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GHF2010 – PS27 – Access to Health for Refugees and Displaced Populations in Urban Settings

Session Outline

Parallel session PS27, Tuesday, April 20 2010, 14:00-15:30, Room 2
Chair(s): Anne Golaz, Barbara Rijks, Migration Health Programme Coordinator, International Organization for Migration, Switzerland
Summary: With an increasing number of humanitarian crises involving IDPs or refugees in non-camp settings, aid needs to be expanded and increased into host communities where they settle, mostly in urban areas. This session will present the tremendous challenges that refugees, IDPs, and migrants encounter in host communities, particularly in urban settings, and will propose strategies to address their health needs.
Iraqi Refugees in Jordan and Syria 
Paul Spiegel, Chief, UNHCR Public Health and HIV Section, Switzerland
HIV-Positive Migrants in Thailand: Important Problems of Access to Care
Liesbeth Schockaert, Analysis and Advocacy Unit, Médecins sans frontières, Belgium
Refuge and Access Denied to Zimbabweans in South Africa 
Jonathan Whittal, Head of Programme Unit, Médecins sans frontières, South Africa
Challenges of Healthcare Provision to IDPs in Non-Camp Settings: The 2009 IDP Crisis in Pakistan 
Anne Golaz, UNICEF Senior Health Advisor, Switzerland

Session Documents

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Session Video

This session is available to watch using Dudal. To watch it you will need to have Java installed on your computer.

Session Report

Contributors: Ailya Jaffrey (ICVolunteers), Christoph Wirth (ICVolunteers)

Refugees waiting for asylum papers. Photo ADH / Freccia

With an increasing number of humanitarian crises involving Internally Displaced Persons (IDPs) or refugees in non-camp settings, aid needs to be increased and expanded into host communities where they settle, mostly in urban areas. This session will present the tremendous challenges that refugees, IDPs and migrants encounter in host communities, particularly in urban settings, and will propose strategies to address their health needs.

Refugees, migrant workers and internally displaced persons all face precarious health challenges, but how can humanitarian intervention adequately address their health needs? This session's panellists illuminated the many ways in which international organisations are currently working to develop more sufficient frameworks to meet these health issues.

Paul Spiegel, Chief, United Nations High Commission for Refugees (UNHCR) Public Health and HIV Section, Switzerland, addressed the current situation of Iraqi refugees in Jordan and Syria. He passionately emphasised the changing realities of refugee work worldwide and urged a drastic re-evaluation of current policies. No longer are refugees solely confined to camp settings.

The number of urban refugees in middle income countries is drastically increasing and current strategies, policies and interventions are ill-suited to meet their health needs. Existing policy, Mr. Spiegel noted, is largely based on older paradigms and continues to influence humanitarian responses, but we cannot think of the refugee problem in these countries as being just confined to camps.

With regard to the Iraqi refugee situation, he outlined a new innovative three-pronged strategy to address refugee urban health: firstly, he stressed the importance of advocacy to ensure that authorities make public health and nutrition a priority; secondly, he highlighted the importance of refugee support, through integration; and thirdly, he emphasised the importance of developing proper refugee assessment and monitoring mechanisms.

In concluding his discussion, Mr. Spiegel once more re-iterated the notion that camp-based models are inappropriate for emerging refugee settings and urged organisations to develop a strong communication strategy in addressing refugee health issues.

Ms. Anne Golaz, UNICEF Senior Health Advisor, Switzerland, and co-chair of the session, addressed the challenges of healthcare provision for IDPs in non-camp settings.

IDP crisis in Pakistan, which began in 2008 as a result of military operations by the army, is on-going. To date three million people, a vast majority of whom (60% +) are children under the age of 18, have been displaced by the conflict. Displacement in the region has unfolded in three waves, in the span of one year (August 2008-September 2009). Ms. Golaz focused mainly on the second wave of displacement, which has unfolded in the Swat valley and which now affects the five neighbouring regions.

What is particularly interesting about the situation of IDPs in Pakistan is the fact that the vast majority of IDPs have sought out community shelters rather than residing in refugee camps. This reality unquestionably posed UNICEF’s response teams with the logistical challenges of adequately reaching these people and ensuring that their health needs were sufficiently met.

As a senior health advisor at UNICEF, the speaker provided insight into UNICEF’s regional refugee response. Though humanitarian action was initially focused on managing refugee camps, it quickly melded to different priority areas. UNICEF was involved in strengthening existing public health facilities; temporarily filling critical human resource gaps; supporting community-based health programmes; initiating a measles vaccination campaign and setting up routine EPI centres.

Ms. Golaz proposed a series of recommendations to address refugee health challenges and called for the strengthening of existing health services and the re-establishment of regular aid programmes.

The following presenter, Liesbeth Schockaert, from the Analysis and Advocacy Unit of Médecins Sans Frontières (MSF), Belgium, addressed the issue of Zimbabwean migrants in South Africa. Of the 4.5 million Zimbabwean refugees, migrants and asylum seekers, a large proportion (1.5-3 million) has fled to South Africa.

This large migration of refugees has, inevitably, resulted in major health and medical needs. The provision of acute health care, primary health care and the treatment of chronic infectious illness (HIV and TB) are of the highest importance.

The MSF project currently underway in Musina aims to address these most pressing health issues. MSF has established mobile clinics, provided basic diagnostic and curative services, and is currently providing psychological support for victims of violence.

MSF operations in Johannesburg address not only these primary health issues, but also additionally provide referrals for specialist care. The aim is not to set up a new medical structure, but rather, to utilise effectively the existing one. Interestingly, in the beginning almost 50% of patients at the MSF Johannesburg operation were residents at a local church shelter. Alarmingly, however, over 75% of patients now arrive from neighbouring areas in search of adequate health care.

Despite these ongoing projects, many barriers remain: fear, language barriers and discrimination. Also many operational challenges need to be addressed in future ventures, namely: the impossibility of distinguishing between migrants and refugees and the difficulty of reaching the target population.

This session provided a crucial insight into the current and emerging challenges facing refugees, internally displaced persons and migrant workers. In concluding, all of the panellists stressed that existing policy needs to be strengthened and that ultimately, current health services require further development.

GHF2010 – PS01 – Migrant Access to Health in Switzerland: From Policy to Practice

Session Outline

Parallel session PS01, Tuesday, April 20 2010, 11:00-12:30, Room 14
Chair(s): Sophie Durieux-PaillardMD MPH, Migrant Health Centre, Department of Community Medicine and Primary Care, Geneva University Hospitals, Switzerland, Corinna Bisegger, PhD, Psychologist, Department of Health and Integration, Swiss Red Cross (SRC), Switzerland
Summary: As in many western countries, the health status of migrants living in Switzerland is often poorer than that of the native population. This is particularly true for migrants living in precarious conditions, due to stressful circumstances before or during migration, exhausting working conditions, discrimination, as well as communication and cultural barriers. Additionally, in many Swiss cantons, undocumented migrants encounter obstacles to accessing care that are related to differing health policies from one canton to another. This session offers case studies and policy views from various actors in the field of migrant health in Switzerland. It also aims at providing an opportunity for ample discussion and sharing of experiences by the session audience on issues such as access to care for vulnerable groups and cultural competences of health professionals.
Migration and Health Strategy in Switzerland: Achievements and Perspectives on Improving Access to Health for Migrants 
Serge Houmard, Health Policy, Federal Office of Public Health, Bern, Switzerland
Access to Care for Migrants: Examples from Various Swiss Cantons
Kirsten AlmeidaRegistered Nurse and Political Scientist, Responsible for National Projects, Médecins du Monde, Switzerland
Access to Care for Vulnerable Immigrants in Swiss Cantons: Today and Tomorrow
Yves Jackson, Department of Community Medicine and Primary Care, Geneva University Hospitals, Switzerland
Improving Access to Health through Transcultural Competence: Impact of Training Healthcare Professionals 
Anke Kayser, Social Anthropologist, Swiss Red Cross, Switzerland

Session Documents

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Session Report

Photo by John Brownlee,

The four speakers engaged in a discussion involving important issues concerning migrants and the Swiss healthcare system, proposing several improvements. Topics included the migrant health strategy, the Swiss healthcare systems, migrant resources and transcultural competence.

Serge Houmard, a political scientist of the National Program for Migration and Health, Federal Office of Public Health, Switzerland, gave a brief introduction into the Swiss health strategy. His presentation focused on the improvement of public health for migrants. He stated that Switzerland is a country of migration where immigration is important due to the fact that it has a very large migrant background. His main concern is that migrants deserve an equal opportunity and they should have the same health benefits as Swiss natives. Key Swiss projects include an intercultural translation service, migrant friendly hospitals and telephone interpreting services, some which have proven to be cost effective.

Yves Jackson, from the Department of Community Medicine and Primary Care, University Geneva Hospitals, expanded on the serious issues involving Swiss migrants’ access to healthcare.

Mr. Jackson believes that migration is a fact of life. He stated that 1 in 4 Swiss nationals are migrants and 23% of residents are foreigners. Migrants in irregular situations are particularly vulnerable. They may find healthcare unaffordable, inaccessible or too complex to understand. They may have difficulty in understanding the system and be unable to find culturally sensitive healthcare workers. Switzerland has adopted three strategies: (1) public organisation or mixed public and NGO, (2) NGOs and (3) no programme at all. Further a brief introduction to migrant services was given, such as the Programme Santé Migrants (PSM) for rejected asylum seekers or the Unité Mobile de Soins Communautaires (UMSCO) which is specifically for migrants in irregular situations. In conclusion the speaker stressed that vulnerable migrants have specific health needs frequently similar to that of the host population. His aim is to overcome barriers such as lack of federal control on law enforcement and disparities between healthcare availability to different sections of the population.

Kirsten Almeida, working for Médecins du Monde in Neuchâtel, focused on NGO systems. She spoke of the origin of NGOs, which have a history of solidarity. Today’s models of NGOs have a legal background that allows them to exercise pressure in a certain way against the authorities. NGOs have experience in creating access to healthcare for vulnerable people. She gave examples, one of which was Meditrina, a resource for undocumented migrants located in Zurich. The focus of Médecins du Monde is to promote the right of access to health services for all and to promote non-discrimination. Médecins du Monde is involved with both international and national projects.

Unlike the three previous speakers, Swiss Red Cross employee Anke Kayser spoke of a need to improve access to health through Transcultural Competence. This is “the ability to understand individual lives in terms of the particular situation and in various contexts and derive from them suitable adapted procedures” (Domeing, 2001). The Swiss Red Cross acts on different levels with transcultural competence. They rely on interaction as well as transcultural background knowledge: such as the re-examination of static and dynamic cultural understanding, racism, discrimination, religion and lifestyle choice. This background knowledge helps healthcare professionals to ask the right questions in order to make the patient more comfortable. Healthcare professionals use such methods, instruments and resources to facilitate their work for without these methods the professionals would find themselves frustrated. Therefore transcultural training is suggested on a cognitive level, affective and behaviour level

Cardiovascular Risk in Type 2 Diabetic Immigrants in Spain: IDIME Study

Author(s): Francesc Xavier Cos Claramunt1, 2, Josep Franch Nadal2, Albert Goday Arno2, Sara Artola Menendez2
Affiliation(s): 1CAP sant Marti de Provençals en Institut Catala de la Salut, Barcelona, Spain, 2redGDPS (Spanish type 2 diabetes Primary Care Network)
1st country of focus: Spain
Relevant to the conference theme: Vulnerable groups
Summary (max 100 words): To study the presence of cardiovascular risk factors and their treatment among the diabetic immigrant population in Spain.
Background (max 200 words): To study the presence of cardiovascular risk factors and their treatment among the diabetic immigrant population in Spain.
Objectives (max 100 words): To study the presence of cardiovascular risk factors and their treatment among the diabetic immigrant population in Spain.
Methodology (max 400 words): National cross-sectional case-control study (diabetic immigrants versus native diabetic, a proportion of 2 to 1) including 877 patients with diabetes mellitus (307 native, 169 South-Americans, 126 Hindustani, 184 Maghribian and 89 from other countries). Sociodemographic, anthropometric and clinical variables of DM were analyzed. The existence of cardiovascular risk factors, their treatment and the presence of complications related to diabetes was studied. Descriptive and analytical statistics were utilised. Cardiovascular risk at 10 years was calculated with UKDPS risk engine.
Results (max 400 words): Diabetic immigrants are younger than native diabetics (50.4 ±11.5 vs 62.7 ±13 years) with less diabetes evolution years (5.8 ±6.4 vs 10.5 ±8.3 years) (p<0.001). The sample population of smokers contributes to practically an non-existent percentage (0.2%). The diagnosis of hypertension is less prevalent among diabetic immigrants (40% vs 63.2%) (p<0.001). There is no statistical significance considering the prevalence of dyslipidemia between immigrants and natives (86.6 vs 86.5%), although the percentage is slightly higher among hindustani (92%), whom show higher values of triglycerides and use more fibrates (39.4%). Diabetic immigrants use less antiaggregation (21.1 vs 39.5%) (p<0.001). The calculated coronary risk is clearly lower in diabetic immigrants (9.9 vs 17.1%) as well as the risk of stroke (2.5 vs 8.7%) (p<0.001). The prevalence of all complications is fewer in diabetic immigrants, especially the macrovascular ones (7.7 vs 24.4%) (p<0.01).
Conclusion (max 400 words): As a whole, diabetic immigrants manifest less cardiovascular risk than native diabetics, due to their younger age, lower disease evolution time and less prevalence of hypertension.

Type 2 Diabetes and Migrants: A Twelve Country Study

Author(s): Manuel Carballo1, Klea Faniko2, Alexandre Lefebvre1
Affilation(s): 1International Centre for Migration, Health and Development, Geneva, Switzerland, 2University of Geneva, Switzerland,
1st country of focus: Greece
Additional countries of focus: Austria, Canada, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This twelve country study (Austria, Canada, Greece, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK) addressed the prevalence of type 2 diabetes (T2DM) in migrant and non-migrant populations and responses to its diagnosis and management.  Respondents were recruited from health care facilities and they were interviewed using a standardized questionnaire in their language of choice.  Statistically significant differences emerged between migrants and non-migrants with respect to a number of health care indicators, and the study highlights the importance of reaching out to migrants with T2DM diagnostic and therapeutic services designed around their particular needs and sociocultural situation.
Background (max 200 words): Over the last two decades the number of people with diabetes mellitus (T2DM) has increased by almost 50 percent. While better diagnosis and reporting may in part account for this increase, there is growing evidence that the problem is in fact becoming more common in developing as well as developed countries, and that migrants and ethnic groups tend to have a higher risk of developing T2DM than other groups do.  Chronic psychological stress, poor nutritional acculturation, radical changes in lifestyle and difficulties with health care in general may be important factors in the development of T2DM in migrants and ethnic minorities. There is also evidence that migrants and ethnic minorities are not always able to benefit from diabetes-related programs as they are currently structured.  There is a growing understanding that the complex relationship of T2DM and migration must be better characterized and that more should be done to ensure that migrants and ethnic minorities are reached with timely prevention, diagnosis and care programs that take into account their risk factors and special needs.
Objectives (max 100 words): The overall aim of the project was to provide a body of socio-epidemiological data that could form the basis for national policies and programs, including training of healthcare personnel and development of guidelines that can be used in the day-to-day prevention, diagnosis, care and treatment of T2DM in migrants and ethnic minorities.  The specific objectives of the project were to: • define what is currently known about the link between migration and T2DM and its treatment/management in migrants;• determine the incidence/prevalence of T2DM among people meeting the study definition of “migrant”, and identify contributing factors;• describe how people meeting the study definition of “migrant” perceive T2DM and its care and treatment/management;• assess how healthcare personnel working with people who meet the study’s definition of “migrant” and are diagnosed with T2DM perceive their interaction with them;• assess how a control group of non-migrants with T2DM perceive the disease and its care and self-management;• develop a program to sensitize stakeholders, including migrants, their families, health care personnel and others, on the needs of migrants with respect to T2DM;• develop guidelines on the prevention, diagnosis, care and treatment of diabetes in migrants and ethnic minorities;• develop public information materials for migrants (and ethnic minorities) on T2DM prevention, diagnosis, care and treatment;• develop training materials and training programs for healthcare personnel on the theme of multi-cultural health care with special reference to diabetes;• evaluate the impact of these interventions by measuring changes of attitudes and knowledge among healthcare personnel and migrants (and ethnic minorities).
Methodology (max 400 words): The study focused on four groups of interest: migrants and non-migrants diagnosed with T2DM; healthcare staff working with migrants and others with T2DM.  Respondents were recruited from pre-selected public health care facilities in locations with a known high presence of migrants.  Respondents were recruited with the agreement of healthcare authorities and patients.  Contact with respondents was made by letter from the PIs in the countries concerned.  Healthcare personnel working with migrants with T2DM were also contacted directly by the PIs.  All migrants and non-migrants were aged between 35-59 years, and PIs were also asked to ideally involve healthcare providers within the same age-range as the patient/respondent group in order to minimize possible “time-cultural” differences.  Participating centers were asked to select and interview the following; between 50 and 100 migrants with T2DM; between 50 and 100 non-migrants with T2DM; at least 20 healthcare staff providing diabetes care to migrants and others.  Information about the study and its aim was disseminated through local healthcare facilities in each city and through associations, clubs and other facilities known to be frequented by migrants and non-migrants.  Potential participants in the study were given details on the purpose of the study, namely to improve the quality of care available to migrants and others with respect to diabetes, and were given an opportunity to ask questions about the study.  They were assured of confidentiality.  No incentives were offered, but in cases where the participant requested assistance with counseling or referral, this was provided.  Face-to-face interviews were conducted using structured questionnaires specially developed for the purpose of the study by interviewers who were capable of speaking the language of the respondents. If respondents chose not to participate in the project, this was recorded as a refusal.  If respondents started and then decided to discontinue the interview, it was recorded as a discontinued interview and the reason was recorded.  The interviews lasted approximately 40 minutes.  Focus groups were also organized to generate information from health care personnel using guidelines developed specially for the purpose of this study.  Data entry was done locally on an on-going basis using data entry sheets provided by ICMHD and sent to ICMHD and analyzed centrally.
Results (max 400 words): Statistically significant differences emerged between migrants and non-migrants in a number of areas, such as knowledge about T2DM, factors influencing its occurrence, its short and long-term implications, the ways in which it can and should be managed, and where help can be had if and when complications arise.  Attitudes to T2DM also differed; migrants were far more inclined to take a more fatalistic view of the disease than non-migrants were.  There were also significant differences with respect to the circumstances in which T2DM was diagnosed; data from all the countries suggested that migrants tend to be diagnosed with T2DM as a result of other health problems/complaints and not as a result of regular checkups; almost 60% of migrants with T2DM had been diagnosed during medical examinations for other problems including occupational injuries.  On the whole, migrants diagnosed with T2DM were much more likely to say that the diagnosis had been poorly explained to them, or that they had not understood what had been said. There was also a fairly widespread feeling that the people treating them were not interested in them as migrants or in their needs, even though the diagnostic setting was typically described as friendly. Migrants frequently expressed concern at not feeling sufficiently “in control” of their lives to manage their diabetes, and they had much more difficulty keeping appointments with healthcare providers.  They were also more likely to use emergency call numbers (hotlines) for diabetes related problems than non-migrants.  One of the background characteristics we believe may be important in the development of T2DM is the relatively large proportion of migrants who had been separated from their significant others by migration and who said they were chronically stressed.  There was a clear tendency for migrants to also have less economic/occupational security than their host population equivalents; contractual employment was less common among migrants and was also seen by them as a source of stress. There was also a tendency for migrants to work longer hours than non-migrants and have little time for personal activities including cooking, a fact that they said contributed to their use of pre-prepared foods. In accordance with what has been observed elsewhere, migrants were also more likely to be living in overcrowded dwellings and sharing accommodation with a number of people to whom they were not related.
Conclusion (max 400 words): The prevalence of T2DM is significantly higher among migrants than non-migrants in Europe and Canada. A number of factors may be linked to this, including chronic stress, rapid and often difficult changes in lifestyle, high dependence on ready-made foods and fast foods outlets, poor awareness of the factors contributing to T2DM and the importance of T2DM as a disease. It is also clear from the study that the diagnosis of T2DM in migrants often occurs incidentally to other complaints and not as part of any targeted regular checkups. Migrants also appear to have more difficulty coping with T2DM than non-migrants and in many cases do not have the level of personal control needed to make self-treatment easy or successful. On the whole communication between healthcare providers and migrants with respect to explaining the nature of the disease, the contributing factors and ways of dealing with it is also lacking, and many migrants tend to interpret this as a lack of interest on the part of healthcare providers in them as migrants and, in particular, as people with different medical and socio-cultural histories. In view of the growing problem of T2DM and the growing magnitude of migration it is clear that much more will have to be done to tailor national diabetes strategies in ways that address the specific needs of this new population. There is a need for more and better outreach to migrants, and there are grounds for promoting regular screening for T2DM in migrants.  Certainly more needs to be done to convey to migrants what the risks of developing T2DM are and what the main factors contributing to those risks are.  It is also clear that providing psychosocial support to migrants could well help them to manage their diabetes better and be less reliant on health care providers and emergency care in particular.  Although this type of intervention might at first seem costly, it is probably one of the more cost-effective investments that can be made once migrants have been diagnosed with T2DM.

Knowledge and Access to Healthcare of Migrant Workers Returning From Libya: Bangladesh

Author(s): Anita Davies1, Afsana Karim1, Samir K Howlader1, Saiful I Shaheen1
Affiliation(s): 1Migration Health Division, Department of Migration Management, International Organization for Migration (IOM), Dhaka, Bangladesh
1st country of focus: Bangladesh
Relevant to the conference theme: Vulnerable groups
Summary (max 100 words): Migrants’ access to health services varies widely depending on their legal status, employing company, recruitment agency and understanding of language and culture in a destination country.  Migrants can return home in a worst health status than when they left to work abroad, particularly when forced to return because of a crisis.  This project will present information on health issues including non–communicable diseases, accidents in the workplace and the mental health of Bangladeshi migrant workers returning during the Libyan crisis in 2011. Information presented promotes the need for migrants to access national Non communicable disease programmes at home and abroad.
Background (max 200 words): During the civil unrest in Libya the International Organization for Migration (IOM), and its partners provided assistance in the form of shelter, medical care, and repatriation to 641,820 migrants from Asian, African, Europe and the Middle East. Bangladeshi migrant workers made up the third largest group of people fleeing the violence in Libya. The government of Bangladesh as part of a reintegration programme offered Bangladeshi migrants a lump sum of money upon return to Bangladesh. This was made possible through a World Bank load and the implementation of the programme by IOM.  To complete the health assistance provided to the returning migrant workers, the migration health division of IOM Dhaka use the opportunity during the disbursement of the repatriation funds to collect information from the returning migrants on their health status, access to health care in Libya and their basic knowledge attitudes and practices relating to communicable and non- communicable diseases. Often studies on the health of migrants focuses on communicable diseases. This study collects information on migrants’ knowledge attitudes and practices relating to migrant health issues including non -communicable diseases, work related accidents and access to health care in destination countries.
Objectives (max 100 words): The overall objective of the study was to assess the health vulnerabilities and needs of returning Bangladeshi migrants from the Libyan Crisis.

Specific objectives are
1. To understand the migrants’ access to health services/ insurance for general and occupational health while in a destination country Libya
2. To identify migrants’ knowledge, attitudes, behaviour and practices to communicable and non- communicable diseases in Libya and upon return to Bangladesh
3. To highlight the health vulnerabilities of migrant workers
4. To identify health needs gaps of migrants workers throughout their migration process for migration health policy recommendations for countries of origin and destination.
Methodology (max 400 words): A large number of the migrants were low skilled workers and had very little health knowledge, so it was felt that it was best to collect qualitative data at this exploratory stage of studying the health needs of returning Bangladeshi migrants as the group dynamics would encourage discussions. Each focus group consisted of 6- 8 persons. Focus group discussions were conducted among male groups and female groups only as the culture would not permit mixed gender focus groups. The focus groups were conducted in the local language. Each focus group had a discussion leader, a note taker and observer.  In-depth discussions were conducted with the same gender to ensure it was acceptable culturally and religiously as some of the health questions were sensitive. The focus group and in-depth discussions were tape recorded. Each participant was given an information sheet and a consent form at the beginning of each session. The information sheet and consent form were in the local language Bangla. The information was read out to those participants who could not read. The information collected was stored in a safe place by the researchers. Transcripts were written mainly in Bangla and translated into English. Some of the transcripts were written in English  as the in depth interviews were conducted in broken English when the participants claimed that they were able to understand some English. Counselling was offered to participants who showed signs of stress during the discussions. Participants were also referred to relevant services when they requested assistance for other health related matters. The focus group  and indepth discussions were held over a period of two months.  The information collected from the focus group and in-depth discussions were analysed manually through indexing, management and interpretation   As participation was voluntary we were not able to conduct the planned number of interviews as many of the migrants had travelled in public transport from their home villages four to 5 hours away to collect the reintegration grants and were in a hurry to get back home before night. Quantitative data was not collected on health information as the migrants had already undergone a long interview to collect basic demographic and labour migration data before they were eligible for receive the reintegration grant.
Results (max 400 words): A summary of the findings are: The majority of migrant workers had undergone health assessments arranged by agents in Dhaka before going to Libya. They knew that their blood pressure, chest X- Ray, urine tests had been conducted but they did not know the results or  specific reasons why these tests were needed. All they could say was that occurred to ensure they had good health. Some of the migrants who stayed in Libya for a long time and needed visa renewals were required to have a repeat medical examination. Access to health services in Libya depended on the employer. The foreign companies provided the best health services.  The migrants preferred to go to health services where there were Bangladeshi health workers. It was difficult to get time off work to go to health services. The only time they could visit health services was at night. In cases where the migrant did not have money for healthcare, fellow compatriots provided money. There is a good communal spirit among Bangladeshi migrant workers abroad. The migrants had a vague idea about communicable diseases such as TB, HIV and STDs. They claimed that most of the information they received was when they were in Bangladesh and not when they were in Libya as they did not understand Arabic. They accessed Bangladeshi Television programmes in Libya and got health information this way.   The participants associated diabetes and hypertension with people who were overweight and did little exercise. Some of them knew they were diabetic or hypertensive and were on treatment. Others did not know their health status but mentioned that a family member had a predisposing factor but did not think they had diabetes or hypertension. Participants mentioned that some migrants were under a lot of mental and psychological stress and presented with mental illnesses. There were reports of suicide. None of the applicants personally admitted to mental illness.  Some of the men admitted to the use of cigarettes and alcohol.  Visits to sex workers were also mentioned highlighting that condoms were not available to buy openly and that often the sex workers were the only ones with supplies. Male participants stated that they would often bring essential drugs like paracetamol with them from Bangladesh but none of them travelled with condoms. Women who had children in Libya expressed that the child health services were good and they had ready access to immunization and maternal care.
Conclusion (max 400 words): Bangladeshi migrant workers are exploited from the point they conduct the health screening in Bangladesh. They pay exorbitant amounts for medical tests which are unethical as they are not informed of why the tests are being conducted. There was no evidence of pre and post counseling before HIV tests were conducted.   Migrant workers who do not have health services provided by their employers have limited access to health care. Most low skilled migrant workers have very little knowledge about their health. Most of the migrants have heard about TB, HIV and STDS and other communicable diseases but less is known about non-communicable diseases such as Diabetes and Hypertension. This is alarming considering that non communicable diseases such as diabetes and hypertension have a high prevalence in Bangladesh. Psychological stress and mental illness is high among Bangladeshi migrant workers and  not all outcomes are positive. It is interesting to find that the Bangladeshi communities support each other abroad including providing psychological and financial support. There is potential to train peer group supporters to provide health promotion within their community when at home and abroad. Bangladeshi television programmes are still watched in Libya and this is clearly a good way to conduct health promotion for Bangladeshi migrants in a language and culture that they understand. This medium of communication should be used for programmes that prevent and control non- communicable disease for migrants, at home and abroad. Source country governments should have a code of ethics for the recruitment agencies to ensure that migrants are not exploited. National expatriate agencies should promote the welfare of migrants and ensure that contracts provide access to appropriate health care services and health insurance for migrant workers at home and abroad. Consular offices in countries with large numbers of their nationals as migrant workers should constantly provide health promotion social mobilization activities within their national communities.

GHF2006 – Interview with Mary Robinson

September 3, 2006

Submitted by: Viola Krebs (ICVolunteers); Contributors: Jean-Pierre Joly (ICVolunteers)

"With the human rights as a framework... the objective of 'access to health for all' will certainly have made some progress through the conference." Image: Viola Krebs,

Mary Robinson, the first woman President of Ireland (1990-1997) and more recently United Nations High Commissioner for Human Rights (1997-2002) shared with the conference team some of the main challenges at hand when it comes to access to health for all: accountability, financing, the brain drain and the responsibility of those who have the means to make a difference, such as the private sector. She pointed out that the high turnout at the Forum was an indicator of the need for it and the urgency of discussing access to health. Access for all is the concern of all.

Q: Accountability of politicians for decisions affecting human health and dignity is a key issue. If everybody agrees on the principle, the question remains of how to assess their achievements and how to enforce accountability?

I speak more and more about accountability including accountability in the social context. Human rights help greatly. We know what the legal commitments mean for countries. The UN Committee on Economic, Social and Cultural Rights has provided guidance to governments and standards against which they can be held accountable. We have more and more ways to measure their ability to fulfill the right to health. Some of the core obligations such as ensuring that no one is discriminated against in terms of access to basic treatment are to be fulfilled regardless of available resources. The increasing sophistication of civil society groups also enhances social accountability. The Treatment Action Campaign case in South Africa proved that governments can be required to implement comprehensive and coordinated programmes in order to realize the right of access to medical treatment. On 4th September, I will be in London to help Paul Hunt, the UN Special Rapporteur on the Right to Health, to defend his ideas on this matter with the UK Government. It is an important move because we need to keep accountable rich as well as poor countries.

Q: Requesting from developing countries that they finance themselves the access to health for all at a national level seems unrealistic. On the other hand it appears that financing provided by the developed countries for the South has short term effects. Is there a methodology that could be followed to obtain long-term sustainable results?

The current situation is actually shocking. Public health systems in poor countries are broken, in particular in rural areas where many problems surface. We need absolutely to change the approach. It is being recognized that the local parameters have to be far more taken into account. Many errors have been made by the IMF and the World Bank, which actually weakened the ability of countries to take local action. The new trend amongst donors to privilege general budget support since the Paris declaration on aid will put more responsibility on the countries' decision makers. Health ministers will have to be very skilled managers which is not necessarily always the case currently. In quite a number of countries corruption also remains a major issue. Everything should be done to support health ministers and their ministries in order to allow them to manage funding from the GAVI (Global Alliance for Vaccines and Immunization), NGOs, foundations and other donors and to enable them to meet, amongst other things, the Abuja declaration which targets that 15% of national budgets would go to their health systems.

Q: When one thinks of resources, a major one is the human resource. Developing countries suffer from an ongoing brain drain affecting deeply their health systems. How to stop and even reverse this trend?

It is of utmost importance to stop the brain drain. Mid-level workers need to be trained. These middle-skilled personnel are undervalued and invisible. Yet, these health personnel show more sustainability while not being tempted by migration like highly trained health professionals. A good example of this is the use of Tanzania's paramedical personnel to dispense anti-retroviral medication. On 12 September, we will have a high level meeting in New York on migration. The aim is to stimulate more bilateral agreements between countries to avoid permanent migration and to enhance shared training efforts. All countries should share responsibility in this field. In this respect, the pull factor is of importance, meaning that the rich may agree to train more. In the US, where I am currently living, 500,000 nurses and 200,000 doctors are needed by the year 2015. Nurses are being imported. The fact of acquiring them cheaply by not having to educate them is unacceptable. There are many ideas to think about.

Q: The pharmaceutical industry is often criticized. Do you think there is evolution to provide medicine at lower costs? Is there a will within those companies to become socially responsible beyond just a superficial marketing move?

We regard the private sector as an important player either providing good resources or a negative influence. We are keen to see them fully responsible and specific companies have taken this direction. Paul Hunt, the UN Special Rapporteur on Health, is developing guidelines related to the human right to health. The subject is vast and goes from intellectual property to pricing. It is evident that we need a structure and guidelines and pharmaceutical companies, as well as all other stakeholders, have to buy into this.

Q: What are your expectations from the debates during the present Forum and in what way can they influence decision makers?

The Forum comes at the right time. This is proven by the fact that the attendance overshot all expectations. I am convinced that we can initiate change in most of the fields which are on the agenda. The dynamics exist to accelerate a breakthrough in areas such as safer food and water supply, improving educational levels and other social determinants. The Millennium Development Goals have set a 0.7% of GDP level for the aid to be provided by the North to the South. The US Administration is today more willing to commit itself as well. All of this needs to be thought through. The errors of the past often found their origin in the non-coordinated approach of health issues and systems. This Forum gives the opportunity to encompass government representatives, healthcare specialists, donors and NGOs, to strengthen sustainable long-term health systems and to develop common views. With the human rights as a framework it seems that the objective of access to health for all will certainly have made some progress through the conference.

Q: A few weeks ago you attended the World Conference on AIDS in Toronto. What was your overall impression and what conclusions could be drawn from the debates?

My impression was quite similar to the one that prevailed during the previous conference two years ago in Bangkok. A lot of emphasis was put on the progress to be expected from fundamental scientific work. Subjects such as the status of development of microbicides were at the centre point of the majority of the debates, but the use of female condoms got little mention in the context of sub-Saharan Africa. The ability of women and girls to protect themselves from contracting the virus is as important as the process to prepare effective microbicides. The issue of the identification of risk groups did not seem to draw a lot of attention. It appeared as if there was a tendency not to want to address real problems. In a sense it was quite disappointing. Community groups know what they are doing and what they need, but they did not always get enough attention. The focus was more on well known guests than on rallies on women's issues and rights. A number of key issues were not addressed. The planning for the next conference in Mexico needs to put the priorities right.

More Information

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