This section provides an overview of selected programmatic areas for action in migration health, along with policy approaches and practical examples. It is by no means exhaustive. Priorities will be established according to the national context, as identified in multi-stakeholder and cross-sector consultations and outlined in a national migration health plan (see Developing a comprehensive national migration health plan in this chapter). The areas explored below are usually of high relevance and may be considered in such plans.

Social protection mechanisms for promoting the health of migrants

Migrants in vulnerable situations, those who cannot afford health insurance and those who may lack the necessary documentation are routinely excluded from all but emergency health care in most countries around the world. Providing affordable and accessible quality health care to migrants not only benefits migrant populations but also protects the people of the transit and receiving communities (read more on gender aspects related to social protection and health insurance in a discussion of Access to services in Chapter Gender and migration).

Catastrophic health spending is what occurs when out-of-pocket payments for health services consume such a large portion of a household’s available income that the household may be pushed into poverty as a result (see World Health Organization [WHO], n.d. and WHO, 2019). Providing universal health coverage (UHC) to migrants will require innovative practices and policies that balance public health costs due to exclusion and neglect with the positive dividends of a healthy and integrated migrant population. An example of such a practice would be social security schemes. Mechanisms for extending social protection in health and increasing social security coverage for migrants and their families can enhance access to needed health services and avoid excessive out of pocket payments by migrants in need of health services. These could include flexible and cross-border (portable) health insurance schemes.

Case Study
Health insurance scheme in Thailand

Thailand is expanding health coverage for all through a phased approach. One phase is the social security scheme, which is made available to Thai nationals as well as regular migrants. This is an example of a payroll contribution scheme. Another scheme is for migrant workers in the informal labour sector, some of whom are undocumented migrants. In 2004, the Thai Government implemented the migrant health insurance scheme. This is a comprehensive prepaid, premium-based health insurance scheme offered to migrants, including undocumented migrants. To be covered by this health insurance scheme, migrants pay a fee of USD 50 per year. In order for undocumented migrants to access this health insurance, they must register with the Government, making insurance provision part of the process of becoming documented and regularized. The benefits offered by the various health insurance schemes are similar, so there is no discrimination in terms of packages for migrants or nationals. Such a practice contributes to the expansion of health coverage, as well as to inclusion and social cohesion.

Source

Guinto et al., 2015.

To Go Further
Policy Approaches
Social protection measures to promote universal health coverage for migrants
  • Consider increasing social security coverage for migrants and their families, which could include flexible and cross-border (portable) health insurance schemes to:
    • Allow migrants to export their social benefits to families left behind;
    • Provide future social benefits, such as health care in old age;
    • Cover costs of repatriation due to medical needs or public health emergencies;
    • Cover integration assistance, upon arrival or return, including psychological services.
  • Invest in the provision of primary health care that is migrant inclusive (WHO, IOM and Government of Spain, 2010).
  • Provide more funding to enable other partners and communities to respond to the immediate, medium-term and long-term health needs of migrants.
Migration-sensitive health systems to reach global health goals

People-centred and migration-sensitive health systems help to accelerate gain in health outcomes and reduce health inequalities between populations, including between migrants and receiving communities. Putting people at the centre of such systems requires building a culture where the health of migrants is integrated into the decisions made in all sectors of society, and in particular, into public policies. Current discourse in the migration and health domains recommends a shift towards equity and inclusiveness for migrants, emphasizing the approaches countries can take that target the areas below (see Figure 7).

Image / Video
Figure 7. Health, health systems and global health
Source

IOM, WHO and Government of Sri Lanka, 2017.

Policy Approaches
Developing migrant-sensitive health services
  • Establish firewalls – that is, measures to separate immigration enforcement activities from the provision of health care – to avoid migrants delaying, limiting or having no access to health care.
  • Design and implement tools, including capacity-building for health-care providers, that address cultural and linguistic barriers, xenophobia and discrimination, and legal and financial hurdles, with the involvement of migrant health workers.
  • Provide factual, timely, user-friendly information on the human rights and health needs of migrants in order to counter stigmatization.
  • Engage migrant communities and civil society in design, delivery and evaluation of health services among migrants and receiving communities.
  • Identify and strengthen the health-care skills within migrant populations through training and certification, in keeping with national standards and evaluation.
Example
Tuberculosis prevention and care for migrants

On 19 May 2014, the sixty-seventh World Health Assembly (WHA) adopted the new post-2015 global tuberculosis (TB) strategy and targets. The strategy aims to end the global TB epidemic with specific benchmarks and targets through to 2035. The strategy builds on a “know your epidemic” approach, and focuses particularly on serving those not typically reached: the most vulnerable and marginalized populations. In line with the principles and three pillars of the new strategy, TB and migration can be addressed through:

  • Migrant-inclusive national TB plans:
    • Address the burden of TB in migrants and their needs in epidemiological assessments and national programme reviews.
    • Include migrants in country processes for development of national TB strategic plans and resource mobilization.
    • Strengthen country monitoring systems to include disaggregated data on migrants, where relevant.
  • Migrant-sensitive care and prevention:
    • Sensitize health personnel to migrants’ TB needs, and build cultural competency reflective of those needs.
    • Ensure that TB diagnostics, treatment and care services are adapted to the needs of migrants, including the management of multi drug resistant tuberculosis (MDR TB) and of the tuberculosis–HIV/AIDS co-epidemic (TB/HIV), as well as access to new TB technologies.
    • Establish cross-border referral systems with contact tracing and information sharing to ensure continuity of care for migrants and harmonize treatment protocols across borders along migration corridors.
    • Empower migrant communities through social mobilization and health communications.
  • Bold intersectoral policies and systems:
    • Ensure policy coherence between health and non-health sectors, such as immigration and labour, to support migrant TB interventions within and across countries.
    • Adopt policies and/or regulations that improve migrants’ access to services and to financial and social protection, regardless of status.
    • Eliminate discriminatory legal and administrative barriers.
    • Promote inclusion of TB in bilateral or regional agreements on migration with appropriate accountability; pursue innovative public–private partnerships.
  • Operational research:
    • Pursue research, including on social determinants, new tools and intervention approaches, taking into account migrants’ needs.
Source

IOM and WHO, 2014.

To Go Further

 

Global health security approaches along the mobility continuum

Local, regional and global human mobility may amplify the spread of communicable diseases and the impact of public health events if comprehensive public health prevention and services are not migrant-sensitive and migrant-inclusive. The ongoing COVID-19 pandemic and Ebola outbreaks in West Africa are a reminder of this fact. To effectively address global health security (GHS) concerns will require improving prevention, detection and response to the spread of diseases along the mobility continuum (at points of origin, transit, destination and return) and the spaces of vulnerability (SOVs) where migrants and mobile populations (MMPs) interact with stationary, local communities. This requires a multisectoral approach that unifies border management with health security and ultimately supports the implementation of the International Health Regulations (IHR, 2005). Understanding human mobility dynamics is essential for the development of public health interventions that will prevent, detect and respond to international health threats and, thereby, support the realization of the Global Health Security Agenda (GHSA). Up-to-date knowledge of mobility patterns should be complemented with the identification and prioritization of SOVs, where public health measures need to be strengthened. Knowing the origins, routes and destinations of travellers and, ensuring that migrants are included in health systems, helps to predict disease transmission patterns.

Population mobility mapping (PMM) is an important activity to guide public health interventions. It can serve as an evidence-informed tool for installing health screening posts and referral mechanisms at SOVs, especially at international border crossing points, in the event of a rapidly progressing disease outbreak or other health threat. It is especially important to have public health and surveillance measures in place in border communities in order to prevent, detect and respond to health threats. Through identifying and prioritizing SOVs, public health responses may be activated whenever a health threat is detected, through close coordination between transit and congregation points, emergency operation centres (EOCs), and referral health services.

To Go Further
  • Global Health Security Agenda (GHSA). Launched in 2014, the Agenda is a partnership of nearly 70 nations and other stakeholders that aims to promote security from infectious disease threats, bring together nations to make concrete commitments, and elevate GHS as a national priority. Global health security activities aim to minimize risks and devastating outcomes posed by pandemics, health emergencies and weak health systems.
  • IOM, Health, Border and Mobility Management Framework, 2021. The IOM Health, Border and Mobility Management (HBMM) Framework empowers governments and communities to prevent, detect and respond to health threats along the mobility continuum. HBMM endeavours to build health systems that are mobility competent, inclusive and responsive to the dynamics of human mobility, ensuring universal health coverage, which is essential for global health security.
  • IOM, Assessing Population Mobility Dynamics and Patterns for Public Health Emergency Preparedness and Response, 2017c. Discusses population mobility mapping, which is a methodology that adapts elements of the Displacement Tracking Matrix framework to understand cross-border mobility patterns for guiding health sector preparedness and response.
Policy Approaches
Selected mechanisms for strengthening cross-border health

Establish bilateral or multilateral agreements addressing access to health, such as:

  • Access to health services across borders;
  • Timely transfer of data concerning migrants’ health to ensure continuity of care; it is also important to ensure that appropriate data protection protocols are in place, and that migrants’ ownership of their personal health records is guaranteed;
  • Harmonization of treatment protocol and regimens and interoperability of information between health providers and border authorities across borders;
  • Engagement of migrants, mobile populations and communities along border areas for an empowered approach to health education, promotion and prevention;
  • Separation of border control measures from access to health care;
  • Cross-border collaboration, or regional harmonization, between destination and origin countries for treating communicable diseases, such as tuberculosis (TB), HIV/AIDS and malaria.
Addressing health vulnerability and promoting the resilience of migrants

A combination of factors during the migration process can influence health outcomes among migrants. As shown in figure 8, these factors may occur at the individual, societal, structural and contextual level (see Migration as a determinant of health in Health in the context of migration).

Image / Video
Figure 8. Vulnerability and resilience in migrant health
Source

IOM, WHO and Government of Sri Lanka, 2017.

In the context of health, vulnerability encompasses the notion of unequal opportunities, social exclusion, and other socioeconomic and cultural factors that make a person more susceptible to ill health (IOM, WHO and Government of Sri Lanka, 2017) (read more on migration as determinant of health in Health in the context of migration). Women, children, persons with disabilities and those identifying as LGBTI may be more vulnerable, and displacement induced by environmental degradation and climate events may increase migrants’ health risks (Further details in the interlinkage The environment, climate change, migration and health, and in Gender, protection and services in Chapter Gender and migration).

In contrast, resilience (IOM, WHO and Government of Sri Lanka, 2017) would be influenced by certain individual characteristics such as younger age, good living conditions, and higher levels of support that can enable the good health outcomes for migrants. Self-help groups, safe spaces for community-based discussions, skills-building support and good communication channels with families left behind can all be culturally responsive and migrant-friendly interventions to build resilience. Also relevant in the context of migration health is empowerment and recognition of the role of migrant and diaspora health workers in building resilience among communities in both origin and destination countries (IOM, 2018b; see also the interlinkage Health-related considerations in labour migration).

Policy Approaches
Promoting migrants’ resilience for good health outcomes
  • Improve or modify regulatory and legal frameworks to address specific health needs of vulnerable migrant populations, in accordance with applicable national and international laws.
  • Prioritize funding and timely implementation of health services for migrants such as maternal health care (including prenatal and postnatal care), specialized care for survivors of violence, child health activities and mental health services.
  • Ensure equitable access to occupational health treatment for migrant workers, especially in sectors known to be prone to exploitation and hazardous working conditions.
  • Promote empowerment and resilience building of migrants through health interventions. In parallel, promote the inclusion of migrants in societies so they can access and benefit from health care. Promote intersectoral partnerships that support such empowerment, resilience building and inclusion (see the case study below for an example.)
Case Study
Resilience building to engage migrants as change agents and active participants in health interventions

The Dutch Government is funding an ongoing programme for improving the sexual and reproductive health, rights and HIV outcomes for migrants, adolescents and young people and sex workers in migration-affected communities in Southern Africa, with a primary focus on border regions with high levels of mobility. Over 1,400 community change agents have been engaged since 2016, and the high quality of their work is evident in the increase in persons reached by the comprehensive sexual and reproductive health services, and in the referral follow-through rate of above 60 per cent among clients referred from communities to local health facilities. The use of a holistic service delivery capacity model – with sensitization and upskilling of health-care facility staff, from security guards to clinicians to administrators – has helped to ensure migrant-friendly services are delivered in communities in need.

Source

IOM Regional Office for Southern Africa, 2019b.

To Go Further
Technology and social innovation

Technology and social innovation across the globe not only support migrants’ connections with their families but also offer opportunities to link them to health information and services.

Innovative internet- and mobile-based technologies for health providers include e-learning, telemedicine, and telesurgery support offered to health professionals working in remote areas, in conflict areas and other settings (further details on crises contexts in Emergency and response). Appointments online are one way that internet-based solutions may improve health system efficiency in contexts where resources –such as available trained medical professionals – are scarce.

Innovative internet- and mobile-based technologies for health for migrants. The use of mobile phones in medical care, and mobile health, is called mHealth. Given the number of mobile phone users, mHealth interventions can potentially remove some of the health challenges associated with mobility. mHealth can help to address adherence to medical regimens among marginalized or hard to reach populations, such as certain groups of migrants, through directly observed therapy (DOT) using mobile tech or video observed therapy. It may improve health system efficiency in contexts where resources, including available trained medical professionals, are scarce (for example, through the use of short message service [SMS] to track or remind patients to take their medication). Solutions can further make information on health systems more readily available for migrants.

Case Study
Implementing the electronic personal and health record to promote access and integration in the European Union

In recent years, international migration into the European Union has increased markedly. As a consequence, the importance of directives aiming at improving cross-border health care and data sharing is increasingly apparent. Backed by extensive prior field assessments, and in line with the European Agenda on Migration, the project Re-Health1 was launched in 2016 in partnership with IOM. Re-Health1 aims to assist European Union Member States, especially those under particular migratory pressure, to address migration health issues, while addressing possible communicable diseases and cross-border health events.

The project reinforces the need for a unified tool for health assessment at the European Union level. Such a tool enables retracing the medical history of newly arrived migrants, facilitates transit to destination countries and fosters the integration into national health systems. The project established an electronic health database of electronic personal health records (e-PHR) and piloted it in different countries across Europe. Croatia, Greece and Slovenia, with the support of IOM, then started implementing and consolidating the use of e-PHR as a single tool for health assessments. IOM is also developing a revised version of the tool and its related electronic platform with the overall objective of contributing to the integration of newly arrived migrants and refugees, including those to be relocated, in the European Union Member States’ health systems.

These efforts are aligned with the priorities and actions set out under the EU Public Health Work Programme 2017 as well as with the SDGs towards well-managed migration, universal health coverage and government commitments to “leave no one behind”, and WHA70.15 on promoting the health of refugees and migrants and the Global Compact for Migration.

Source

E-PHR.

Mental health and psychosocial support

Any form of migration implies a redefinition of individual, family, group and collective identities, roles and value systems, which can put the individuals, the families and the communities involved under stress. An inclusive and human rights-based approach that guarantees the availability and accessibility of psychosocial support and mental health care to all migrants (irrespective of their status) and their receiving communities can contribute to positive social, economic and cultural outcomes for migrants, their families, communities, and also the societies of both origin and destination countries. In the context of migration health interventions, this can involve, for instance:

  • Capacity-building of service providers in mental health and population mobility;
  • Actions promoting migrants’ access to mental health services, including ensuring that there is continuity of psychosocial support;
  • Integration of mental health care for migrants in primary health-care settings;
  • Capacity-building for mainstreaming interpretation, mediation, outreach to diverse populations and cultural diversity awareness in mental health services.
To Go Further
Key messages
  • Global health goals require a shift towards equity and inclusiveness for migrants; people-centred and migration-sensitive health systems accelerate gains in health outcomes and reduce health inequalities between populations.
  • Advancing the Global Health Security Agenda requires understanding human mobility dynamics and multisectoral approaches to develop public health interventions to prevent, detect and respond to international health threats along the mobility continuum.
  • Technology and social innovation, such as internet- and mobile-based technologies for health providers and for migrants, can be used to support migrants’ connections with their families and link them with health information and services.
  • All migrants – regardless of their status – need access to mental health and psychosocial support in addition to physical health services, which contribute to positive social, economic and cultural outcomes for migrants, their families, communities, and societies of both origin and destination countries.
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