What we learned in the “Report on the health of refugees and migrants in the WHO European Region" (2018)
No public health without refugee and migrant health
Von Santino Severoni and Soorej Jose Puthoopparambil
Produced by the WHO Regional Office for Europe, the Report on the health of refugees and migrants in the WHO European Region is the first WHO report of its kind giving a snapshot of the health profile of refugees and migrants in the WHO European Region and of the health system responses. Creating an evidence base is paramount to assist Member States to develop evidence-informed policies to meet the health needs of both refugees and migrants and host populations. The report reveals that refugees and migrants are likely to have good health, but it can deteriorate before departure, during transit and/or after arrival in a host country due to exposure to various risk factors for health such as violence, poor living conditions and other social determinants of health.
Group photo of participants at the School on Refugee and Migrant Health 2018. Palermo, Italy. 2018. Photo: © Francesco Bellina
The movement of people across the planet seeking opportunities or fleeing danger has consistently influenced human activity and has shaped our societies, including the countries in the WHO European Region. However, despite hosting 35% of the international migrants (91 million), accounting for 10% of the population in the region, there exists limited data on the health of refugees and migrants at a regional and sub-regional level.
The Report on the health of refugees and migrants in the WHO European Region is first of its kind providing an overview of evidence on the health of refugees and migrants in the region. The evidence in the report comes from over 13,000 documents and data collected by WHO and provided by partners. The report provides an evidence base for the member states to develop a refugee and migrant sensitive healthcare system. The report provides an overview of the migratory trends in the region, health profile of refugees and migrants, the health system response, progress made in the region to safeguard and promote refugee and migrant health and a brief account of initiatives taken by various member states, WHO and other international organizations. The report highlights examples and strategies that the Member states could adapt into their own contexts to strengthen the health system benefitting refugees and migrants and host population.
Supporting Syrian refugees in Jordan thanks to UK aid and UNHCR. Photo: DFID - UK Department for International Development/flickr, CC BY 2.0
The health of international migrants in the WHO European Region
A very common misperception is that there are “too many” refugees and migrants, and citizens in some European countries estimate the number of refugees and migrants at three or four times more than there actually are. The recent estimates suggest that refugees and asylum seekers account only for approximately 7% of the international migrants in the region. The distribution of international migrants in the region varies from approx. 1% in Bosnia and Herzegovina to almost 55% of the national population in Monaco. International migrants, including refugees, in the region has risen from almost 50 million in 1990 to 91 million in 2017 and majority of the international migrants belong to the working age (25- 50 years).
Health of refugees and migrants in the WHO European Region: Refugee and migrant health is a highly complex topic and the available evidence does not provide an overall picture of their health. This is mainly due to the lack of comparable and systematically collected data. One of the main issues contributing to the non-comparability is the use of unclear or varying definitions for migrants across studies. However, some common patterns could be identified. In general, the report found that refugees and migrants are likely to have good health upon arrival in host countries and seem to have a mortality advantage when compared to the host population for several disease categories, except for diseases of the blood, respiratory system, cardio vascular system, infectious diseases and external causes. There are many possible causes for this pattern, but it is important to note that refugees and migrants can be at risk of falling sick during transition or whilst staying in a host country due to poor living conditions and social determinants of health.
Majority of the published evidence available is on communicable diseases. The proportion of refugees and migrants among newly diagnosed cases of TB or HIV varies from less than 3% some countries in the Balkan to more than 80%, especially in the northern European region. Hence the impact of refugees and migrants on the national health systems also vary. It is of relevance to note that a significant proportion of refugees and migrants originating from countries of high prevalence of HIV acquire infection after arriving in Europe. It is concerning to note that refugees and migrants are more likely to be diagnosed at a later stage of their HIV infection. It is important for the local and national health systems to adopt policies that address these challenges. However, despite the widespread assumption to the contrary, there is only a very low risk of refugees and migrants transmitting communicable diseases to their host population.
Amina Aboukar, Nigerian refugee from Damassak. Photo: EU Civil Protection and Humanitarian Aid/flickr, CC BY-NC-ND 2.0
While communicable diseases are commonly linked with displacement and migration, there is a growing awareness that a range of acute and chronic non-communicable diseases also require attention. In the area of non-communicable diseases, refugees and migrants appear to be less affected than their host populations on arrival; however, several factors such as duration of stay change the health outcomes of refugees and migrants over time, especially with increasing risk for overweight/obesity. Diabetes is another chronic condition where migrants have higher incidence and prevalence than the host population, with female migrants having higher prevalence than male migrants with variation seen among various groups. Mental health is a prominent health issue among refugees and migrants, as depression, post-traumatic stress disorder and anxiety seem to be more prevalent compared to host populations. Unaccompanied minors experience high rates of PTSD. However, variations within migrant groups and the methods used to assess the prevalence can make it hard to draw firm conclusions. Refugee and migrant women tend to have worse pregnancy related outcomes and migrant children seem to be more prone to overweight/obesity.
Gaps and discrepancies in health coverage and delivery
Access to health care services varies greatly across the Region and within national boundaries of its Member States with various groups of migrants having varying conditional access. Irregular migrants often have very limited access to healthcare. Availability of health services at places where migrants are detained are also limited, adding to the poor health among detained migrants. Available health services need to be linguistically and culturally sensitive. For example, only a few countries in the Region have national immunization programs that target refugees and migrants as well. Failure to ensure access to equitable health care for refugees and migrants can have negative public health repercussions and is in direct opposition to global health goals such as Universal Health Coverage (UHC) (WHO UHC Factsheet 2017) and increased access to Primary Health Care (PHC) (Declaration of Alma Ata 1978). The far-reaching discrimination, acts and manifestations of racism, violence, xenophobia and related intolerance against refugees and migrants, addressed in Objective 17 of the Global Compact on Safe, Orderly and Regular Migration (GCM), also work against achieving these goals.
Progress achieved in the region
By continuing to implement the strategy and action plan for refugee and migrant health in the WHO European region and several other initiatives, the countries in the region are moving towards creating a refugee- and migrant-friendly health system. Majority of the countries in the Region have an explicit component on migration and health in their national policies or strategies. Several countries in the region have also conducted at least one assessment on health needs and coverage for refugees and migrants and have contingency plans to respond to public health consequences of sudden influx of refugees and migrants. One of the main challenges in developing the report was the lack of availability of systematically collected and disaggregated data on refugee and migrant health. Such data is required to form evidence informed policies and reduce inequalities. Available data shows that at least 20 countries in the Region routinely collect and include data on migration-related variables in the existing local, regional or national datasets.
Progress Towards Universal Health Coverage. Photo: United States Mission Geneva/flickr, CC BY-ND 2.0
Way Forward: A vision for health of refugees and migrants in the WHO European Region
Following the suit of the WHO European region in developing a regional strategy (EUR/RC66/8 Strategy and action plan for refugee and migrant health in the WHO European Region), WHO now has a Global action plan to promote the health of refugees and migrants, contributing to the achievement of the vision of the 2030 Agenda for Sustainable Development (Transforming our world: the 2030 Agenda for sustainable development). Safeguarding and promoting the health of refugees and migrants involves taking measures to ensure that access to health care is based on clear and consistent legislation, that is protective of human rights, including the highest attainable standard of health. The realization of the goals of preventing disease, morbidity and premature death has two main aspects: enhancing and monitoring access to preventive and curative health care for refugees and migrants; and creating societal conditions conducive for the health and well-being of refugees, migrants and communities. To support this aim, the Migration and health programme (MIG), at the WHO European Regional Office works within 4 main pillars of work: technical guidance and country assistance, health information, research and training activities, partnership building and finally with advocacy and communication. In addition to producing evidence such as the report, MIG also produces evidence informed technical guidance and disseminates it through the Knowledge Hub for Health and Migration and through training programmes such as the annual summer school on refugee and migrant health.
It is imptant to state that migration should not be viewed as a “crisis” nor as an emergency limited in time. Conversely, it should be considered as one of the key global dynamics forming Europe now and in the years to come. Therefore, besides emergency preparedness and response, it needs long-term inclusion policies and structural adaptations in health systems to address some of the key challenges refugees and migrants face. In moving forward, WHO is committed to enhancing the necessary capacities for countries to meet the health needs of refugees and migrants which will benefit refugees and migrants, host countries and countries of origin. The Report on the health of refugees and migrants in the WHO European Region provides an evidence base to inform such policies and structural adapt.
- Report on the health of refugees and migrants in the WHO European Region: no public health without refugee and migrant health (2018). Copenhagen: WHO Regional Office for Europe (https://apps.who.int/iris/bitstream/handle/10665/311347/9789289053846-eng.pdf?sequence=1&isAllowed=y).
- Universal health coverage (UHC). Geneva: World Health Organization; 2017. Fact sheet; http://www.who.int/newsroom/fact-sheets/detail/universal-health-coverage-(uhc).
- Declaration of Alma-Ata. In: International Conference on Primary Health Care, Alma-Ata, 6–12 September 1978. Geneva: World Health Organization; 1978 (http://www.who. int/publications/almaata_declaration_en.pdf).
- Global compact for safe, orderly and regular migration (2018). New York: United Nations (https://refugeesmigrants.un.org/sites/default/files/180713_agreed_outcome_global_compact_for_migration.pdf).
- Strategy and action plan for refugee and migrant health in the WHO European Region (2016). Copenhagen: WHO Regional Office for Europe (EUR/RC66/8; http://www.euro.who.int/en/about-us/governance/regional-committee-for-europe/past-sessions/66th-session/documentation/working-documents/eurrc668-strategy-and-action-plan-for-refugee-and-migrant-health-in-the-who-european-region).
- Promoting the health of refugees and migrants: draft global action plan 2019–2023 (2019). In: Seventy-Second World Health Assembly, Geneva, 25 April 2019. Geneva: World Health Organization (https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_25-en.pdf).
- Transforming our world: the 2030 Agenda for sustainable development. New York: United Nations; 2015 (United Nations General Assembly resolution 70/1; http:// www.un.org/ga/search/view_doc.asp?symbol=A/ RES/70/1&Lang=E).
- Technical guidance: http://www.euro.who.int/en/health-topics/health-determinants/knowledge-hub-on-health-and-migration/knowledge-library?category_code=354705
- Knowledge Hub on Health and Migration. http://www.euro.who.int/en/health-topics/health-determinants/knowledge-hub-on-health-and-migration
- Summer School 2019. http://www.euro.who.int/en/health-topics/health-determinants/knowledge-hub-on-health-and-migration/summer-school
Dr. Santino Severoni MD, MHE, Acting Director, Division of Health System and Public Health & Coordination Migration and Health, Division of Policy and Governance for Health and Well-being.
Since 2000 he has held senior positions at the World Health Organization European Office. He is a medical doctor, health economist, epidemiologist and experienced system manager. He has over 24 years’ of experience as an international senior technical advisor and executive, and has worked for governments, multilateral organizations, NGOs and foundations in Eastern Africa, Balkans, Central Asia and Europe. During his professional career he has dedicated his work to global health with a particular focus on health sector reforms, health system strengthening, health diplomacy, aid coordination/effectiveness, management of complex emergencies and since 2011 coordinating the public health aspect of migration work for the WHO Regional Office for Europe. Email
Soorej Jose Puthoopparambil is a senior lecturer and researcher (Global health and migration) at the Dept. of Women¡¯s and Children¡¯s Health at Uppsala University, Sweden. Previously he has worked with the Migration and Health Programme at the WHO Regional office for Europe overseeing the research and evidence generation agenda of the programme, and with the International Organization for Migration (IOM) evaluating migrant health policies in the southern EU member states. He has a PhD in Medicine (International health and migration) from Uppsala University, Sweden.
Further co-authors: Emilie Comeau and Elisabeth Waagensen