|Migrants' Right to Health (UNAIDS, 2001, 60 p.)|
A. Financing of health care
Financing of health care may be predominantly government funded, predominantly privately funded or a mixture. Governments also determine the priorities for available funds: in Zambia, for instance, only 0.8% of the gross national product (GNP) is spent on health care, compared with about 7-10% in most industrialised countries.
It should be noted that financial resources for health are overwhelmingly provided within countries. This situation does not change even in those countries which are the recipients of significant international development assistance from sources such as development banks, bilateral development agencies, international nongovernmental organizations, foundations and UN agencies. For example, in 1994 health spending in low and middle income countries totalled about US$250 billion, of which only US$2 or 3 billion was from development assistance.
Substantial reforms in the health systems of many countries in the past few decades have led in many cases to substantial privatization or significant increases in co-payments by patients. Dr Gro Harlem Brundtland, Director-General of WHO, states in her introduction to the World Health Report for 1999 that "Active government involvement in providing universal health care has contributed to the great gains of recent years - but many governments have overextended themselves. Efforts to provide all services to all people have led to arbitrary rationing, inequities, non-responsiveness and inadequate finance for essential services." She notes that governments cannot "provide and finance everything for everybody" but also rejects the approach of rationing health services to those with the ability to pay: "Not only do market-oriented approaches lead to intolerable inequity with respect to a fundamental human right, but growing bodies of theory and evidence indicate markets in health to be inefficient as well...But the very countries that have relied heavily on market mechanisms to achieve the high incomes they enjoy today are the same countries that rely most heavily on governments to finance health systems."71 She calls for changes in all countries to ensure participatory, fair and efficient regulation of the health sector.
71 WHO. The World Health Report 1999: Making a Difference. World Health Organization, 1999, p xiv
In many developing countries and due to many factors, health facilities are often poorly equipped, drugs are not always available and in particular, STD/HIV prevention and care is poor. A recent WHO paper commented on the use of resources within poor countries: "National health systems tend to spend money on poor quality and low-impact interventions."72 And of course, in some developing countries, the increased mortality of health sector staff due to HIV has started to directly affect the delivery of health services.
72 WHO. "The Global Health Priority: Reducing the burden on the poor", World Health Opportunity: Developing Health, Reducing Poverty. Meeting Report, May 1999, p36
Most industrialized countries provide universal or widespread health insurance for all nationals and legal permanent residents: thus, the burden of health care is rarely substantial for any individual, and in particular drug costs are relatively cheap - in marked contrast to the situation in most developing countries.73
73 "The inequities are striking", says Dr Jonathan Quick, Director of Essential Drugs and Other Medicines at WHO. "In developed countries a course of antibiotics can be bought for the equivalent of two or three hours' wages. One year's treatment for HIV infection costs the equivalent of four to six months' salary. And the majority of drug costs are reimbursed. In developing countries, a full course of antibiotics to cure simple pneumonia may cost one month's wages. In many of these countries one year's HIV treatment - if it were purchased - would consume 30 years' income. And the majority of households must buy medicines with money from their own pockets." Quote taken from Press Release WHA/13 22 May 1999 WHO to Address Trade and Pharmaceuticals
Even between neighbouring developing countries, there may be disparate health care provision: Burkina Faso, Ghana and Togo have large numbers of cross-border workers - migrant patients mainly attend clinics in Ghana (sometimes crossing over specifically for this purpose), because health services cost the least among the three countries.
Given that, due to global mobility, health risks can not be addressed adequately if they are only dealt with inside national boundaries, many industrialized countries provide direct funding assistance to health care in targeted developing countries. For instance, the New Zealand (NZODA) South Pacific Regional Health Programme was established in 1997 as a direct result of the concern in New Zealand about the adverse health trends in neighbouring Pacific Island countries, especially those with the closest connections with New Zealand.74
74 New Zealand Ministry of Foreign Affairs and Trade. NZODA Regional Health Programme Initiatives, 1997-1999
Another issue is that of differential cost for access to health care for nationals/legal residents and others: many industrialized countries allow free access to health care services for legal migrants but require full-cost recovery for non-residents. In a few countries, health care provision may also be regulated by bilateral or multilateral agreements, thus providing full health care access to a national of a country with whom such agreements are in force. For example, Australia has bilateral agreements with Finland, Italy, Malta, Netherlands, New Zealand, Sweden and the United Kingdom.
B. The "new" public health
One of the fundamental public health principles is that major gains in health require the development of preventive and early intervention programmes. The improvements in population health status of this century have exemplified this principle.
Environmental, social and personal changes that promote health and prevent the onset and development of disease hold the most promise for the future, as there is general acknowledgement that therapy and rehabilitation have always been insufficient by themselves to conquer disease. Active prevention is required to achieve such an outcome.
These insights have led in the last twenty years to the development of a "new" public health: one that relies less on exclusion and screening and moves more to inclusion and cooperation with the relevant sub-population. With an increasing emphasis on illness prevention, aimed mainly at reducing smoking and cardiovascular risks, there has been a substantial change in the public health approach to population-related behaviour modification - because coercive models were proving to be ineffective.
The new model, as described by Haour-Knipe:75 "This model, one of social learning, of inclusion and cooperation, involves harm reduction, persuasion in modifying lifestyles linked to disease, education, voluntary testing and counselling, protecting privacy and social interests. When emphasis is transferred away from control and towards information, and basic assumptions are transformed in a critical epistemological shift: fruitless and potentially harmful calculation of risks is sidestepped, and all segments of the population are put on an equal level. The assumption underlying obligatory measures, that people will necessarily behave irresponsibly, is replaced by the opposite, that enabled, they will behave responsibly. The ground rules are first and foremost to protect lives and keep the disease from spreading and second to work in collaboration with those who are to be protected to develop and utilize their own possibilities to avoid risk."
75 Haour-Knipe M. Social enquiry and HIV/AIDS, Background paper prepared for the XIV International Conference on the Social Sciences and Medicine, Peebles, Scotland, 2-6 September 1996
Much of this 'new' approach is summarized in the five principles of the Ottawa Charter:76
· build healthy public policy;
· create environments that support health and health-improving choices;
· strengthen community action;
· help people develop necessary skills for health-improving choices; and
· reorient health services to prevention and early intervention.
76 Ottawa Charter, WHO/HPR/HEP/95.1. Charter adopted at an International Conference on Health Promotion, November 1986
Unfortunately, although there has generally been a philosophical change in approach among public health specialists in the last twenty years, in many countries legislation and regulations still reflect old approaches and attitudes. Various restrictions are in place in both industrialized and developing countries (generally based on the traditional infectious disease/public health legislation approach of the 19th century). Many of these provisions are not enforced (and, in the case of the developing world generally minimal inward migration makes the application there limited), but nevertheless, the restrictions are there and can legally be used.
Fluss77 refers to "Incorporating principles of objective risk assessment, evaluation of efficacy, minimization of human rights burdens into communicable diseases statutes encourages decisions based on rational, scientific findings rather than public fear or ignorance."
77 Fluss S., Some recent patterns and trends in communicable disease legislation in selected European countries presentation at the May 1996 meeting of the Biomed 2 Project on Communicable Diseases, Lifestyles and Personal Responsibility: Ethics and Rights
C. Levels of access
Migrants tend to occupy a relatively vulnerable position in terms of access to health in the receiving society, due to general factors such as language barriers, different concepts of health and disease, and racism among service providers and the general society. In addition, undocumented migrants in particular will often be operating in unsafe working conditions and accommodation, and may be exploited for meagre wages. Many migrants may lack the money to buy health services or be unable to access local services due to their legal status.
These general problems are often compounded in relation to HIV/AIDS, and to a lesser extent to STD matters.
Sometimes governments may directly add extra barriers to health care access even for legal migrants. For example, as noted by Bronfman: "The US Congress, presumably motivated by the belief that authorized and non-authorized migrants participate 'excessively' in public assistance programmes, approved migrant-related provisions as a part of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996. This law restricts access to social assistance programmes even to the authorized migrants."78
78 Bronfman M. "Mexico and Central America" in Appleyard R and Wilson A (eds.). "Migration and HIV/AIDS", International Migration Quarterly Review, Vol. 36 (4), 1998, p614
However, the barrier to health care may vary greatly between countries. Decosas notes that in the African context, "some migrant labourers and their families in fact receive health services superior to those available to their communities of origin, and sometimes even superior to those available to their host communities."79
79 Decosas J. Labour Migration and HIV Epidemics in Africa, presentation at the 12th World AIDS Conference, Geneva, Switzerland, July 1998
There have been a number of specific projects aimed at improving access. Some of these approaches are mentioned later in section five of this paper. Unfortunately, few address the issues of access to prevention and care at the origin, transit places and final destination of migrants. All points on the moving continuum need to be addressed if migrants are to achieve full access to their right to health.
As Gilmore80 notes, "When non-nationals are deprived of opportunities to be healthy this not only endangers their own health, but also promotes denial and discrimination. It jeopardizes public health efforts, in particular prevention efforts, thereby threatening the public's health."
80 Gilmore N. Human Rights Issues and Migration, presentation at the 12th World AIDS Conference, Geneva, Switzerland, July 1998
Speakers at a session on Mobile Populations and HIV: vulnerability, risk and human rights at the 12th World AIDS Conference presented clear evidence that "the health of migrant populations has often not fared very well when the matter is left to national instances in either the country they have left or that to which they have gone."81 It will be essential for more countries to acknowledge that migration is a process that affects two (or more) communities, not just one, and adjust their policies accordingly.
81 Haour-Knipe M. In conclusion, presentation at the 12th World AIDS Conference, Geneva, Switzerland, July 1998
D. Early intervention is cheapest
Despite the widespread acceptance of the importance of prevention and early intervention, a variety of personal, social and economic forces have generated barriers to the widespread development and implementation of prevention and early intervention programmes.
Traditionally, health only becomes of personal significant concern to people when they are in danger of losing it through injury or disease.
Secondly, as noted by Barlinguer,82 "the notion of health as a cornerstone of economic growth, as a multiplier of human resources, and most importantly as a primary objective of such growth, has been replaced far and wide by an opposing notion. Public health services and health care for all are now perceived as an obstacle, often as the hardest obstacle, threatening public finance and the wealth of nations; reduction in health expenditure (not rationalisation, which is the imperative everywhere) has become one of the top priorities for all governments.
82 Berlinguer G. "Indivisibility and Globalisation of Health" in The Effects of Globalisation on Health, Report from a Symposium held at the Annual Meeting of the NGO Forum for Health, Geneva, May 1998
The model of primary health care as fundamental for the prevention and treatment of diseases has been almost abandoned. The trend is now towards dismantling the whole machinery of public health. Even in countries with minimal resources, priority is given to costly technologies."
Some of the past change in the understanding of the importance to economic growth of health has been perceived to arise out of the policies and approach of the World Bank and the International Monetary Fund. The World Bank is now committed to highlighting that health sector reform is a means rather than an end in itself, and to ensure that there is a focus again on the determinants of health (education, poverty, environment, gender) and on tangible health outcomes.
Ngwena recently noted83 that, in Africa, "the state health care sectors are overburdened, ill equipped and badly managed. Declining health budgets as a result of reduced government expenditure on public services have seen many public health services collapsing in several African countries. Drugs for common diseases are either unavailable or of poor quality and so is the medical equipment. The structural adjustment programmes that have been imposed by the Bretton Woods institutions to assist Africa in economic reform, are at the same time leaving little by way of adequate resources for health care."
83 Ngwena C. AIDS and Right of Access to Treatment: The Scope and Limits, op. cit, p10
The World Bank announced in July 1999 that it planned in future to take more aggressive action against AIDS. A Bank official noted that AIDS is no longer solely a health problem, but a development crisis that is particularly affecting Africa. Working with governments and other groups, the World Bank has stated it will review its existing efforts in Africa and plans to redirect funding, if needed.
Discussing the World Bank's new emphasis on the African AIDS epidemic, Mr Callisto Madavo, Vice President, Africa Region, said: "With ferocious speed, AIDS has wiped out many of the development gains Africa has achieved over the last decades. It has reduced life expectancy in the most-affected areas and now threatens businesses and economies", he said. "Africa is in urgent need of resources and support to turn around this catastrophe. For this reason we are putting the epidemic at the centre of our development agenda, mainstreaming AIDS into all aspects of our work in Africa."84
84 UNAIDS Press Release: UN Officials in Lusaka Commit to Increased Action against AIDS in Africa. Lusaka, 15 September 1999
A similar review of the interaction between economic development and AIDS may shortly occur in Asia: the Malaysian Prime Minister called in October 1999 for regional leadership, including "all heads of Governments in the Asia-Pacific region to hold a summit on AIDS so that we may better co-ordinate our efforts...underline the seriousness of the AIDS pandemic and the need for urgent action to combat it." Dr Mahathir also talked about the rights of migrant workers, emphasising "the transborder nature of the epidemic".85
85 Report posted on 25 October 1999 on Sea-aids, an independent electronic forum provided by the Fondation du Prnt http://www.fdp.org
An additional major barrier to appropriate emphasis on prevention or early intervention has been that in almost all countries, health care systems have been structured in accordance with acute care models of disease and illness. Health professionals are trained to operate within the usual parameters of the system - and preventive health is rarely where 'the best and brightest' focus their time and energy.
In general, for most countries massive commitments of public monies have been dedicated to supporting acute health care delivery systems. Many decision-makers tend to be oriented toward after-the-fact treatment of disease rather than prevention, perhaps because the benefits of prevention are more long-term and therefore not immediately obvious.
Lomas86 has taken the problem of heart disease as a tool to examine the effectiveness of possible interventions: the points on an intervention continuum of possible responses to premature death from heart disease comprised:
· rescue, e.g. coronary artery bypass surgery, thrombolysis
· routine medical care, e.g. cholesterol-lowering drugs, hypertension control
· improved access to health care, e.g. 'free' care, increased supply of care
· traditional public health, e.g. lifestyle modification programmes
· family and support services, e.g. home visitors, social support
· social cohesion, e.g. subsidized clubs, reduced income inequality.
86 Lomas J. "Social Capital and Health: Implications for Public Health and Epidemiology", Soc. Sci. Med. Vol. 47, No. 9, pp1181-1188, 1998
The last intervention, social cohesion, is rarely mentioned in health policy discourse. As Lomas states "these are measures to ensure and advance social cohesion. This involves preservation and advancement of social structures such as meeting places, sports leagues, clubs, associations and all the other elements of a community that allow for the exchange of views and values and engender mutual trust."87 Lomas found, using a cost-effectiveness approach, that interventions to increase social support and/or social cohesion in a community are at least as effective in preventing premature death from heart disease as improved health care access or routine medical care.
87 ibid, p1183
If Lomas' work is able to be extrapolated to HIV/AIDS, which is likely, then greater attention to support services and social cohesion (well within the reach of even the poorest developing country) may result in improved access for migrants (and others) to prevention and care, at no more and possibly less cost than currently. Similarly, if the formation of support groups for people living with HIV and AIDS is useful not only for psychological support of group members, but also understood as part of a necessary strategy in HIV/AIDS cost-effective prevention and care, then greater attention and support for such support groups may eventuate from government and other key players. It should be noted that at the XIth International Conference on AIDS and STDs in Africa (Lusaka Conference), a Satellite conference on the 'Principle of Greater Involvement of People Living with HIV/AIDS' reported that though less than 1% of those who are HIV-positive in Africa have come out in the open declaring their sero-status, they have become powerful change agents in the sub-continent.
In addition, an approach focusing on social support and social cohesion would also imply the need for a greater focus on 'community-level' interventions rather than merely 'community-based'. (Community-level interventions attempt to modify the entire community through community organization and activation, while community-based interventions attempt to modify individual health behaviours.)
Decosas has also stated that "Small improvements in the physical and social environment of migrants and of their communities may in fact reap greater benefits then targeted service provision." He cites the example of some plantations in Cd'Ivoire, where employers have started improving social infrastructure by providing schools, family housing, and recreational facilities.88
88 Decosas J. Labour Migration and HIV Epidemics in Africa, op. cit.
The account of a session on 'What Works?' in the HIV/AIDS/STDS and the Community Track at the September 1999 Lusaka Conference reported that the major findings of the session were:
- It is important not to impose programmes on the community but to go in on their invitation
- Communities are able to use their resources and expertise to run effective and sustainable prevention programmes
- It is necessary to involve community mobilizers and facilitators in planning and implementation of programmes
- Linking care to prevention and sustaining volunteer service is indispensable to a successful prevention strategy
- It is important to integrate care of HIV infected and affected in existing structures89.
89 AF-AIDS listing no. 408 Community initiatives - what works? XIth International Conference on AIDS and STDs in Africa, Lusaka (Zambia) 12-16 September 1999, September 22, 1999
These basic premises should also inform specific programmes aimed at mobile populations.
E. Are only specific HIV/AIDS interventions required?
There is a strong link between sexually transmitted diseases (STDs)90 and the sexual transmission of HIV infection. The presence of an untreated STD can enhance both the acquisition and transmission of HIV by a factor of up to 10. Thus, STD treatment is an important HIV prevention strategy in any population.
90 Increasingly being referred to as Sexually transmitted infections (STIs)
Treatment of STDs, which is relatively inexpensive, is highly cost-effective in its own right. It becomes even more cost-effective when the benefits of reduced HIV transmission are added.91, 92 In addition, in developing countries STDs are a major public health problem making up the second cause of healthy life lost in women between 15 and 45 years of age after maternal morbidity and mortality.
91 UNAIDS: Technical Update: The public health approach to STD control. May 1998
92 Piot P. "Sexually transmitted diseases in the 1990s. Global epidemiology and challenges for control" Sex Transm Dis 1994 Mar-Apr, 21 (2 Suppl.): S7-13
UNAIDS has stated that "the magnitude of the problem of STDs, and the strong association with HIV transmission, highlight the need to explore new and innovative approaches to prevent and control their spread. One such approach is the adoption of the 'public health package'. This package for STD control consists of the following components:
· promoting safer sex behaviour
· strengthening condom programmeming
· promoting health-care-seeking behaviour
· integrating STD control into primary health care and other health care services
· providing specific services for populations at increased risk
· comprehensive case management
· prevention and care of congenital syphilis and neonatal conjunctivitis
· early detection of asymptomatic and symptomatic infections.93
93 ibid, p2
A complementary approach is to broaden out family planning activities so that all people can realize their right to reproductive health. Several countries with significant migrant populations have developed targeted family planning services for their migrant communities - these migrant-specific services could be further developed in line with global changes in family planning. Since the 1994 International Conference on Population and Development, most governments and major donor agencies have pledged a commitment to implementing an agenda which emphasises:
· the need to develop better quality services for reproductive and sexual health care
· the need for gender equality and, therefore, the empowerment of women
· greater male responsibility for their sexual and reproductive behaviour and their social and family roles
· greater attentions to the sexual and reproductive needs of adolescents
· elimination of violence against women
· special efforts to counter the spread of sexually transmitted infections, including HIV)
· wider participation in reproductive health and family planning programmes.
Policy-makers may need to review their existing reproductive health and STD services and expand the scope and/or target populations for these programmes. There are extensive and clear links between the general goal of safeguarding sexual and reproductive health, and the specific goal of containing STD and HIV.
In practice for most countries, migrant and mobile populations have tended to have less access to reproductive health and STD services than non-mobile nationals. Planning and implementing appropriate programmes for migrant and mobile populations thus requires urgent attention in almost all countries.