That migrants carry the threat of spreading infectious diseases is a common but ill-founded concern. Most immigrants are in fact young and healthy upon arrival. The overall health gaps observed between migrant and non-migrant populations across Europe can largely be explained by risk factors people with a migrant background are disproportionately exposed to, both during the migration journey and upon arrival in the host countries. These factors include dangerous routes, poverty, administrative hurdles, etc.
Given that the well-being of each resident group has a direct effect on public health as well as social and economic implications for the entire country, improving migrants’ (early) access to basic healthcare services is of public interest. The lack of social security and protection only exacerbates health conditions that could have been prevented if lower-cost services were available. Principles of health economics indeed show that cost containment is achieved in the case of timely and appropriate use of health services.
This paper sets out to map commitments made by ministries responsible for Health and Integration to close the health gap between migrant and non-migrant populations. Have they created migrant sensitive health systems? Are they providing tools that allow migrants to successfully realise their right to health care? Have they set clear indicators to monitor their efforts? Are these efforts coordinated with other relevant authorities?
Results show that although most Member States define migrant health as a separate policy field, in most cases, no comprehensive migrant health policy is put in place and the need for tools to ensure accountability and evaluation remains. Encouraging measures and good practices such as dedicated government departments, clear hierarchical division of responsibilities between governance levels and availability of cultural mediators can nevertheless been found across Europe.
International and European Framework
Internationally, the right to health was first articulated in the 1946 Constitution of the World Health Organization (WHO). The 1948 Universal Declaration of Human Rights also mentioned health as part of the right to an adequate standard of living (art. 25) and the right to health was again recognised as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights. Subsequent international and regional human rights instruments continue to address health as a fundamental human right that applies to every human being, regardless of their migration status; and governments are obligated to uphold this right in the interest of good public health governance. The adoption of the Resolution 61.17 on Migrant Health during the 2008 World Health Assemblyreaffirmed the need for a rights-based, equity-driven and multi-sectoral approach that strengthens health systems.
Portugal played an important role in bringing the topic of migrant health to this Assembly during its EU presidency, as underlined by the Council Conclusions on Health and Migration. The health of migrants has since then continued to be addressed by several other presidencies. Guiding outputs range from the 2010 Spanish Council Conclusions on Equity and Health to the 2016 Dutch report putting forward best practices investing in social determinants of health.
The European social charter and the charter of fundamental rights are also relevant to migrant health. The EU further issued a number of legally binding directives that impinge on migrant health. These include the racial equality directive, the long-term residents directive and the directive laying down minimum standards for the reception of asylum seekers. To foster the implementation of these legal frameworks, the european commission supports several projects under the eu health programme. The projects focus on both health provision for migrants and relevant training packages for health professionals. Furthermore, in june 2016, the commission adopted an action plan to better integrate third country national that includes several health proposals.
Migrant-sensitive health governance?
International and European frameworks pave the way for health equity but no equal access to health care is possible without national commitments. National legislations, policies and actions are therefore required to comply with international and European standards that set parameters for the respect of human rights, including health. A 2017 research on the implementation of the right to healthcare under the UN Convention on the Rights of the Child (UNCRC) commissioned by the European Commission established that although all EU Member States have ratified the UNCRC, only four (Cyprus, Croatia, Italy and Spain) have introduced a legal disposition that guarantees this right to all children living in their territory, irrespective of their legal status (nationality, social insurance or residence) and seven (France, Greece, Malta, Poland, Portugal, Romania, Sweden) ensure health care to all groups of children residing in their territory through regular health care legislation by setting out the eligibility criteria or by organising special additional schemes for specific groups that fall outside the main statutory coverage.
At the end of 2017, No EU Member States had an ongoing health strategy or action plan designed by ministries responsible for Health to specifically target migrants and people of migrant descent. Striking is also many Member States which have a National Health Strategy in place that does not make any reference to migrant health and accessibility of healthcare for migrants, while addressing the needs of other ‘vulnerable’ groups. And where a reference is made to migrants’ health needs, there is a lack of target setting or basis for accountability.
Despite the lack of strategies specifically addressing migrant health, tools currently in place to address migrant health in Malta are exceptional and worth bringing forward as a good practice. The Maltese Ministry for Health has a department dedicated to solely dealing with migrants and their access to healthcare. The Migrant Health Unit was set up in 2008 in view of the large influx of irregular immigrants. The Unit was renamed as Migrant Health Liaison Office (MHLO) in August of the same year and expanded its activities to all Third Country Nationals. Migrants are here provided with information on available healthcare services as well health education sessions. To further address migrants needs, diversity trainings are available for cultural mediators and other healthcare professionals.
It is apparent that in the recent years, following the refugee arrivals of 2015, ministries of health or their technical bodies have started to issue recommendations for good practices in immigrant healthcare (see examples in Finland, United Kingdom and Italy), as well as to formalise their cooperation with service providers, organisations and authorities working directly with migrants. In January 2017, the Swedish Health Ministry had for example tasked the Swedish Association of Local Authorities and Regions (SALAR) to implement the national program Health in Sweden through which health professionals are trained on how to better meet the needs of asylum seekers and newcomer immigrants showing signs of mental illness. Another example is the programme PHILOS – Emergency health response to refugee crisis launched by the Greek Ministry of Health and implemented by the Hellenic Centre for Disease Control and Prevention (HCDCP). The programme, funded by the EU’s Asylum, Migration and Integration Fund (AMIF), is designed to address the sanitary and psychosocial needs of refugees living in the open camps. In Cyprus, the health legislation granted TCNs and refugees the same rights to social security as nationals in 2017 and the Strategy on the Rights of the Child in Health for 2017 – 2025 defines access of migrant children to health services as one of its action areas.
The Integration authorities in Austria, Croatia, Denmark, Finland, Germany, Ireland, Italy, Latvia, Portugal, Slovakia and Spain define migrant health as a separate field of action in national Integration Plans and in many Member States, the Ministry responsible for Health takes an active role in the drafting process of National Actions Plan on Integration. And these policy documents therefore do occasionally outline goals such as raising the share of employees with immigrant background in medical professions or improving intercultural competences among health professionals.
A recent example is the Croatian 2017-2019 Refugee Integration Action Plan which sets measures to provide better health care to beneficiaries of international protection, especially by overcoming linguistic and cultural obstacles to the provision of health services. Attention was also brought to the topic in Germany where the Commissioner for Immigration, Refugees and Integration set health and care provision at the centre of her integration policy in 2015. Health has similarly been given a central position in Finland’s Integration Programme for 2016-2019. However, many of the Action Plans often fail to specify concrete actions to achieve goals and to assign responsibility for implementation. The Irish National Intercultural Health Strategy for the period 2007-2012 is the only example of an accomplished national strategy for migrant health. Unfortunately, the document was never implemented. A second Intercultural Health Strategy is nevertheless foreseen within the country’s 2017-2020 Integration Strategy.
Responsibilities to Implement these targeted health measures are sometimes be blurred between the different levels of governance but Italy can be considered a pioneer with regards to clear hierarchical chains and division of labour. Its three-tier system in health services: central, regional and local health authorities, is an appropriate response to discretionary interpretation of national laws. An Agreement between the central government, the regions and the autonomous provinces was established in 2012 and the Guidelines for the correct application of legislation on healthcare to the foreign population by regions and autonomous provinces largely leave health care provision to regions. There are therefore some inter-regional differences in migrant health outcomes, depending on the financial strength of the regions for example. Devolution of healthcare powers and funds is also a reality in the Netherlands since 2015 when, following the decentralisation of healthcare services, all local governments developed plans to provide full coverage and accessible healthcare to every city’s inhabitants. Some cities have even created neighbourhood-level plans. However, the extent to which these plans specifically target migrants remains to be analysed.
Diversity-competent health care?
Targeted efforts can increase health equity but to reach equal access to health care, effective communication on health rights and the health care system toward migrants and service-providers are needed. While written information (in form of websites, brochures or leaflets) about migrants’ right to healthcare and available services does exist all across Europe, none of the Member States have clear government policies and defined practices on this issue. Overall, access to information for migrants remains inadequately addressed by governments. First, very little practical information is provided on how to access these services. Then, linguistic barriers are insufficiently tackled to increase the responsiveness of the healthcare system to migrants, meaning the extent to which health services are adapted to meet their needs. Some tools are nevertheless provided:
Intercultural mediators or patient navigators can play a wide range of roles, including patient advocate, health educator and interpreter. As successful as this practice proves to be, Belgium is the only Member State that guarantees the provision of cultural mediators and patient navigators to migrants across the healthcare system. A free pilot online video-conference platform was additionally launched in 2017. If positively evaluated, it will be deployed at a larger scale and will be accessible for all the practitioners. While other Member States such as Ireland have adopted comparable practices, this service is offered on a much smaller scale or on ad hoc basis. In half of the Member States (Bulgaria, Croatia, Cyprus, Estonia, Greece, Hungary, Ireland, Latvia, Portugal, Poland, Romania, Slovenia, Spain and the UK), there is no legislation or policy regarding cultural or health mediators for migrants nor patient navigators, impeding many migrants of fully exercising their rights. Among the 12 Member States that do have official standards and guidelines in place, the most culturally sensitive areas include mental-health services (le Service de Santé Mentale Ulysse, MyMind), elderly care (multilingual & multicultural care home) and services tailored to female migrants (specialised treatment of FGM), just to name a few.
Interpreters are available free of charge to patients with inadequate proficiency in the host country’s official language(s) in 13 Member States (Austria, Belgium, Cyprus, Denmark, Finland, Germany, Ireland, Italy, Luxembourg, Portugal, Spain, Sweden and the UK). Patients must pay all (or a substantial part) of the costs in 5 Member States (Czech Republic, France, Hungary, Malta and the Netherlands). But whether or not this service is free of charge can have a significant impact. Research show for example that the use of interpreters dropped sharply, particularly in mental healthcare, when the Dutch government stopped funding the provision of qualified interpreters in 2012. This does not only disadvantage the patient, but it also creates a burden for the care providers, as doctors are legally obligated to inform the patient about their rights, diagnosis and treatment in order to obtain informed consent. Such cut-backs are also observed in Ireland, Estonia and Greece. Overall, the lack of interpreters has been identified as one of the main challenges about healthcare provision at receptions centres by the European Union Fundamental Rights Agency.
Translation – Documents specifically compiled for migrants are far too often only available in the country’s national language, or with limited translations. Though brochures limited to newcomer asylum seekers and refugees are translated in their most frequent native languages in an increasing number of Member States. The multi-lingual web-portal co-funded by the Danish National Health & Medicines Authority is one of the few positive examples targeting all migrant groups. It provides short informational clips about the health system, health insurance, pharmacy and interpreters in 8 languages.
Indicator-based health systems?
Upon arrival, migrants are often younger than the host country average and generally healthier than native-born populations. This so-called ‘healthy immigrant effect’ however deteriorates with the time of residence. Once the age factor adjusted, studies find a disproportionate share of migrants among the population groups with low health outcomes. This is explained by the fact that people with a migrant background are disproportionately exposed to risk factors.
Risk factors are one of the best documented aspects of migrant health. Studies find that the immigrant population face poverty, stigma, discrimination, social exclusion, exploitation, administrative hurdles, as well as language and cultural barriers which exacerbate their vulnerability. The combination of these factors often leads migrants to become a marginalised and invisible group with limited access to health and social services.
To develop strategies aiming to improve migrant health and achieve health equity, up-to-date information on a series of interconnected data such health status, determinants and service utilisation by migrants are needed. In the same vein, good-quality and comprehensive data are indispensable to measure and evaluate the impact of services and policies on the health outcomes of migrants.
At the end of 2017, Austria, Croatia, Germany and Portugal were the only four Member States to have defined indicators to measure immigrant integration in the field of health and healthcare. Though more governments issue national targets in health policies. One reason for this may be that in the majority of EU Member States, data on migrant health is not routinely available, as collection of data on ethnicity and migrant status is forbidden by law in many EU countries. MIPEX 2015 showed that the inclusion of data on migrant status, country of origin or ethnicity in medical databases or clinical records is required only in 8 Member States (mainly through registration forms in hospitals and clinics), optional in 14 and never included in 6. The 2016 thematically focused research about the fundamental rights situation of newcomers in 14 Member States confirmed this data vacuum. None systematically collects data on health status of newly arrived migrants nor of their use of the healthcare system. The European Commission launched a tender in December 2017 to evaluate existing data on the health condition of migrants and refugees who have reached the European Union since 2015.
In the handful of countries which do conduct migrant health research, most data are drawn from small studies or unrepresentative samples. In the majority of cases, respondents are only asked to report nationality (naturalised migrants become invisible) or country of birth but rarely on additional information such as residence status or years of residence. France is one the few countries where specific groups are the subject of research. Specialised organisations such as the Observatoire du droit à la santé des étrangers and the Comité médical pour les exilés produce annual reports highlighting the health status of specific groups of migrants.
A one-off project on immigrant health that has left a long-lasting mark is the 2010-2012 MAAMU project, coordinated by the National Institute for Health and Welfare (THL) in Finland. The findings of the project fed directly into the Government Integration Programme for the period 2012-2015 and were later used to design indicators for measuring the health and welfare of immigrant children and youth. Some years later, in May 2017, the Finnish National Institute for Health and Welfare has introduced an official set of indicators on the health and well-being of immigrants to support the monitoring of national integration.
Elsewhere the need for the identification and implementation of health indicators to ensure accountability through health targets and policies evaluation remains. Tools that can assist in acquiring migrant-relevant health information include integrating migration questions to existing data collection exercises, such as census, national statistics reports and health surveys in a way that allows for disaggregation by specific population groups and their usability by all relevant stakeholders. The Migrant Integration Policy Index (MIPEX) provides an example of a migration policy monitoring initiative that could be used to monitor health.
Coordinated health policies?
Targeted international standards, legal frameworks, policy efforts, indicators and communication tools are essential to address migrant health issues but general policy areas such as labour, social affairs and anti-discrimination can also influence migrants’ health vulnerability and health outcomes. Our research in fact finds that among countries which have defined migrant health as a separate field of action in their National Integration Plan, the Ministry responsible for Health has most often been consulted in the drafting of the migrant integration strategy.
A systematic review of available evidence on the association between health outcomes and integration policies, prepared for the 2nd Global Consultation on Migrant Health, show that overall, immigrants experience a clear disadvantage for most health outcomes compared to non-immigrants. However, these disparities were generally reduced in countries with a strong integration policy. Further work would be required to link current policy measures with health outcomes.
Social and health equity are also interlinked. “Health in all Policies” (HiAP) is a term and concept that gained visibility during the Finnish presidency of the European Union (EU) in 2006 to stimulate health considerations in policy making across several sectors. The Commission’s Directorate-General for Health and Consumers, at the time, had supported Finland in the development of its Presidency theme, and made HiAP one of four main principles in its own strategic work on health.The HiAP approach improves accountability of policymakers and emphasises the consequences of public policies on health systems and determinants. Comparative EU research reveals that a HiAP approach, from a migrant health point of view, is still practically unknown in most countries. Only in the UK is there a mandatory consideration of the impact on migrant or ethnic minority health of policies in other sectors than health. Ad hoc consideration of the impact policies in other sectors on migrant or ethnic minority health nevertheless takes place in Austria, Spain, Finland, Ireland and Italy.
With respect to the economic aspects of migrant health, there is a need to generate and disseminate further evidence on the overall cost-effectiveness of providing affordable, timely and preventive health services and to strengthen the link between the latter and an active and economically productive workforce, as in line with health economics, policies and financing for migrant health are not a burden, there are an investment.