Health care provision for migrants in the African context
If nobody really cares...
Von Kaspar Wyss / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
This article reviews the access to health care for migrants in African countries as well as interventions targeting these people. Obstacles for access to health care for migrants are for example, the existence of racism, communication and language skills, knowledge about available health care in the host setting or altered cultural concepts of health and disease. Although large scale interventions implemented by bi- and multilateral and non-governmental institutions for specific groups of migrants such as refugees do exist, there are enormous gaps in the knowledge how best to provide cost-efficient, adequate and acceptable health services to other groups of migrants such as migrant workers or nomadic people.
Increasing movements of migrating people, both inside Africa and between Africa and other parts of the world, has made of migration a priority topic to deal with. There is no universally accepted terminology to describe migrants and to distinguish them from other parts of the population. However, one can distinguish three very broad groups: nomadic people, migrant workers (resident migrant workers, temporary migrant workers, internally and externally migrant workers), and refugees and internally displaced people. Another category are "illegal" migrants, characterised by an intermediary legal status before becoming resident migrant worker or asylum seeker.
Reasons to migrate are related to the economic, political or social situation of certain segments of the population and migrants are found in a wide variety of circumstances. Refugees and internally displaced people have most frequently been associated with armed conflicts such as those in Liberia, Somalia and Rwanda, where large numbers of persons have been forced to flee. But, there are also many situations in which people have to move as a result of environmental calamities, development projects, infrastructural schemes or disastrous economic situations. So, internally and externally migrant workers can be found in many countries such as for example in mines of South Africa or Botswana.
There is no doubt that a large proportion of migrant people lives in conditions of great risk. Migrants are not only exposed to poor working and living conditions, which are in their own right determinants of poor health, but they also have reduced access to health care compared to other parts of the population. This is due to a number of political, administrative and cultural reasons, which vary in different societies and for different groups. For example, barriers in accessing health care may reflect administrative obstacles to receive care, including residence conditions which need to be fulfilled before services can be accessed. In other situations racial, cultural and linguistic barriers may prevent migrants from making appropriate use of the available health services. Furthermore, health care services are hardly ever defined according to the needs and demands of migrants.
There are several reasons why migrants should receive specific consideration while planning, managing and administering health interventions. For marginalised and socially excluded people such as migrants, most importantly, there is the reason of equity and right to health care. According to the universal declaration of human rights, "everyone has the right to a standard of living adequate for the health and well-being of himself and his family including food, clothing, housing and medical care and necessary social services". Their high vulnerability to the social, economic and environmental context is another argument justifying special attention to migrants by health care providers.
Reactions of governments and international institutions to migration
The extent of migrant people and especially of complex humanitarian emergencies in Africa over the last decade have posed a big challenge to governments as well as to international institutions with mandates for interventions for migrating people.
On the governmental level, it can be argued that there exists the state responsibility. This principle stipulates that governments have a primary duty to act in a way that is conducive for preventive and curative health care, specially also for less advantaged groups. However, the operational capacities of national governments are in most situations very limited due to resource constraints and administrative, managerial and organisational weaknesses of public services. Moreover, many situations of migration are linked with the state’s collapse such as seen recently in Somalia, Sierra Leone or Liberia.
In many African countries, the structure of the state to protect migrants is weakened to an extent that humanitarian and development organisations have to fill the vacuum. The task to address the provision of health care for migrating people lies in most situations in the hands of bi- and multi-lateral and non-governmental institutions. Besides ministries of foreign affairs and of development assistance of countries of the North, various UN agencies including UNICEF, UNHCR, UNDP, WFP, and FAO shape the interventions, whereas UNHCR and IOM have a clear mandate for at least specific groups of migrants. Non-governmental organisations are extremely diverse, ranging from ICRC and MSF to CARE and OXFAM as well as many others.
Migrant workers, internally displaced people and nomads receive less attention
Top priorities of interventions addressing health needs of refugees have been the provision of food aid, water and sanitation, disease prevention (including vector control), and first aid and surgical support, followed by the provision of social services (education, counselling, etc.) and physical rehabilitation of wounded people. Through their medical and public health programs humanitarian and development organisations have acquired sound knowledge on how to deliver primary care interventions to refugees. There exists also a large body of literature documenting the operations of relief agencies in the field of immunisation, clean water supplies, vector control, sewage systems as well as treatment of severe child malnutrition.
The health care interventions of organisations with mandates for migrants have been more difficult for internally displaced people and working migrants remaining under the jurisdiction of the state - in spite of the states’ evident unwillingness or inability to guarantee health care for these people. The provision of health care to migrants within their own country thus raises in a very direct manner the question of state sovereignty. To what extent can bi-, multi-lateral as well as non-governmental organisations substitute for an absence of protection by the state to all segments of the population including the most disadvantaged? If consent is not forthcoming, do these actors have the right to intervene in an assertive or coercive manner?
Although demographically often not less important, migrant workers, internally displaced people and nomads have so received much less attention and fulfil hardly ever the necessary criteria to benefit from specific interventions even though that their needs and demands for health care are important. Subsequently, there exists little synthesis on key operational aspects of health care delivery to these groups of migrants. This although classical concepts of health care delivery in Africa, such as the concept of the district, do not well take into account realities of working migrants and nomadic people.
Enormous gaps in the knowledge how best to provide specific, cost-efficient, adequate and acceptable health services to migrants are still existent. Definitively, these interventions targeting internally displaced people, migrating workers and nomadic people would need specifically to address current obstacles of access, specifically the existence of racism, knowledge about available health care, communication and language skills (interpreters), as well as altered cultural concepts of health and disease.
Kaspar Wyss is project co-ordinator at the Support Centre for International Health, Swiss Tropical Institute, Basel