Access to health care encompasses three core dimensions – accessibility, affordability and acceptability (WHO, 2013), all of which describe the fit between patients and the health system (Penchansky & Thomas, 1981) with regards to their potential and actual use of health services to achieve health gains (Shengelia et al., 2005; Gulliford et al., 2002; Aday & Andersen, 1981). Despite physically available and accessible quality health services, the existence of legal, financial and cultural barriers could still hinder use of health care among particular groups, including migrants. Excessive direct (out-of-pocket payment) and indirect costs make health care unaffordable to many, which could be partially due to inequities in legal entitlements to formal care. A lack of awareness or distrust in health providers can deter people from seeking such services. Universal health coverage (UHC), which relates to Sustainable Development Goal (SDG) Target 3.8, encourages universal coverage of all persons in health systems (Vega, 2013), including migrants and refugees irrespective of their legal and migratory status (WHO, 2019). The intended outcome of universal health coverage is that everyone can have access to appropriate promotive , preventive, curative and rehabilitative services at an affordable cost (WHO, 2017; Carrin et al. 2008). Given remaining challenges in ensuring universal health care access and use among migrant populations, this review will focus on the factors that shape how specific groups of migrants interact with health systems. The objective of this article is twofold: (i) to review existing international evidence on health care access for various types of migrants (including regular/irregular migrants, internal migrants, asylum seekers, refugees, and internally displaced persons); and (ii) to identify knowledge gaps in the literature related to these groups. First, general barriers faced by migrants will be outlined, followed by specific sections highlighting the situation of irregular and internal migrants. These groups are important to focus on, as their legal statuses create group-specific barriers and empirical evidence on their interactions with health systems is scant. The article will conclude by identifying the main research gaps in the literature.
Common barriers to access for migrants and refugees
The following section will present existing evidence on the common obstacles to health care access for migrants and refugees in the legal, financial, cultural and physical aspects. Equitable rights to health for migrants and refugees have been enshrined in numerous international conventions, such as Universal Declaration of Human Rights (1948), the International Covenant on Economic, Social and Cultural Rights (ICESCR) (1966), and the 1951 Refugee Convention. However, major legal and financial barriers to health care access persist in many countries (Médecins du Monde, 2015). Legal entitlements to health services differ according to individual migration characteristics such as duration of stay, documentation status, and channel of entry. In 35 out of 40 more developed countries, legal migrants do not have the same entitlements as the nationals; and 5 of these countries offer only limited entitlements to asylum seekers (MIPEX, 2015). Even given the right to access, utilization is not guaranteed in practice. On one hand, in most cases these entitlements have restrictive conditions, such as residence in reception centers or designated areas (MIPEX, 2015). In the case of Turkey, asylum seekers with non-European origin, though granted the same entitlements to health care coverage as nationals by law, can access health care only upon complete registration, before which they have access to no more than health services for emergency and communicable diseases (AIDA, 2018) unless they resort to expensive private clinics (Médecins du Monde, 2015). On the other hand, delay in payment of health insurance prevents utilization in some cases such as in Bulgaria (AIDA, 2016). Cultural differences often pose difficulties for migrants’ health care access, such as through a lack of knowledge of their entitlements, limited knowledge of the health system, and language barriers in accessing health care services (Médecins du Monde, 2016). For such reasons, health services that are migrant-sensitive and adapted to the needs and constraints of migrants need to be developed (MIPEX, 2015; European Commission, 2011). Examples of intercultural approaches, which are commonly lacking in health systems worldwide, include the provision of free or inexpensive language services and community-based cultural support staff, culturally-informed care delivery, and culturally-tailored health promotion, disease prevention and treatment (WHO, 2010; Suess et al., 2014). Discrimination and xenophobic hostility from health professionals and providers, which are found to be present in many country contexts, further discourage migrants from future use of health services (ILO, 2017; Médecins du Monde, 2012; HUMA, 2011; ECDC, 2009). Diverse perceptions about how best to respond to ill health across cultures is another reason that migrants opt out of formal health care and seek non-biomedical treatments, such as in the case of HIV-positive migrants (Thomas, 2013). Physical accessibility to health services is a pressing problem for refugees in developing countries. Local facilities may have limited capacity to address the health needs of newly-arrived populations in case of mass influx. For example, non-camp Syrian refugees in Jordan reported facing long waiting times, long distances to health facilities, and unavailability of medicines for chronic diseases (UNHCR, 2017; Ay, Gonzalez & Delgado, 2016). Access to quality health services could be particularly constrained in refugee camps, which are generally remotely located and poorly accessible by road, while on-site health facilities are often resource-limited for conducting medical diagnosis (Adler, Mgalula, Price & Taylor, 2008).
Irregular migrants are a particularly vulnerable group in terms of health care access. For example, among 28 EU countries, 22 restricted undocumented migrants’ access to only or something more than emergency care which is far less than the full range of primary and secondary health services (WHO, 2016). Fear of being reported to the police or immigration enforcement services may deter irregular migrants from seeking help (Global Health Watch, 2009). The lack of access to pre- and post-natal care among undocumented migrant women has been highlighted in many reports to be highly concerning (WHO, 2016; Biswas et al., 2011; IOM, 2009), as they are found more prone to maternal mortality and their new-born to low birth weight or mortality (WHO, 2016).
Internal migrants, including internally displaced persons (IDPs) and rural-to-urban workers, do not always have access to health services outside of their places of administrative registration. Unprotected by international refugee law, the IDPs cannot access international aid and services provided for refugees while having unequal access to health services in the relocated region as the locals (Thomas & Thomas, 2004) or staying in areas where health care is inaccessible (WHO, 2015). In some countries with strict internal mobility controls, as in the case of China, internal migrant workers may have limited access to health services (Hong et al., 2006) due to their lower legal and social status compared to permanent residents (Zhan, Sun & Blas, 2002) and have high costs of health care and insurance (Hesketh et al., 2008). A recent update is provided by Shao et al. (2018) who find persistence of such barriers despite increasing political awareness about the legal status of migrant workers in the past decade. A study in Vietnam (Le et al., 2015) finds inequities in access to healthcare within the group of internal migrants – compared to non-migrants and to migrants working in industrial zones, seasonal migrants and migrants working in small private enterprises, to a lesser extent, utilized healthcare the least, which can be at least partially attributed to the lack of labor contracts and health insurance.
Improving the understanding of barriers to health care access for migrants and refugees will pave way for realizing universal health coverage and strengthening global health systems. What is known from the literature is that, compared with nationals, migrants and refugees are faced with additional obstacles to healthcare access in the legal, financial, cultural and physical aspects. Specific barriers exist for irregular migrants and internal migrants because of complexities related to their legal statuses. Future research can further strengthen the following four areas. First of all, mapping of discrepancies between the legal and actual health coverage gaps for different migrant populations is needed as the first step to assess the current policy loopholes. Although the number of related research has seen a significant increase in the past decade, such information is particularly scant (i) in the context of non-EU countries, and for the groups of (ii) asylum seekers and (iii) irregular migrants. In addition, internal migrants in developing countries, who often have less protected legal rights than the locals, have received relatively little attention as a group, not to mention the various subgroups marked by differential migration purposes and nature. Further research is needed to identify determinants of their healthcare access. Specific attention should also be paid to vulnerable population sub-groups such as children, youths and old people when assessing the accessibility of health services for each migrant category. Last but not least, understanding the perceived cultural acceptability of health services of different migrant groups in the local context could help the government and health providers develop more effective intercultural approaches to be systematically incorporated into the health system.
About the Author
Anny Yip-Ching Yu is a PhD fellow at UNU-MERIT. She holds a double master degree in Public Policy and Human Development from Maastricht University and United Nations University with a specialization in Social Protection Policy Design and Financing. Formerly, she worked as associate technical officer at the World Health Organization (WHO) and junior researcher at the International Centre for Reproductive Health (ICRH). In collaboration with the Statistics Netherlands (CBS), her doctoral research explores the immigrant welfare dynamics in the Netherlands. Her main research interests lie in social protection system strengthening, horizontal inequality and integration of vulnerable populations.
Profiles: https://www.linkedin.com/in/anny-yip-ching-yu-93814175/ ; https://www.merit.unu.edu/about-us/profile/?staff_id=2430
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