Health services may not be equipped to identify or treat the presenting problem, or the individual may not have the resources to pay for treatment. Conversely, migrant workers may return with greater income to afford better healthcare for themselves and their family members. Migrants may also return with greater skills and knowledge to contribute to their community (Davies et al 2011). In conclusion, the migration process is increasingly diverse and complex. Health risks and opportunities differ based on the type of migration and stage of the migration process.

Question 36

3 Migration and health policy

Answer 36

Having considered the different stages of migration, we will now look at the health-related policy processes and perspectives in relation to migrants.

Question 37

3.1 UN agencies working in migration and health

Answer 37

As with most global health policy issues, addressing migration and health requires a multi-sectoral response, reflected by the multiple agencies involved at the global level. Table 1 outlines some of these agencies:

Question 38

3.1 UN agencies working in migration and health International Organization for Migration (IOM)

Answer 38

principal intergovernmental organization in field of migration, with 169 member states; and promotes humane and orderly migration

Question 39

3.1 UN agencies working in migration and health International Labour Organization (ILO)

Answer 39

tripartite U.N. agency bringing together governments, employers and workers of187 member States; and sets labour standards, develops policies and programmes to promote decent work for all women and men, including labour migrants

Question 40

3.1 UN agencies working in migration and health World Health Organization (WHO)

Answer 40

key agency directing and coordinating international health work through collaboration, with 189 member states; and role includes promoting access to quality, essential health services for refugees and migrants

Question 41

3.1 UN agencies working in migration and health United Nations High Commission on Refugees (UNHCR)

Answer 41

UN programme with mandate to protect refugees, forcibly displaced communities and stateless people

Question 42

3.1 UN agencies working in migration and health

Answer 42

These organisations, along with other development-related organisations and national governments, are instrumental in the negotiation of global-level targets and frameworks. Migrants were largely left out of the Millennium Development Goals but are recognised explicitly in two SDGs – SDG 10.7: Orderly, safe, regular and responsible migration and mobility and SDG 17.18 as mentioned above. International debate on implementation of the SDGs takes the principle of “leave no one behind” to include migrants, meaning migration-related factors must be acknowledged across both health and non-health related SDGs.

Question 43

3.1 UN agencies working in migration and health

Answer 43

In the relation to the health SDGs, migrants may experience higher maternal mortality rates, in some cases resulting from interrupted care during travel (SDG target 3.1), others may be disproportionally affected by infectious diseases such as HIV, TB and neglected tropical diseases (SDG target 3.3). Some groups may be more likely to misuse tobacco, alcohol and other drugs, often related to migration-related stressors and isolation (SDG target 3.5).

Question 44

3.1 UN agencies working in migration and health

Answer 44

Amongst the non-health SDGs, ensuring social protection for migrants is key to reducing poverty (SDG target 1.3). Reducing violence and related death rates (SDG targets 16.1, 16.6) and promoting peace will also address conflict, an important driver of migration (ODI 2016).

Question 45

3.2 International agreements on migration and health

Answer 45

Historically, measures around migrant health operated primarily to protect the public health of the native population from the ‘threat’ posed by immigrants and travellers. For example, in the 19th century, attempts to restrict movement were undertaken in response to cholera and in the 20th century to yellow fever (Vanderslot et al 2020). Over time, there has been growing recognition that international policy-level attention to the health and human rights of migrants is required, with several international treaties now including provisions to protect migrants’ rights to health.

Question 46

3.2 International agreements on migration and health The International Health Regulations (IHR)

Answer 46

The International Health Regulations (IHR) were first developed in 1969 to address the threat of trans-border infectious diseases but were narrowly defined with only a few diseases such as cholera included. The re-emergence of infectious diseases in the 1980s and 1990s – including new diseases such as HIV and viral haemorrhagic fever – led to the IHRs being revised and adopted by the World Health Assembly (WHA) in 2005. The updated IHRs are among the first WHO global policy responses to migration-related risks of infectious diseases and epidemics, and importantly cover all public health risks including known and newly emerging infectious diseases, spread of non-communicable diseases by chemical agents and/or intentional or accidental release of biological, chemical or radiological substances (Fidler et al 2006). Later WHA and WHO Executive Board resolutions and decisions (2007, 2008, 2017) placed greater emphasis on migrant rights and needs, including that migrants – like all individuals –have the right to the highest attainable standard of health, to equitable access to health services and services that are culturally, linguistically and gender- and age-appropriate. In light of the COVID19 pandemic, the IHR were revised in 2021, noting the need to strengthen the evidence on travel-related matters, for example to address infectious diseases (Aavitsland P et al. 2021). Through a two-year process of negotiations, revised IHR were adopted in June 2024. Key changes include the creation of a new category of a ‘pandemic emergency’, stricter asks of Member States to report disease outbreaks within 24 hours, and a greater attention to migrant issues, finding that the Review Committee does not focus in sufficient detail on equity and solidarity of migrants as defined in response, including through financial assistance (Habibi et al 2024). The impact of the revised IHR remains to be seen. However, focus on migration within the debates appeared limited. The New York Declaration for Refugees and Migrants was adopted by the UN General Assembly in 2016 and also commits to “people centred, sensitive, humane, dignified, gender-responsive approach” to migrants and refugees. As already mentioned, migrants are also explicitly recognised in several Sustainable Development Goals.

Question 47

3.2 International agreements on migration and health The Global Compact for Safe, Orderly and Regular Migration

Answer 47

The New York Declaration for Refugees and Migrants set into motion a process of intergovernmental consultations and negotiations towards the development of a Global Compact for Safe, Orderly and Regular Migration, which was intended to become an international standard or agreement on migration. As a result of this process, the Global Compact was adopted in December 2018 and endorsed by the UN General Assembly. As such, it marks the first intergovernmental agreement on migration. However, it is non-binding to Member States and signals intent and commitment rather than concrete actions (Pecoud A 2021). At the same time, the Global Compact has been criticised for side-stepping rather than addressing the complex political issues relating to migration because it does not articulate clearly enough ‘what’ should be done. Instead, it focuses on governance mechanisms. One ambition by the migrant health community has been for the Global Compact to provide proactive management of migrants’ health challenges and realise migrants’ potential to have positive impact on population health (Gottardo C et al 2019; Deyakumar D et al 2019).

Question 48

3.3 Immigration versus health: policy conflict?

Answer 48

In some countries, the debate on ‘immigrants can sway elections, hindering migrant-inclusive health policies. Immigration is a policy arena that is considered ‘high’ politics – that is, a national security concern and highly political in the public eye. Health is generally considered ‘low politics’ because it relates more to individual or social well-being, which has historically been considered not critical for the survival of a state (Brown GW et al 2018). When migrants’ rights to health are pitted against immigration goals of reducing the number of foreigners entering a country or preventing disease transmission across national borders, individual health will be of secondary concern. Punitive laws, xenophobia and the threat of deportation can also seriously affect the mental health of migrants. Europe provides two examples of how high and low politics have collided in relation to migrants.

Question 49

3.3 Immigration versus health: policy conflict?

Answer 49

Firstly, migrants were disproportionately affected by the 2008 financial crisis in terms of job loss and consequent income loss, in the European Region. Poorer living conditions can also increase infectious disease risk. Austerity measures reduced overall health and welfare spending and structural reforms to health systems. These measured included imposing user charges or reducing entitlements for non-citizens, which decreased the availability of health care, especially for the most vulnerable migrants (Kentikelenis et al 2015).

Question 50

3.3 Immigration versus health: policy conflict?

Answer 50

Secondly, between January 2015 and May 2016 alone, there was an influx of over 1·2 million people, including economic migrants and refugees, crossing the Mediterranean Sea to Europe. Such mass movements are associated with overcrowding, poor sanitation, restricted access to clean water and therefore increased risk of infectious disease outbreaks, leading some instances to fear and stigmatisation of migrants in the destination country (Khan et al 2016). These fears are often unfounded, as exemplified by the spread of tuberculosis, which, is prevalent in some migrant communities but unlikely to be transmitted to host populations in high-income countries because of better housing and nutrition and limited close contact between the two groups (Khan et al 2016).

Question 51

3.4 The politicization of migration

Answer 51

The potential for disease transmission between disparate epidemiological zones, particularly in the travel/interception and destination stages of migration, has resulted in a heightened perception of threat, especially in migrant-receiving nations. Recent examples of infections where the role of migrants has been politicized or received significant media attention include the 2003 Severe Acute Respiratory Syndrome (SARS), the Ebola Virus Disease outbreaks, and recently COVID-19 (Koinova et al 2023). Migrants moving from high to low prevalence countries may change the epidemiological patterns of disease in countries of destination. Tuberculosis, HIV, hepatitis B and strongyloidiasis are all more common in foreign-born compared to native-born residents in many high-income countries (Gushalak et al 2006).

Question 52

3.4 The politicization of migration

Answer 52

Policy responses to health and migration generally focus on national border control, but movement of people is not necessarily dictated by these borders but by other factors such as available transportation, social networks and natural boundaries, such as mountains and bodies of water. As previously discussed, the IHR (2005) recognises this and requires signatory countries to notify WHO of a possible public health emergency of international concern which may cause international spread of disease, thus enabling effective global coordination and action to be taken. At the national level, Immigration or Home Affairs Ministries are often responsible for establishing health-related requirements for different migrant categories. Applications can be denied because of the assumed cost of particular conditions to the health system in the destination country. Ministries of Health or Social Welfare however are often responsible for policies on health care access and eligibility for migrants who have already arrived. However, immigration protectionist strategies, such as immigrant screening, are not aimed to prevent the influx of pathogens such as influenza (Selvey et al 2018).

Question 53

3.4 The politicization of migration The COVID19 pandemic

Answer 53

COVID19 dramatically highlighted many of the interactions between migration and health. First, it demonstrated the link between mobility and spread of disease (in part due to the high infectiousness of pathogen SARS COV 2). At the same time, it underlined limitations of policies seeking to contain disease or new variants through restrictions on movement (Kurcharski et al 2022, Russell et al 2021). Second it highlighted specific vulnerabilities and aspects of labour migration, through the circular migration (and in some instances linked migration) but also importantly by showing increased vulnerabilities directly related to working and living conditions of migrant workers (Hayward et al 2021). Third, it underlined the limitations to and importance of universal health coverage for migrants (ibid), including for wider population health. Analysis of geospatial data from Germany for example identified migratory background as an independent variable for higher incidence of COVID19 in addition to socioeconomic deprivation (Rohleder et al 2022). As vaccinations became more widely available countries had very strong and very publicly evident imperatives to vaccinate all people, including migrants. Many countries needed to adapt and target immunisation services to reach migrant populations thus underlining the importance of universal health coverage that includes migrants.

Question 54

3.5 Migrant-sensitive health systems and Universal Health Coverage (UHC)

Answer 54

Immigration or Home Affairs Ministries are often responsible for establishing national health-related requirements for different migrant categories. Applications can be denied because of the assumed cost of particular conditions to the health system in the destination country. Ministries of Health or Social Welfare however are often responsible for policies on health care access and eligibility for migrants who have already arrived. In previous sessions, you learned about universal health coverage (UHC) and its importance in ensuring access to health services and the right to health. Providing UHC represents a major financial commitment particularly in developing countries that may already struggle to provide basic health services for their host population. Migrants are often excluded from risk-based insurance schemes, and irregular migrants can be completely invisible. Even where health-care access is free, irregular migrants may not utilize services because of registration barriers, including a fear of deportation where migrants are irregular (Vearey J et. al. 2018). As a result, they may face high out-of-pocket expenditures or simply not access care, resulting in avoidable illness and death. Internal migrants may also face challenges if provision of UHC is linked to being registered in a particular geographic area or health service (Guinto 2015, ODI 2016).

Question 55

3.5 Migrant-sensitive health systems and Universal Health Coverage (UHC)

Answer 55

In countries with decentralized health systems, discrepancies can occur between central government policies and local practice. In Spain for example, national-level policies dictate that asylum seekers and undocumented migrants are ineligible for publicly funded health services, however at the regional level laws and policies have been enacted overturning these restrictions (Cimas et al 2016).

Question 56

3.5 Migrant-sensitive health systems and Universal Health Coverage (UHC)

Answer 56

Some countries have explicitly sought to include migrants in their efforts to achieve UHC. Thailand, for example provides documented migrants the opportunity to participate in its government social security scheme which is funded through employee, employer and government contributions. Migrants who are unable to join this scheme can join an alternate Migrant health Insurance Scheme that is funded by contributions (Tschirhart et al 2021). Yet even though Thailand is recognised for its leadership in this area and compares favourably to other countries, (Onarheim K et al 2018), research identified several challenges for undocumented migrants seeking access to, for example, emergency obstetric care (Tschirhart et al 2021). Challenges may in some cases be due to migrants’ unclear legal status or their limited information about their rights, which may delay health care for fear of possible immigration consequences.

Question 57

3.5 Migrant-sensitive health systems and Universal Health Coverage (UHC)

Answer 57

In conclusion, migrant health policy-making is highly sensitive to political, social, and economic environments and public opinions. These competing pressures create policy tensions between border protection, disease control and the rights of migrants. Ensuring migrants access to health services requires services to be migrant friendly. Given that migration often follows a circular pattern, for example, it is important to consider continuity of care across borders, as well as the provision of care in border areas.

Question 58

Activity 2 Consider a country context with which you are familiar.Think of the political debate about migrants’ rights to or use of the health and welfare resources? What were the main political arguments in favour of and against including migrants in health and social welfare schemes?

Answer 58

There are many arguments for and against the inclusion of migrants in universal health coverage schemes. The arguments for include: Human rights and equality based on international norms and standards; Public health threat of delayed health-care seeking, creating the opportunity for spread of infection to the general public; Chronic illness and injury leading to permanent disability, poor maternal and child health, ultimately greater morbidity and increased cost to the health and social service sectors; and Societies depend heavily on migrant labour.Migrant workers generally have less protective equipment and training and are at higher risk of harm. They have a right to care in exchange for their contribution to local economies.The arguments against UHC for migrants include: Irregular migrants do not contribute to the social insurance system; Migrants take employment options or lower wage structures, contributing to local unemployment; Providing high quality health services to migrants will increase illegal and legal immigration; it will serve as an enticement; and Health systems will be overloaded by increasing especially ‘at-risk’ populations.

Question 59

4 Modern aspects of human mobility

Answer 59

Having considered the stages of migration and migration and health policy-making, we will now look at some specific aspects of modern migration.

Question 60

4.1 Monitoring migration and health

Answer 60

How do we measure human mobility and its impact on health? When calculating the flow of international migrants, the inflows or outflows of people across international borders are taken into account. Net migration in a location is the net total of migrants during the period, that is, the number of immigrants minus the number of emigrants, including both citizens and noncitizens. (UNPD 2022). Monitoring the health-related risks and needs of migrants is difficult, with no international standardised approaches (Hanefeld et al 2017). Country of birth or migrant status may not be routinely collected in health and administrative datasets and surveys, so data cannot be disaggregated in a way which allows analysis and tracking of health issues in various groups of migrants. Understanding and addressing the effects of migration on infectious diseases, such as malaria, often requires cross-border collaboration between countries in surveillance and response, which is also challenging. In recognition of these issues, SDG target 17.18 is to “Increase the availability of high quality timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status … and other characteristics relevant in national contexts”.

Question 61

4.2 Human trafficking and health

Answer 61

The United Nations (2000) defines human trafficking as: The recruitment, transportation, transfer, harbouring or receipt of persons by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power, or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. People may be trafficked for forced low- or no-wage labour, including domestic servitude, agricultural work, commercial fishing, textiles, factory labour, construction, mining, and forced sex work, as well as bride trafficking, forced begging and petty crime. Estimates from 2021 suggest that 50 million people were living in modern slavery, of whom 28 million were in forced labour and 22 million were subjected to forced marriage (ILO et al 2022). The health implications of human trafficking are significant, including injuries and illness from physical and sexual abuse, occupational injuries, and psychological morbidity. Among trafficking survivors in Southeast Asia, nearly half (48%) reported physical or sexual abuse and 22% sustained severe injuries, including lost limbs, and reported symptoms indicative of depression and anxiety disorders (Kiss et al 2015).

Question 62

4.3 Feminization of migration

Answer 62

Increasingly, women are migrating independently for work, rather than as wives or dependents under a male head-of-household. For women who opt to migrate on their own, moving away from home and family for a job can mean increased equality and freedom, including control over their sexual and reproductive health when they move to places with more progressive cultural norms (Tittensor D et al 2017).

Question 63

Integrating activity

Answer 63

Find an example of a national, bilateral or multi-lateral policy or programme for which the aim is to address migrant health or the health effects of migration. Examine this policy or programme and answer the following questions: Describe the policy or programme and which migrant group(s) it targets; Which health needs is the policy or programme trying to address? Who is involved in implementation? What are the weaknesses in the policy/programme and/or its implementation and how can it be addressed? Does the policy consider how migrants can gain information about the service or programme and does it seek to address potential concerns, including for example fear of deportation or report to other national authorities? Does the policy engage with or reference an international standard? Does it cover more than one country? Please post your answers on the discussion board and respond to at least one other classmates’ post.

Question 64

Summary

Answer 64

1. In summary: Migration and mobility are increasing throughout the world; this brings with it significant health considerations. It means that diseases travel alongside people, and it is important for everyone’s interest to consider the impact of migration and ensure universal health coverage. It also means that narrowly-focused national health policies and services are not suited for the vast numbers of people who are on the move. The effects of mobility on health are dependent on the type of migration (e.g. international or internal, voluntary or forced, documented or undocumented) and often related to the phase of migration (pre-departure, travel/interception, destination, return). While definitions are important, including legal categories which often determine access to services for people on the move, often clear definitions are lacking.

Question 65

Summary

Answer 65

2. Forced or undocumented migrants may be at greater risk of poor health because they may use dangerous modes of transport during the travel phase or having less entitlement to services along the way and in the destination country.

Question 66

Summary

Answer 66

3. International agreements call for migrants to enjoy the same right to health as everyone else. Yet political factors, including fear and stigma surrounding migration often prevent evidence and rights-based policy from being implemented. Migration is arguably not sufficiently addressed in current legal instruments.

Question 67

Summary

Answer 67

4. The COVID19 pandemic highlighted the extent to which mobility can be linked to greater transmission of disease. It also demonstrated the specific vulnerabilities faced by people with migratory backgrounds. Addressing migration is essential to achievement of the Sustainable Development Goals but requires explicit inclusion of migrants for example in efforts to provide universal health care, and in monitoring and evaluation of health programs.