Essential Knowledge - Health and Migration

Why a WHO focus on health, migration, displacement and human mobility

Why a WHO focus on health, migration, displacement and human mobility
IOM/Keith Dannemiller
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Migration and displacement have been a constant dynamic in human history. People have migrated since the beginning of human history to escape poverty, natural disasters, war and dictatorships, and to seek a better lives for themselves and their families. These flows have greatly benefited the world, leading to cultural, societal and intellectual advances. Yet the process and context of migration and displacement may have a negative impact on both migrants and communities. This can happen when their specific health needs are not met or when the circumstances of their movement act as adverse determinants for their health.

The health of refugees and migrants bridges the spheres of human rights, public health, humanitarian assistance and development:

  • migrants are human-beings and have a right to health;
  • migrant-inclusive health systems improve public and global health outcomes for all;
  • saving lives, reducing mortality and morbidity and creating better health systems for both the migrants and the hosting communities are key tenets in the context of displacement and humanitarian crises; and
  • healthy migrants are better able to contribute to positive and sustainable development outcomes.

The adoption of inclusive health policies in relations to refugees and migrants has not been universal; in most countries, the level of access to health care for refugees and migrants is determined by factors such as their status; national migration policies; societal values; and their capability in overcoming linguistic, cultural, economic and social barriers. A further determinant is the capacity of the health sector to produce evidence for and advocate for the adoption of adequate public health responses to the growing and changing reality of modern migration, which is a global megatrend. Additionally, migration places individuals in situations that may impact their physical and mental well-being; this is particularly true for those who are forced to flee natural or man-made disasters (whether across borders or within their own country), those in an irregular situation and those with particular vulnerabilities and health and protection needs.

Although comprehensive data sources on refugee and migrant health are scant, and often systematic disaggregation of health data as a function of migratory status is lacking, there are converging views in the available literature. These views identify recurring areas of concern in relation to migration and health outcomes, particularly infectious diseases, noncommunicable diseases, trauma and mental health; gender- and age-specific factors of vulnerability are also identified. Some studies have shown that migrants frequently experience poorer health and a lower average life expectancy than that of the general population and have increased infant/child mortality and lower reproductive health, ineffective access to health services (over- or underuse, or both) and a higher risk of being insufficiently treated by health services.

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Who are the refugees and migrants? What are their challenges?

There is no universally accepted definition of the term migrant. Migrants may be granted different legal status depending on their country of stay because national legislations may have different interpretations regarding entitlement and access to essential health-care services. However, such access is a universal right for all under international law, in line with the 2030 Agenda for Sustainable Development (2030 Agenda) and its Sustainable Development Goals (SDGs), in particular SDG 3 (ensure healthy lives and promote well-being for all at all ages).

In recent years, concerns have been expressed about the apparent erosion of the rights recognized by the 1951 Convention and other human rights instruments. These include a marked increase in security at borders; the indiscriminate application of highly restrictive and deterring policies to refugees, asylum seekers and so-called economic migrants attempting to cross borders in mixed flows; the externalization of border control; anti-migrant and anti-refugee sentiments; violence, detention and abuses; and the growing attribution of security threats to the presence of refugees and migrants in legislation, media or political discourse. While the safeguard and possible enlargement of protection regimes is in the purview of human rights and migration laws, it is incumbent on health systems to adopt remedial public health interventions that curtail the negative health impact of these trends.
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Who are the refugees and migrants? What are their challenges?
UNHCR/Roger Arnold
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Current migration and displacement situation and trends

It is estimated that there were 1 billion migrants worldwide in 2020, of whom 281 million were international migrants (i.e. 3.6% of the world population), and approximately 763 million were internal migrants, with a tendency for a marked increase in this last group (UNHCR, 2020). The International Organization for Migration estimates that the vast majority (65%), of international migrants, both displaced people and economic migrants, are workers or people seeking employment. Those seeking employment tend to be a young and productive population, with an estimated average age of 39 years and 15% (37 million) under 20 years of age. There is a marked female preponderance within migration, with women making up 48% of global migrants. The vast majority of these women are economically active.

As of 2020, Europe and North America hosted the greatest number of international migrants, followed by northern Africa and western Asia. The total numbers and percentages of international migrants by World Health Organization (WHO) region (including migrants, refugees and asylum seekers) are shown in Fig. 1.1. The number of people who have been forcibly displaced globally continues to increase as a result of conflict, humanitarian and climate-related disasters. UNHCR has estimated the number of forcibly displaced globally to be at 82.4 million. Refugees and asylum seekers account for approximately 12% of international migrants, as estimated by the United Nations Department of Economic and Social Affairs (UNDESA), and most of them live in countries adjacent to their country of origin.

Developing countries hosted 86% of the world's refugees and Venezuelan migrants. (Note that the term "Venezuelans displaced abroad" is defined by the UNHCR as "persons of Venezuelan origin who are likely to be in need of international protection under the criteria contained in the Cartagena Declaration, but who have not applied for asylum in the country in which they are present". More than half of newly recognized refugees during the first half of 2021 were from five countries: the Central African Republic (71 800 refugees), South Sudan (61 700), the Syrian Arab Republic (38 800), Afghanistan (25 200) and Nigeria (20 300). At the same point in time, there were 92 100 newly displaced Venezuelans (refugees, asylum seekers and migrants) in Latin America and the Caribbean. By the end of 2020, more than three quarters of the global refugee population (15.7 million) was in a situation of protracted displacement.

Figure 1. Total number and percentage of international migrants, refugees and asylum seekers, disaggregated by age and sex, by WHO Region

Source: WHO (2022). The World report on the health of refugees and migrants. Geneva: World Health Organization.

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What are the key health factors and public aspects in the context of migration and displacement?

Structural issues

Key structural issues having relevance in migration and displacement health outcomes are disparities, inequalities and social and contextual health determinants.

Disparities
  
Movements most often take place between countries with marked disparities in terms of wealth, opportunities, governance, access to needed health care and health system performance. Health profiles and migrant backgrounds are more often a reflection of the burden of diseases and performance of the health system in the countries of origin and transit, such as immunization status, health-seeking behaviour, failure to meet immediate or chronic health needs before departure or during travel, or exposure during the journey to endemic diseases. During their journey, migrants cross not only geographical borders but also epidemiological ones and migration, therefore, bridges health disparities and can lead to disease burdens that may persist for years.
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Inequalities  
While a variety of international instruments assert the right to health, in practice refugees and migrants fall in the crack between principles and policies, especially those awaiting clarification of their status, such as asylum seekers and those without documents. Many countries limit right of access to health services to only their citizens, and migrants might have fewer entitlements. Some migrant groups, such as irregular migrants, may only have access to emergency care and can be denied access to preventive care or other essential health services. Regular migrants may also need to pay higher costs. In addition to legal barriers to health, migrants can face a combination of geographical, administrative, social, cultural, economic, behavioural and linguistic barriers to health services; these might exclude them from equal access even when regulatory frameworks affirm otherwise. The realization of migrants' equity to health unfortunately remains a distant, aspiration in many countries.
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Social determinants of health
  

Migration and displacement circumstances act as factors of risk; these can be individual (e.g. gender, age, skills and societal capital, or health profile), related to living and working conditions (e.g. overcrowding, exploitation, lower wages or poor sanitation), related to social and community values and norms (e.g. xenophobia, intolerance and religion) and/or they may be inherent to migration policies and overall governance.

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These structural and policy elements might fuel health inequities and may expose refugees and migrants to health risks and negative health outcomes. The context of the migration and displacement journey itself might expose refugees and migrants to violence, abuses and death. Consequently, migration and displacement are considered as critical determinants of migrant health.

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Legal frameworks
  
The human rights of refugees and migrants are guaranteed by a broad range of United Nations conventions whether related to human rights, refugee protection, labour migration, people smuggling or trafficking of migrants. Refugees and migrants’ access to health care is shaped by legal frameworks governing the rights of them and by the regulation of the migration process. However, the legislation on refugees and migrant rights to healthcare and entitlements varies among the countries reflecting different political and societal choices for refugee and migrant populations.
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Access to healthcare services
  
Access to health care services for refugees and migrants varies within national boundaries of each country. It depends on the person’s legal status and usually refugees and migrants having the required residence permits follow the same pathways and services as the host population. In most countries barriers to access healthcare for refugees are often identified as, communication difficulties (e.g. lack of interpreters), cultural issues (e.g. gender preference for doctors), structural problems (e.g. transport) and bureaucratic barriers (e.g. social insurance systems). Access to specialist services can also be difficult. The nature and length of the asylum process plus the use of detention and dispersal can have a significant impact upon health outcomes.
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Policy issues

The health of refugees and migrants intersects with two key policy sectors: public health and migration governance, with often competing, if not conflicting, goals.

  • Health goals are inclusive (i.e. based on Health for All Policies, health equity, universal health coverage, etc.) and are grounded on inclusive and egalitarian principles and values (e.g. human rights, equity, public health in the best common interest of all, multilateralism, intercountry and intersectoral cooperation and partnership).
  • Migration goals are often exclusionary and restrictive and can be related to issues such as secured borders, national security and identity, trade interests, social control and, in some cases, nationalism and issues of sovereignty.
  • Consequently, until recently, the topic of health has been absent from migration governance debates, and health policies and strategies have rarely explicitly recognized migrants. Combining these two policy sectors to achieve positive health outcomes remains both a challenge and an obligation for public health policy-makers and practitioners.
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Common health needs of refugees and migrants

Refugees and migrants may have health needs that differ from those of the host population, requiring effective and culturally responsive care that recognizes the impact of migration on physical and mental health. Refugee and migrant populations may also face a number of challenges to accessing health care that can shape their interactions with the host country’s health system and health workforce, including language and cultural differences, low levels of health literacy, discrimination and restricted access to mainstream health services. Details can be found at: https://apps.who.int/iris/handle/10665/346743 

Health and migration phases_0
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Global legal frameworks, charters and treaties related to migration

Charter of the United Nations
  
Human rights, development, and peace and security are the three interlinked pillars of the United Nations system. Encouraging respect for human rights is a fundamental purpose of the United Nations under its Charter. All agencies and organizations under the United Nations system are committed to the common values and purpose of the Charter in addition to their own unique mandate and contribute directly and indirectly towards the realisation of human rights.
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Universal Declaration of Human Rights
  
The Universal Declaration of Human Rights was adopted by the General Assembly in 1948. The Preamble asserts the “inherent dignity and the equal and inalienable rights of all members of the human family [which] is the foundation of freedom, justice and peace in the world”. It further affirms that “all human beings are born free and equal in dignity and rights” (Article 1) and that “everyone is entitled to all the rights and freedoms set forth in this Declaration” (Article 2). The Universal Declaration establishes no hierarchy between human rights; all rights are universal, inalienable, indivisible, interdependent and of equal importance. Human rights law thus provides that every person, without discrimination, must have access to his or her human rights. Simply put, all human beings have all human rights, including all migrants, regardless of their migration status.
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International human rights law treaties
  

Since 1948 a series of international human rights treaties have been adopted and ratified by Member States to give legal form to the inherent human rights enshrined in the Universal Declaration of Human Rights, and these have further expanded and developed the international human rights framework. The nine core international human rights treaties apply to everyone without discrimination (UNHCR, 2020):

  • International Convention on the Elimination of All Forms of Racial Discrimination (1965);
  • International Covenant on Civil and Political Rights (1966);
  • International Covenant on Economic, Social and Cultural Rights (1966);
  • Convention on the Elimination of All Forms of Discrimination against Women (1979);
  • Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1984);
  • Convention on the Rights of the Child (1989);
  • International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (1990);
  • International Convention for the Protection of All Persons from Enforced Disappearance (2006);
  • Convention on the Rights of Persons with Disabilities (2007).
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Other global frameworks

In 2006 the First United Nations General Assembly High-level Dialogue on Migration and Development was held to discuss the multidimensional aspects of international migration and development and to identify appropriate ways to maximize its development benefits while minimizing negative impacts. Although health issues were not addressed, this first global migration debate set in motion opportunities for intersectoral exchanges; these started in 2008 when the first ever World Health Assembly resolution on the health of migrants (WHA 61.17) was adopted and made reference to the High-level Dialogue. The fundamental public health tenets of the resolution led to the following initiatives.
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The 2030 Agenda
  
The United Nations General Assembly in the 2030 Agenda set 17 SDGs and 169 targets to build on the Millennium Development Goals. Within SDG 3 (ensure good health and well-being for all at all ages), SDG 3.8 specifically refers to achieving universal health coverage. Issues linked to migration feature prominently in the 2030 Agenda: SDG 10 addressed reduced inequalities and SDG 10.7 called for the facilitation of orderly, safe, and responsible migration and mobility of people, including through implementation of planned and well-managed migration policies. Although migrant health was not explicitly recognized within the SDGs, synergies within the SDGs include with SDG 1 (no poverty), SDG 5 (gender equality), SDG 8 (decent work and economic growth), SDG 11 (sustainable cities and communities), SDG 16 (peace, justice and strong institutions) and SDG 17 (partnerships for the goals). These offer a new, larger, and widely supported framework for advancing the migrant health agenda at multisectoral and interagency levels consistent with the scope of the social determinants of health. Recently, the Political Declaration that concluded the High-level Meeting on Universal Health Coverage at the United Nations General Assembly in September 2019 recognized the need to address the physical and mental health needs of refugees, internally displaced people and migrants (paragraph 70).
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New York Declaration for Refugees and Migrants
  
In 2016, heads of state and governments from around the world gathered at the United Nations General Assembly in New York to address comprehensively the issues of refugees and migrants. The meeting adopted the United Nations New York Declaration for Refugees and Migrants with the intent of improving the way countries respond to large movements of refugees and migrants, firmly linking migration to the realization of multiple SDGs including in health. The Declaration pledged to protect the rights of people on the move; support countries that shelter them; share international responsibilities more collaboratively, equitably and predictably; and combat xenophobia, racism and discrimination towards all migrants.
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Global Compact for Safe, Orderly and Regular Migration
  
The Global Compact for Safe, Orderly and Regular Migration was adopted by Member States in 2018. Its adoption provided an opportunity to interlink processes and to relaunch the theme of health and migration within the health sector. The Global Compact comprises 23 objectives; Objective 15 is to provide access to basic services for migrants and directly includes provision for the health of migrants, linking this process with the WHO Framework of Priorities and Guiding Principles to Promote the Health of Refugees and Migrants (noted by the 70th World Health Assembly in 2017). The United Nations Network on Migration, of which WHO is a member, was established to strengthen accountability mechanisms that link the implementation of the Global Compact with follow up, verification and results, including a Multi Partner Trust Fund and an International Migration Review Forum that took place in May 2022.
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The Global Compact on Refugees
  
Similarly, the Global Compact on Refugees, also adopted in 2018, represents a more predictable and equitable responsibility-sharing mechanism, recognizing that a sustainable solution to refugee situations cannot be achieved without international cooperation; as far as health is concerned. It implies a progressive shift from a purely emergency approach in the provision of refugee assistance to a longer-term health system strengthening and the enhancement of the humanitarian–development nexus.
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WHO resolutions and frameworks

At its 140th session in January 2017, the WHO Executive Board in decision EB140(9) on promoting the health of refugees and migrants requested the Director-General, inter alia, to prepare, in full consultation and cooperation with Member States and, where applicable, regional economic integration organizations, and in cooperation with the International Organization for Migration and the United Nations High Commissioner for Refugees and other relevant stakeholders, a draft framework of priorities and guiding principles to promote the health of refugees and migrants. The framework should be a resource for Member States in meeting the health needs of refugees and migrants and contributing to the achievement of the vision of the 2030 Agenda.

In May 2017, the World Health Assembly in resolution WHA70.15 on promoting the health of refugees and migrants noted with appreciation the Framework of Priorities and Guiding Principles to Promote the Health of Refugees and Migrants and urged Member States, in accordance with their national contexts, priorities and legal frameworks, to strengthen international cooperation on the health of refugees and migrants in line with paragraphs 11 and 68 and other relevant paragraphs of the New York Declaration for Refugees and Migrants. In addition, the World Health Assembly requested the Director-General, inter alia, to identify best practices, experiences and lessons learned regarding the health of refugees and migrants in each region in order to contribute to the development of a draft global action plan on the health of refugees and migrants for consideration by the Seventy-second World Health Assembly. The Framework of Priorities and Guiding Principles includes the following guiding principles:

  • the right to the enjoyment of the highest attainable standard of physical and mental health;
  • equality and non-discrimination; equitable access to health services;
  • people-centred, refugee-, migrant- and gender-sensitive health systems;
  • non-restrictive health practices based on health conditions;
  • whole-of-government and whole-of-society approaches; and
  • participation and social inclusion of refugees and migrants; and partnership and cooperation.
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WHO Resolutions and framework
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The Global Action Plan on promoting the health of refugees and migrants (2019–2030)

At the World Health Assembly in 2019, Member States agreed a five-year global action plan to promote the health of refugees and migrants. The Global Action Plan focuses on achieving universal health coverage and the highest attainable standard of health for refugees and migrants and for host populations. The Global Action Plan was fully embedded into the vision of the WHO Thirteenth General Programme of Work, 2019–2023 and its triple billion goals. In 2023, the Seventy-sixth World Health Assembly adopted a resolution to extend the WHO Global Action Plan on promoting the health of refugees and migrants until 2030.

The Global Action Plan identified the following six priority areas.

WHO Health and Migration Programme

Welcome to refugees from Ukraine at the Medyka border in Poland - 2022
WHO / Uka Borregaard
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To provide health leadership and support Member States in implementing the Global Action Plan and the health-related objectives in the Global Compacts and the SDGs, WHO headquarters has established the Health and Migration Programme with the following mission, core strategic functions and actions:

  • provide global leadership, high level advocacy and dialogue to raise awareness and political commitments, coordination and policy development on health and migration;
  • set norms and standards on health and migration including co-development of guidance and tools and promote a research agenda aimed at generating evidence-based information to support decision making and global guidance for new tools and strategies on health and migration;
  • monitor trends, strengthen health information systems, develop accountability frameworks and indicators for progress monitoring and reporting on the implementation of the Global Action Plan;
  • provide specialized technical assistance, response and capacity-building support to Member States, WHO technical departments, regional and country offices and partners in addressing public health challenges that are associated with human mobility wherever needed nationally and transnationally; and
  • promote multilateral action, intercountry, interregional and global collaboration for continuity of care and coherent and integrated actions, and accelerate progress through working across United Nations systems including the United Nations Network on Migration and other intergovernmental and nongovernmental mechanisms.
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Key resources

Global research agenda on health, migration and displacement: strengthening research and translating research priorities into policy and practice

Globally, there is a global lack of high-quality and policy-relevant research on health, migration and displacement. There is also lack of clarity about...

Promoting the health of refugees and migrants: experiences from around the world

This publication is a compendium of 49 country examples highlighting efforts in improving refugees’ and migrants’ health following the adoption...

World report on the health of refugees and migrants

Worldwide, more people are on the move now than ever before, yet many refugees and migrants face poorer health outcomes than the host populations. Addressing...

Common health needs of refugees and migrants: literature review

This review explores how the health needs of refugees and migrants may differ from those of host populations, requiring culturally sensitive and effective...

Closing the gap in a generation: health equity through action on the social determinants of health - Final report of the commission on social determinants of health

Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death....

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Analysis of barriers and means to overcome them is central to equity-oriented, rights-based and gender transformative health system strengthening towards...

Capturing the evidence on access to essential antibiotics in refugee and migrant populations

The fourth report of the Global Evidence Review on Health and Migration (GEHM) series synthesizes available evidence on access to essential antibiotics...

Ensuring the integration of refugees and migrants in immunization policies, planning and service delivery globally

The third report of the Global Evidence review on Health and Migration (GEHM) series “Ensuring the integration of refugees and migrants in immunization...

Continuum of care for noncommunicable disease management during the migration cycle

Noncommunicable diseases (NCDs) are a major health burden worldwide but global NCD policies do not specifically address refugees and migrants. This interpretative...

Promoting the health of refugees and migrants: global action plan, 2019–2023

At its 140th session in January 2017 the Executive Board in decision EB140(9) on promoting the health of refugees and migrants requested the Director-General,...

Rio political declaration on social determinants of health

The Rio Political Declaration on Social Determinants of Health was adopted during the World Conference on Social Determinants of Health on 21 October 2011....

health-of-migrants-the-way-forward

The 2010 Global Consultation on Migrant Health was convened as a result of the 2008 World Health Assembly Resolution on the Health of Migrants,...