a rapid assessment of migrant health assessment services ... · content validity of the study...
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A Rapid Assessment of Migrant Health Assessment Services
in Four Labour-sending Countries (Sri Lanka, Nepal, Bangladesh and Philippines)
Dulani Samaranayake
Consultant Community Physician and Senior Lecturer
Faculty of Medicine
University of Colombo
Background• Immigrant Medical Examinations (IMEs) are conducted in
isolation.
• Standards of practice are not uniform across centers /countries screened for.
• Pre-departure assessments providers are a major stakeholderof most disease control programmes due to the largequantum of screening they conduct, but are not identified asa stakeholder on most instances. Linkages if any, are at thediscretion of individual IME providers.
• There is an immense potential for using IMEs for public healthbenefits.
Labour Migrant Outflow in the selected countries
CountryTotal Migrant Outflow 2013
Labour Migrant Outflow 2013
Total Remittance 2013 (USD Billion)
Sri Lanka 1 245 187 293 105 6422.19
Bangladesh 7 757 662 409 253 13857.13
Nepal 1 044 688 450 834 5588.9
Philippines 5 481 683 1 469 179 26716.84
Table 1: Total Migrant outfow, Labour Migrant Outflow and Total Remittance in the selected countries
ObjectivesGeneral Objective
• To describe the current status and practices followed at selected IME centers in Asia-Pacific countries with high outbound migration, by studying practices in Bangladesh, Nepal, Philippines and Sri Lanka.
Specific Objectives
• To describe the profile and characteristics of IMEs
• To conduct a rapid assessment of selected facilities in the center providing IME
• To provide recommendations for national guidelines on IMEs.
• To provide empirical evidence for bi-lateral, multi-lateral, and regional negotiations on standards for IMEs
Methods
• Descriptive cross sectional study
• A study unit was defined as a medical center / hospital located in Bangladesh, Nepal, Philippines and Sri Lanka, providing IME services for any destination country
• IME centers registered in the relevant government authority in each country were eligible to be selected.
• Sample – Sri Lanka – All 27 IME centers were selected
– Bangladesh (n=19), Philippines (n=18), Nepal (n=45) were purposively selected based on location and workload
• Study Instrument – A rapid assessment tool with interviewer-administered questions and observation checklists
Methods• Study Instrument comprised:
General information about the IME center
Volume of IMEs conducted and numbers rejected and deported in the last updated year
Adherence to guidelines with regard to convenient scheduling, maintaining confidentiality, infection control, quality assurance, Standards of Practice
General environment and facilities available at the center
Technical quality of services and follow up activities on screening positive applicants
Content validity of the study instrument was ensured and it was pretested in all four countries.
• Ethics clearance was obtained from ERC, Faculty of Medicine, Colombo
Results
Description of the sample
Country No. of
centers
Coveragea Registration
status
Registering Body
Bangladesh 19 38% 18 (94.7%) Ministry of Health
Nepal 45* 15.8% 45 (100.0%) District Health
Offices/NPHL/MOHP
Philippines 18 10% 18 (100.0%) Department of Health
Sri Lanka 27 100% 27 (100.0%) PHRC**
Table 2: No. of centers studied, coverage and registration details of the IME centers
NPHL – National Public Health LaboratoryPHRC – Private Health Sector Regulatory Council
Non-clearance at IMEs
0
2
4
6
8
10
12
14
16
Sri Lanka Bangladesh Nepal Philippines
No
n-c
lear
ance
rat
e %
Figure 1: Rate of Non-clearance at IMEs in the four countries
1.4( 0 - 2.8)
14.6(10 - 20)
8.8( 0.1 – 16.2)
3.3(0.4 - 6.9)
Reasons for Non-clearance
0.1
10.5
15.714.4
0.5 1.3
57.5
1.0
20.8
3.9
16.1
57.7
0.5 0
5.1
43.6
24.2
14.310.6
2.10
0
10
20
30
40
50
60
70
HIV Tuberculosis STDs Hepatitis NCDs Others Undefined/Unclear
Perc
enta
ge
Bangladesh Philippines Sri Lanka
Figure 2: Main Reasons for Non-clearance at IMEs in Bangladesh, Philippines and Sri Lanka
*This data was not available from Nepal
Investigations conducted in IMEs and their Quality
Condition Bangladesh Nepal Philippines Sri Lanka Tests used Quality
control Tests used Quality
control Tests used Quality
control Tests used Quality
control
Tuberculosis Mantoux / CXR /
Sputum
++ CXR / Mantoux
+ CXR / Sputum
AFB
++ CXR ± Sputum culture
++
HIV Rapid test / ELISA
+ Rapid test / ELISA
+ ELISA ++ ELISA ++
Syphillis VDRL / TPHA ++ Rapid Test / VDRL
+ VDRL / TPHA
++ VDRL / TPHA / TPPA
++
Hepatitis B HBS Ag ELISA ++ HBS Ag ELISA
+ HBS Ag ELISA ++ HBS Ag ELISA
++
Hepatitis C Hep C Ab ELISA
++ Hep C Ab ELISA
+ Hep C Ab ELISA
++ Hep C Ab ELISA
++
Liver function
SGOT/SGPT, S. Bilirubin
+ SGOT/SGPT + SGOT/SGPT ++ SGOT/SGPT ++
Renal Function
S.Creatinine + S.Creatinine + S.Creatinine ++ BU / S.Creatinine
++
Diabetes mellitus
FBS / RBS / HBA1C
+ RBS + FBS ++ RBS ++
Hearing Assessment
None - None - Audiometry ++ None -
Mental Health Status
Mini Mental Examination
++ None - Mental status Ex.
++ None -
Follow-up actions on screening positive applicants - TB
0 20 40 60 80 100
Treatment provided
Referral for further management
Post test Councelling as per protocol
Referral to PH authority
Notification to PH authorities
Data sharing with PH authorities
Sharing expertise with PH authorities
Percentage of Facilities
Figure 2: Follow up actions taken on screening-positive applicants -Tuberculosis
Sri Lanka Philippines Nepal Bangladesh
Follow-up actions on screening positive applicants - HIV
0 20 40 60 80 100
Treatment provided
Referral for further management
Post-Test Counseling as per Protocol
Referral to PH authority
Data sharing with PH authorities
Sharing expertise with PH authorities
Percentage of Facilities
Figure 3: Follow up actions taken on screening-positive applicants - HIV
Sri Lanka Philippines Nepal Bangladesh
Follow-up actions on screening positive applicants - STIs
0 20 40 60 80 100
Treatment provided
Referral for further management
Post-Test Counseling as per Protocol
Referral to PH authority
Data sharing with PH authorities
Sharing expertise with PH authorities
Percentage of Facilities
Figure 4: Follow up actions taken on screening-positive applicants - STDs
Sri Lanka Philippines Nepal Bangladesh
Adherence to Standards of Practice and Quality Improvement
78.9
78.9
63.2
52.6
52.6
63.2
47.1
100
100
100
100
100
100
100
85.2
77.8
70.4
66.7
85.2
14.8
18.5
0
0
0
0
0
0
40
0 20 40 60 80 100
Printed SOPs are available
Staff are trained on SOPs onrecruitment
Staff are trained on SOP periodically
Client satisfaction surveys
Recording of complaints / adverseevents and action taken on them
Quality assurance audits
Maintaining updated statistics ofservices
Nepal Sri Lanka Philippines Bangladesh
Policies and Practices on Infection Control
31.6
31.6
26.3
47.4
36.8
87.5
100
100
100
100
100
100
59.3
63
59.3
63
59.3
77.8
0
0
0
0
0
75
0 20 40 60 80 100
A documented infection control policy forthe institution
Written instructions on universalprecautions on handling infected material
Instructions for handling patient careequipment and soiled linen
System for recording and managingexposures to HIV and Hepatitis B or C.
Guidelines on environment cleaning andspill management
Facilities for infection control in eachroom are satisfactory
Nepal Sri Lanka Philippines Bangladesh
Policies and Practices related to Confidentiality
94.7
100
94.7
68.4
73.7
84.2
89.5
100
94
100
100
100
94
83
92.6
85.2
77.8
81.5
85.2
66.7
66.7
100
100
0
0
0
80
20
0 20 40 60 80 100
Applicants’ records (hard copies) stored in locked cabinets
Applicants’ records (soft copies) password protected
Policy regarding accessing the applicants’ records
Policy on reporting and recordingof IME findings
Policy on storage and disposal ofapplicant records
Results released to applicants
Results released to other parties(e.g. agents)
Nepal Sri Lanka Philippines Bangladesh
Practices related to information provision to applicants
58.8
94.7
36.8
84.2
89.5
100
56
78
28
100
63
63
51.8
18.5
66.7
0
100
100
0
100
0 20 40 60 80 100
Information given routinely
Information given in local language
Printed information available in locallanguage
AV material available to giveinformation in local language
System to clarify doubts of applicants
Nepal Sri Lanka Philippines Bangladesh
Availability of Basic Amenities
Bangladesh
68.4%
Nepal
10%
Philippines
88.8%
Sri Lanka
88.9%
Bangladesh
15.8%
Nepal
0%
Philippines
83.3%
Sri Lanka
25.9%
Bangladesh
100%
Nepal
100%
Philippines
66.6%
Sri Lanka
81.6%
Bangladesh
89.5%
Nepal
80%
Philippines
100%
Sri Lanka
100%
Access, Cleanliness and Waste Disposal
0
10
20
30
40
50
60
70
80
90
100
Physical access Cultural access Disability access Cleanliness Waste Disposal
94.8
79
57.2
73.779
100 100
0
50 50
100
72.2
83.3
100 100
74.174.1
25.9
88.8
96.3
Bangladesh Nepal Philippines Sri Lanka
Conclusions• A large number of applicants are screened annually and a significant
number of applicants are rejected on medical grounds.
• Leading causes for rejections were Tuberculosis or chest infections,Sexually Transmitted Infections, Hepatitis and Non-CommunicableDiseases like diabetes mellitus and hypertension.
• In all four countries screening for TB largely based on chest X-ray. Onlyvery few providers proceeded to definitive diagnosis with sputum tests.
• In all four countries estimates on numbers of persons deported onmedical grounds were unavailable or unreliable.
• Standard screening tests were conducted for diseases and healthconditions. Most had some local or international accreditation for thelaboratory tests and most had quality control practices.
• IME centers in Nepal and Sri Lanka had no objective screening tools toassess mental health status, while in Bangladesh and Philippines standardtests were used. Hearing assessment was conducted using an objectivemethod only in Philippines.
• Pre-test and Post-test counseling was not practised in most IME facilitiesin all four countries.
Conclusions
• Almost all centers referred screening-positive patients to relevant specialists for further care, but no mechanism to ensure referral or back referral.
• Collaborations with the public health authorities were minimal in all four countries. Data on tests done and numbers screened were submitted to the state health authorities in Nepal and Philippines. In Sri Lanka and Bangladesh, there was no routine sharing of information with government authorities.
• Majority of IME centers in all four countries had a satisfactory status with regard to location and accessibility but not disability access.
• Most facilities had infection control practices but policies and guidelines were not available in most.
• A large majority of the IME centers had satisfactory measures to ensure the confidentiality of the patients’ records. However, most of them did not have documented policies with regard to storage, access or disposal of these.
• In Philippines, all facilities had an operations manual and quality standards manual and in Nepal a brief guideline was available. In Sri Lanka and Bangladesh, only TIs of receiving countries were available.
Recommendations
For Labour-sending countries• To have comprehensive National Guidelines on standards of
examination and investigation processes of IMEs and their quality control.
• The Ministries of Health of the labour-sending countries to chair a joint forum with the IME providers to develop the guidelines and standards and mechanisms for monitoring them.
• A system of monitoring and supervision to ensure the adherence to guidelines and general service quality.
• Standardized, objective methods of assessing psychological status and hearing for IMEs in Bangladesh and Sri Lanka.
• Collaborations with public health control programmes to strengthen the referral system and notification of communicable diseases
• A system to ensure the continuity of care of applicants referred for further investigations and treatment following positive screening
• A mechanism to link the deported migrants to the national health system for care and follow up.
Recommendations
For Labour-receiving countries• Negotiations to introduce standard screening protocols for
conditions like Tuberculosis• Regional level negotiations to establish a communication system
where the labour-receiving countries reports the details of the migrants deported on medical grounds, to the country of origin.
• A system to provide continued care by the health system of the receiving country for applicants detected to be having non-communicable diseases and eventually migrate after controlling those conditions.
For IME Providers• Policies and guidelines on infection control and capacity building of
the staff to be provided• An efficient data management system and A system a data
reporting to government health authorities for Sri Lanka and Bangladesh.
Acknowledgement
• Dr Sharika Peiris, Dr Susie Perera, Dr Kolitha Wickramage who are co-investigators
• Ms Jananie Ravi and Dr Elona Wickramasinghe and the Research team members from Sri Lanka, Bangladesh, Nepal and Philippines
• International Organization of Migration for providing financial support
• Ministries of Health and Ministries of Labour and Employment of the relevant countires for their support
• All IME centers who participated in the study