summer institute on migration and global health u c berkeley, june 26 th , 2012

Summer Institute on Migration and Global HealthU C Berkeley, June 26th, 2012

Good Practices and efforts to address Migration and Global Health Issues: an Operational Framework

International Organization for Migration (IOM) Dr.K.Wickramage

Head, Health Programs, IOM SRI LANKA

Learning Objectives & Presentation Outline

• Contextualize migration health in view of global health goals

• Review some good practices in light of the four main ‘pillars’ of action set by the Madrid IOM-WHO Consultation

• Lessons learnt in implementation of the WHA resolution on health of migrants

1. The WHA resolution and the IOM-WHO Global Consultation in Madrid

2. Putting WHA resolution into action – examples from around the Globe

3. The Sri Lanka Case Study

1 Billion Migrants World Wide

215 million international migrants (UNDESA)740 million internal migrants (UNDP)

(includes 15 million refugees (UNHCR)

by 2050 ...405 million international migrants (World Bank)

Global Migration Trends

“Human mobility has been identified as one of the most important geo-phenomena of our era. Today, there are more people on the move than at any other time in recorded history” - GFMD

4

• Some of the countries/areas that are most affected by international migration are in Asia.

• Approximately 2.5 million Asian migrant workers leave their countries every year to work abroad.

• 760 every day leave SL!!

Overview of Asian Migration Trends

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Migration Status• Countries in Asia can be roughly classified

according to their international migration status– “mainly sending”...(COLOMBO process)– “mainly receiving”.. (Abu Dhabi Process)– “both receiving and sending” eg. Sri Lanka & Thailand

Remittances to Asia (by year)

4.1Bn to 5.1Bn 2011

• Migration Heath agenda addresses the physical, mental and social needs of migrants, and the public health needs of

hosting communities through polices and practices corresponding to the emerging challenges facing mobile

populations today”Migration Health for the Benefit of All. IOM Council Session,

MIGRATION

8

Migration as a Social Determinant of Health

• Lack of targeted health information• Gender norms• Service availability, location, hours of operation• Safety & security • Relationship with “host” community• Community

leadership• Sensitivity of

services• Living and working conditions• Stigma,

xenophobia, social exclusion

• Language and cultural barriers • Health literacy• Immigration status• Health-seeking behaviours• service access barriers

• Policy and strategy across sectors • Availability of strategic data for policy change

Mental HealthPsychological

Physical trauma

Health consequencesSexual & Reprod

Emotional Functional

Social impact

Occupational risks

Infectious &unattended chronic conditions

substance abuse

Potential health consequences of migration

Migrant

Host population

Families left

behind

determine health status via SDH lens...

World Health Assembly Resolution on Health of Migrants (WHA 61.17)

Calls upon Member States:

“to promote equitable access to health promotion and care for migrants”

“to promote bilateral and multilateral cooperation on migrants’ health among countries involved in the whole migration

process”

HOW TO IMPLEMENT THIS STRATERGY??





process”

13

INBOUNDimmigration

OUTBOUNDemigration

INTERNALmigration

Multi-sectoral action (e.g. health, labor, social protection, development, security ….)

Economic and Financial Aspects (remittances, who pays?, resource costs for health system, insurance schemes, private/public..)

Public Health aspects (e.g. communicable disease, NCDs, Mental Health, social and health burden…)Cross cutting

issues

IOM Conceptual Framework for Migration Health Action at Country level (Mosca & Wickramage)

4 pillars of WHA resolution

Migrant FLOWS* and STAGES of migration

Migrant and Mobile

Populations

1. Out bound migration: Refers to the movement of people out of the country and encompasses categories such as Labor migrants, irregular migrants, trafficked victims, unregistered workers etc.

2. In bound Migration: Refers to people moving into the country, and encompasses categories such as students, foreign migrant workers, tourists, returning refugees and failed asylum seekers etc.

3. Internal Migration: Refers to the flow of people within a country’s internal borders, and includes categories such as free-trade zone workers, those workers in Board of Investment (BOI) industrial zones, seasonal workers, internally displaced people and students.

4. Families left behind – either spouses and/or caregivers, children etc of left migrants and mobile population.

Families of left behind migrants

• Resident Visa applicants

*Wickramage, Peiris, Perera, Mosca (2010)

Pre-departure

In transit

At destination

Upon return

Stakeholders by stage of migration

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Pre-departure

In transit

At destination

Upon return

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INBOUNDimmigration

OUTBOUNDemigration

INTERNALmigration

Multi-sectoral action (e.g. health, labor, social protection, development, security ….)

Economic and Financial Aspects (remittances, who pays?, resource costs for health system, insurance schemes, private/public..)

Public Health aspects (e.g. communicable disease, NCDs, Mental Health, social and health burden…)Cross cutting

issues

IOM Conceptual Framework for Migration Health Action at Country level (Mosca & Wickramage)


1. Monitoring Migrant Health

a. Develop health information systems

b. Standardization & comparability of migrant health data

c. Migrant health research


a. Migrant health information systems• IOM Health Assessment Program - (Migrant Management

Operational System Application) includes all health data for the US Refugee Admission Program for timely dissemination to CDC, US Dept of State.

- understand morbidity trends (nutritional status of children under 5)

- standardized data collection- comparability of data using ICD10

Classification- Electronic real time-transfer of quality

information to partners

c. Migrant health research

• Research provides an EBM model for developing migrant health policies and programs

• Recommended objectives of migrant health research are, to– increase data collection on health status and outcomes for

migrants– monitor migrants’ health seeking behaviours– access to and utilization of health services

2) Policy and legal frameworks

Development and review of -a. Global, Regional and

National [policy & legal] frameworks on migration health

b. Capacity building, Guidance and standards for countries

c. Social protection in health for migrants


a. Global frameworks• The International Convention on

Protection of Rights of all Migrant Workers and Members of their Families, Articles 28, 43, 45

• International Covenant on Economic, Social and Cultural Rights, Article 12.1, general comment no. 14

• UN General Assembly Special Session on HIV/AIDS (UNGASS, 2001) – Call for strategies to facilitate HIV/AIDS prevention programmes for migrants and mobile workers.

a. Regional frameworks

1. 15 nations in Southern Africa: “SADC framework on population mobility and communicable diseases (CDs)” Provides guidance on the protection of the health of cross- border mobile population

2. “Council of Europe Committee of Experts on Migration, Mobility and Access to Healthcare” on migrants’ living conditions, entitlement to and access & quality of healthcare, as well as general guidelines for migrant health action in the EU Member States.

a. National frameworks

Zambia

In September 2010, a new HIV policy for the transport sector by the Ministry of Communications and Transport (MCT)

addresses HIV for mobile workers in the transport sector.

Model of a funding/insurance system for migrants in the Philippines Philippine Overseas Workers Welfare Administration (OWWA):

• Fully-funded by a mandatory membership fee of US$25 per contract for migrants going abroad as temporary workers.

• Memorandum of Instructions No. 006, Series of 2009 - establishment of Medical Rehabilitation Program for eligible mentally ill and physically disabled OFW members

b. Social protection policies for migrant’s health

3) Migrant Sensitive Health Systems

a. Migrant Inclusive Health Policies

b. Migrant-friendly health services


a. Migrant Inclusive Health Services

Mexico Developed and is implementing the Comprehensive Health

Care Strategy for Migrants, with a designated focal point in the Ministry of Health responsible for its implementation.

Includes• Health Informational Booths (ventanillas de salud)• Leave Healthy, Return Healthy (vate sano regressa sano)• Repatriation of gravely ill countrymen• Health promotion on the northern border• Insurance schemes at low costs

Spain: The Strategic Plan for Citizenship and Integration 2007–2010 (Plan Estratégico de Ciudadanía e Integración).

• Each region of Spain has a specific plan adapted to the local migrant typologies and needs.

• For example, in Almeria: – sensitization and training of health professionals,– community mobilization/campaign– promotion of equitable access to health services.

a. Migrant Inclusive Health Services/Policies

With the integration of migrants every body gains. We gain in economic growth, quality of life, in cultural diversity

43

Africa and Middle East – 38,000 Kenya, Ethiopia,

Jordan, Iraq

Europe – 1,700

Asia – 50,000 refugeesNepal, Thailand, Malaysia

IOM Major Refugee HA Operations 2010

Programmes

Refugee Population

Locations

USRAP, Resettlement to Canada, Australia, New Zealand, EU and other countries

90, 000 refugees in 2010 including 76, 000 of US refugees representing around 75% of USRAP caseload. Overall, about 600, 000 refugees assisted over the last 10 years

More than 40 countries worldwide

b. Migrant-friendly servicesHealth ASSESSMENT

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Core Health Assessment

Expanded Health Assessment

• Enhanced HA Protocols • Preventive care • Surveillance

• Profiling• Local system strengthening

and Capacity building

• TB management (Lab, DoT)• Malaria and De-worming• Outbreaks Management • Pre-departure evaluation

• Enhanced data management and data sharing

Evolution of HA Programmes

TB reach: Genexpert scale up…..

b. Migrant-friendly health ASSESSMENT

IV. Partnerships, networks and multi country frameworks

4. Strengthening inter-country coordination and partnerships


a. Global level

International migration dialogues 1. UNGA High-level Dialogue on

International Migration & Development 2006

2. Global Forum on Migration and Development

3. The Global Migration Group

IV.1.Strengthening inter-country coordination and partnerships

July 2010, Bangkok, Thailand: 13 nation High Level Multi-

Stakeholder Regional Dialogue on Health Challenges for Asian Migrant Workers

–IOM, UNDP, WHO, JUNIMA, Joint UNAIDS and ILO

b. Regional level

Regional Dialogue on the Health Challenges for Asian Labour Migrants

13 – 14 July 2010 , Bangkok

Joint Recommendations

• At national level:

– Strongly encourage and support relevant government ministries to review existing policies, laws and practices related to labour migration and health aiming coherence among policies that may affect migrant's health and their ability to access services.

– Identify and/or designate a focal entity for migration health within concerned ministries tasked to initiate inter-ministerial and cross-sectoral dialogue.

– Increase participation of migrant workers in all aspects of their health and welfare including policy formulation and programme implementation.

– Conduct advocacy and public education activities at national and community levels through participatory and collaborative efforts between NGOs, international organizations, governments in order to build support among stakeholders for migrant-inclusive policies, national strategies and action plans.

– Encourage the inclusion of key migration variables in national census and surveys, including those used in national housing, health, labour, education and migration statistics, in data collection and the proper use and confidentiality of data.

At bilateral, regional, intra-regional:

Governments examine the possibility of bilateral agreements with a view to ensure social protection, portability of entitlements, including health insurance and monitoring of the overall migration process.

Conduct multi sectoral advocacy among health and non-health networks and labour migration frameworks to build support among public, government and key stakeholders, including CSOs, for migrant-inclusive policies and adoption of regional and international conventions and standards.

Develop guidelines and minimum standards to assist countries of origin and destination, based on effective practices and existing models, for migrant workers, including health financial schemes and social protection in health, ie. mandatory health insurance, that will benefit migrants as well as their families, regardless of whether they are joining the migrant workers or whether they stay behind.

IV.1. Strengthening inter-country coordination and partnerships

National migration dialoguesTanzania; Mozambique; South Africa; Kenya

c. National level





process”

Migration, Health and Development in Sri Lanka

Advancing and evidenced-based approach for Migration Health policy development via an inter-Ministry framework….

Sri Lanka– Facts and FiguresEmerging from a 30 year civil conflict between GoSL and LTTE1. Post-war, 2. Epidemiological (NCD), 3. demographic, 4. economic(MIC), 5.labour receiving.. One in ten SL’s are working abroad, an annual

outflow of 300,000 persons One in 5 of Sri Lanka’s total labour force

(23.8%) is currently employed abroad. 49% percent of ILMs are women, and out of

these, 86% are ‘domestic housemaids’. Over 93% were employed in the Middle

Eastern countries. 730 of registered migrant workers depart Sri

Lanka each day3. ILMs contributed 5.1bn USD (8% of GDP) to

the Sri Lankan economy in 2011, with foreign remittances earning expected to increase to 7bn USD in 20162.

76% of the total remittance received to the country was from garment industry and employments overseas (Central Bank, 2008) Sri Lanka becoming a labour receiving country not just a labour sending one: 44,400 Resident visas issued for workers (9000 Chinese and 9000 Indians, mainly on construction related development projects)

Migration

High level political commitment is essential for meaningful programming at country level…

Ongoing policy process in Sri Lanka• Approach adopted by Government:

1. Identified the need in addressing all three types of migration: outbound, inbound & internal

2. A Multi-stakeholder approach adopting an Inter-Ministerial process

3. An evidence-based research agenda to inform policy process enabled

Migration

1 DDG/PHS I 2 DDG/PHS II 3 Airport Health Authority4 Port Health Authority5 Family Health Bureau6 Health Education Bureau7 Epidemiology Unit

8. Policy directorate9. Non-Communicable disease directorate10. Mental Health Directorate

1 General Treasury

2 Department of Census and Statistics

3 Central Bank of Sri Lanka

1 Board of Investment of Sri Lanka2 Sri Lanka Tourism Promotion Bureau3 Sri Lanka Tourism Development Authority

1 Department of Probation and Childcare Services

2 National Child Protection Authority

3 Sri Lanka Women’s Bureau

1 Department of Immigration and Emigration

2 Department of Registration of Persons

Sri Lanka National Migration Health Taskforce

Where does migration health ‘fit’?

Mapping – an essential first step!Problem/Issues identification – e.g. don’t limit to only

labour migration!

Stakeholder Mapping within GoSL* + Academia, NGOs, Civil Society, UN, Development partners

*Selection of Technical focal points within each Government Ministry (contested). Political mapping – also involved in this step of stakeholder mapping.

Mapping of existing domestic legal and policy frameworks linked to MHD

Mapping for advocacy - regional forums (Colombo Process) and global fora (GFMD- Mexico) to push MHD agenda

Service mapping (e.g. health, legal and social protections offered to Labour Migrant workers)

National Steering Committee on

Migration Health(NSC)

Migration Health Task

Force(MHTF)

Migration Health Secretariat

(Housed within the Ministry of Health)

Comprised of Secretary/ Director General level representatives of the key Ministries such as Ministry of Health, Ministry of Foreign Affairs etc. Meets 2-3 times per year (or as per need) to decide on National policy decisions and inter-ministerial coordination issues forwarded by the MHTF

Comprised of technical focal points from each stake holder agency (Key Ministries, UN agencies, NGOs , Academics , Civil Society) that contributes actively to development and planning of the sectoral/ministry policies and programmes related to Migration Health. Meets once in 2 months

The dedicated hub that coordinates the National migration health agenda

for Government of Sri Lanka

Inter-Ministerial Coordination Framework for Migration Health Development in Sri Lanka

Wickramage, Peiris, Perera (2010)

determine health status via SDH lens...

WHAT IS THE SOCIAL COST?WHAT IS THE HEALTH CONSEQUENCE?

Migrant and

Mobile Populatio

nsI’m only presenting data from 1/5 national studies

here due to time constratints…

Assessment of mental health and physical wellbeing of ‘left behind’ family members of international labour migrants: a national comparative study in Sri Lanka

Wickramage, K., Siriwardana, C., Sumathipala, A., Siribaddana, S., Adikari, A, Peiris, S., Perera, S., Mosca, D.

Aim and Methods : This national study utilized both quantitative and qualitative research methods to determine the associations between health status of the left-behind spouse,

children and caregivers, for comparison with families having no history of migration. A multi-stage random sampling method was used to capture 62% of the total migrant worker population in Sri Lanka. We surveyed a total 1,625 adults (from 410 migrant and 410 non-migrant families) and 820 children, matched for both age and sex, within a pediatric and adolescent group. Socio-demographic, and health status data were derived from a range of standardized pre-validated health instruments measuring quality of life and mental health status (adult and child). Anthropometric data on childhood development was also obtained. Univariate and multivariate analyses were used to estimate the differences in health outcomes between migrant and non-migrant families.

Findings:

Children from migrant families have a higher risk potential to develop psychopathology and sustain poorer nutritional development outcomes than children from non-migrant households.

Just over two-in every five ‘left-behind’ children (44%) reported as having any psychiatric diagnosis. A quarter of all left-behind children under 5-years were severely underweight (25.4%). Nearly one-in-three migrant families were also single-parent households. Multivariate models

revealed the association of emotional disorders and psychiatric diagnosis was strongest within single-parent households, and was exacerbated where the sole parent was the migrant worker [OR 0.75(0.34-1.64)].

Significantly high levels of depression were found in caregivers [12.3% (CI: 12.23-12.31)] and spouses from left-behind families [25.5% (CI:25.47-25.60], than those comparative non-migrant group [7.32% (CI: 7.29-7.34)]; with physical health status profile also showing similar trends.

“families left behind”• The absence of parent has a

negative impact on overall health and development of children left behind:

• Growth and development: 25% of the children in the families with migrant parent are “under-weight” (- 2 SD Z-score)

• Child-psychopathology: All domains in SDQ were higher among the children in migrant families

(Wickramage. et al. IOM, 2011).

General health status – SF 36 score

Mental and physical health of the left behind spouses and care-givers were also significantly poor

(Wickramage. et al. IOM, 2011).

Prevalence of Common Mental Disorders of left behind families by standardised Scale for Depression using PHQ

Disorder Migrant family ComparativeFamily (spouse)spouse caregiver

N

277

Prevalence

(95% CI)

N

188

Prevalence

(95% CI)

N

410

Prevalence

(95% CI)

Somatoform 10 3.61 %

(3.59-3.63)

2211.70% (11.65-11.74)

12 2.93%

(2.91-2.95)

Depression 34 12.27 %

(12.23-12.31)

4825.53% (25.47-25.60)

30 7.32%

(7.29-7.34)

Anxiety 3 1.08 %

(1.07-1.09)

7 3.72 %(3.69-3.75)

2 0.49%

(0.48-0.50)(Wickramage. et al. IOM, 2011).

Not Allowed to use the telephone at workplace 50.3 %

Not allowed to use own mobile phone 44.6 %

Passport kept by employer 85.8 %Had no friends outside workplace 52.6 %

More than 3 months to Adapt 85.0 %

Did not inform employer about illness due to fear of losing job

60.5 %

Experienced an Abusive situation 17.5 %

Vulnerabilities faced by Sri Lanka International Labour Migrants.

IOM, Sri Lanka (2012)

Conclusions: The finding that almost 1/3 were single parent

families, that child psychopathology scores were highest in

these left-behind families, a growing reliance on elderly care-givers with ill

health, generational impacts of trans-national parenting, lack of an ‘informed choice’ in the migration journey that multiple cycles of migration may be needed to

achieved economic goals

the need for a clear and comprehensive policy in addressing the social determinants of health affecting migrant workers and their left behind families is evident from the study.

Right to migrate

Right of child

Right of single mother

Elder/Seniors Rights

Right of RECIVING COUNTRYto determine

non-admissibility

criteria for health

assessment

Right of

SENDING

country to

ensure

follow up of

‘rejected’

caseload

complex challenge for Governments in policy formulation at the nexus of ‘rights, remittances, geo-political determinants and responsibilities’

Remittances contribution to

GDP Transformation from ‘unskilled to skilled’ labour

migration

‘Protectionism’ vs.

‘market opportunism’

State control Vs. Free market economy

State to State Bi-lateral agreements Vs. Regional agreements/dialogue

Wickramage, Peiris, Mosca, (IOM, 2012)

SRI LANKA:Millstones, progress, future

vision Conducive legal and policy environment- Immigration act

of Sri Lanka amended to include Health assessment of inbound migrants, right to health for non-citizens ensured too… Presidential support for this decision made!

Government moving towards creation of a singular migration agency to coordination – act for presentation and debate in parliament.

Successful completion of 5 National research studies for EB approach

Currently Drafting “National Migration Health Policy” – via Inter-Ministerial coordination , using EBM

Sri Lankan Government with IOM support will host Governments of 8 nations to undertake regional dialogue to advance WHA framework

(SL model is still a work in progress..)

HEALTH ASSESSMENT FOR RESIDENT VISA APPLICANTS

Upon request of the Controller General for Immigration and Emigration, and the MOH, IOM assisted in the

development of technical guidelines and protocols for “Health requirements for long stay visa applicants” , and for

the development of a Visa Health Unit for the Ministry of Health.

ESTABLISHMENT OF A NATIONAL COORDINATING FRAMEWORK FOR MIGRATION HEALTH DEVELOPMENT IN SRI LANKA

IOM assisted the Ministry of Health to establish: a permanent Migration Health Unit which acts as a ‘hub’ for administrative and technical coordination; a Migration Health Task Force which comprises of technical advisors/senior administrators from more than 9 Government departments and other stakeholders; and a high level National Steering Committee chaired by the Health Secretary to serve as the main policy making body in related to migration health development in Sri Lanka.

SOME KEY ACHIEVEMENTS

OF THE MIGRATION

HEALTH DEVELOPMENT

PROJECT SUPPORTED BY

IOM SRI LANKA: 2009—2012

ENSURING A “HEALTHY RETURN” FOR RETURNING SRI LANKAN REFUGEES

With the technical support of IOM, the Ministry of Health convened an expert subcommittee headed by the Additional Secretary of Health to develop a national plan for ensuring health protection to approximately 87,000 Sri Lankan refugee returnees from Southern India. A major element was for ensuring returnees are provided with health information in collaboration with the Indian Government and are linked to primary health care services upon return to Sri Lanka. Close observation of International Health Regulations and ensuring non-discrimination on health grounds were hallmarks of the ‘healthy return’ plan.

IOM-MOH led 5 NATIONAL MIGRATION HEALTH STUDIES

IRREGULAR MIGRANT FLOWS

IOM supported healthy return of irregular migrants from West Africa

HEALTH PROMOTION FOR MIGRANT WORKERS

Enhance health promotion and education material for outgoing and returning migrant workers with the Sri Lanka Bureau of Foreign Employment, especially at pre-departure orientation, and developing strategies for health and social protection in sending countries.

Post-conflict Health systems recovery – assisting populations of forced migrants (war affected IDPs) to

return to place of origin

Journal article “Malaria burden in cohorts of stranded migrants: people smuggling operations from Sri Lanka”

Wickramage, K.* and Galappaththy, G.** Author affiliations:* Head, Health Programs, International Organization for Migration (IOM), Sri Lanka.** Director, GFATM, Ministry of Health, Sri Lanka.

Abstract Three cases of P.falciparum and one P.vivax malaria were detected in 287 returnees who were part of people smuggling operations. Facilitating ‘safe return’ with active surveillance for irregular migrant flows becomes important as Sri Lanka advances towards the goal of Malaria elimination. We present the first such report of malaria in human smuggling operations.

7 Key Programming principals: lessons from the Sri Lankan Model

1. Adopts an inclusive approach in addressing all typologies of migrant flows

2. Adopts a participatory ‘whole of Government Approach’

3. Adopts a strong ‘evidence-based approach’

4. Adopts structural reform to ensure that policy and legal environment is conducive.

5. A responsive to emergent needs and gaps E.g. refugee return program. E.g. West African smuggling operation E.g. Development of health regulations and a ‘Visa health unit’ resident visa applicants.

6. Moving the MHD agenda at regional and global level.

7. Tracking progress+ knowledge hub

Wickramage, K, Peiris, S & Mosca, D (2011)

• No ‘one size fits all’

• 61st World Health Assembly Resolution on Migrant Health is an excellent advocacy too

• Need for evidence based reseach

• Engaging labour sending and receiving countries a key

• WHO and IOM have an advantage to guide in defining the scope of action globally and at the member state level. ..however member states commitment, funding scarce

Cautions in ‘adapting’ country models

Migration, Health and Development in Sri Lanka

www.migrationhealth.lkAdvancing and evidenced-based approach for Migration Health policy

development via an inter-Ministry framework….

THANK YOU!

http://www.migrationhealth.lk/

summer institute on migration and global health u c berkeley, june 26 th , 2012

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