Sixty-eighth Regional Committee for Europe: Rome, 17–20 September 2018: progress report on implementation of the Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region

W ORL D H E A LT H O RG A N I Z AT IO N R EG I ON A L O F F I C E FO R EU R O P E UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Telephone: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eugovernance@who.int Web: http://www.euro.who.int/en/who-we-are/governance Regional Committee for Europe EUR/RC68/8(F) 68th session Rome, Italy, 17–20 September 2018 6 August 2018 180434 Provisional agenda item 5(o) ORIGINAL: ENGLISH Progress report on implementation of the Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region This report provides an overview of implementation of the Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region, in line with resolution EUR/RC66/R6. It is submitted to the 68th session of the WHO Regional Committee for Europe in 2018. EUR/RC68/8(F) page 2 Contents Background ................................................................................................................................ 3 Health and health service needs for refugees and migrants in the WHO European Region ........................................................................................................................................ 3 The Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region ........................................................................................................................................ 4 Supporting Member States to implement the Strategy and Action Plan .................................... 4 Implementation at country level ................................................................................................. 5 Implementation at regional level ................................................................................................ 7 The Migration and Health programme ............................................................................. 7 The Knowledge Hub on Health and Migration ................................................................ 8 Migration and Health Knowledge Management ............................................................... 8 Lessons learned, recommended policy options, and ways forward ........................................... 9 Conclusions and plans .............................................................................................................. 10 Annex. Definitions ................................................................................................................... 12 EUR/RC68/8(F) page 3 Background 1. In order to address current and future migrant and refugee1 movements in the WHO European Region, the WHO Regional Committee for Europe adopted the Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region in 2016. The Strategy and Action Plan contains nine strategic and priority areas for action as well as five core indicators for measuring and reporting on progress in its implementation. In adopting the Strategy and Action Plan, the Regional Committee requested the Regional Director to report to the 68th, 70th and 72nd sessions of the Regional Committee on its implementation (resolution EUR/RC66/R6). Health and health service needs for refugees and migrants in the WHO European Region 2. Evidence of poor health among refugees and migrants is generally confined to certain infectious diseases, and maternity and mental illness outcomes, with some evidence of increased rates of infant mortality. The prevalence and proportion of infectious diseases such as tuberculosis and HIV/AIDS vary among Member States in the Region, depending on the migratory pattern and the domestic prevalence rates. The proportion of TB case notifications among migrants ranges from less than 2% in certain Member States to more than 90% in some others. Migrants also represent a considerable proportion of newly reported HIV cases in the Region. Mental disorders are prevalent and risk factors for developing such disorders are encountered by refugees and migrants before, during and after migration. Gender differences in health status are manifest: women are more exposed to sexual violence, abuse and trafficking. In addition, women experience risks related to pregnancy and childbirth, particularly when these are unassisted. They frequently face gender-specific inequalities as well as gender-based violence in countries of origin and destination, which can exacerbate vulnerability before, during and after the migration process. 3. Unaccompanied migrant children represent a specific challenge. They may suffer severe health consequences during their journey, traumatic events while travelling and exposure to risk factors such as exploitation, abuse and trafficking, poor living conditions, uncertainty around the reception process and fragmented assistance within destination countries. Unfortunately, assistance – including medical and psychological services, social care and education – is often provided in a fragmented way and there is a lack of harmonization of policies and regulations across countries. 4. Adult migrants account for a high percentage of the working age population in low-paid jobs and are more likely than other members of the population to be employed on insecure, temporary and illegal contracts. These factors can contribute to social exclusion, depression and early onset cardiovascular disease. 1 Refugees and migrants are heterogeneous groups. No universally accepted definitions of migrants exist. The working definitions of these terms as applied in this document are contained in the Annex. While in some contexts the definitions in the Annex may have important implications for entitlement and access to health services, the definitions as applied in this note do not denote any legal status or entitlement. EUR/RC68/8(F) page 4 The Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region 5. In the context of the Sustainable Development Goals (SDGs) and the European health policy framework, Health 2020, the Strategy and Action Plan for Refugee and Migrant Health establishes a framework for collaborative action. The Strategy and Action Plan facilitates a coherent and consolidated national and international response, with Member States acting in a spirit of solidarity and mutual assistance. It encourages Member States to coordinate the activities of, and collaborate with, civil society, and nongovernmental, charitable and religious organizations to optimize the use of resources and promote structural interventions. 6. The nine strategic areas of the Strategy and Action Plan, as listed below, overlap with the global WHO framework of priorities and guiding principles to promote the health of refugees and migrants:2 • Strategic area 1: Establishing a framework for collaborative action • Strategic area 2: Advocating for the right to health of refugees, asylum seekers and migrants • Strategic area 3: Addressing the social determinants of health • Strategic area 4: Achieving public health preparedness and ensuring an effective response • Strategic area 5: Strengthening health systems and their resilience • Strategic area 6: Preventing communicable diseases • Strategic area 7: Preventing and reducing the risks posed by noncommunicable diseases • Strategic area 8: Ensuring ethical and effective health screening and assessment • Strategic area 9: Improving health information and communication Supporting Member States to implement the Strategy and Action Plan 7. By promoting interregional and intercountry collaboration, communication and the exchange of information on experiences and good practices, the Regional Office has supported Member States in implementation of the Strategy and Action Plan. The Regional Office has provided relevant products such as evidence and research reports (for example, through the Health Evidence Network) and networking platforms, and has helped to develop modular training on health equity and human rights-based approaches for health and non-health workers. 8. The Regional Office has provided leadership on, and helped Member States to implement, the European Action Plan for Strengthening Public Health Capacities and Services. 2 The framework of priorities and guiding principles was adopted in 2017 by the World Health Assembly in resolution WHA70.15. EUR/RC68/8(F) page 5 9. The Regional Office has supported countries in conducting preparatory and ongoing assessments and implementing reporting systems that monitor health system performance. It collects and shares good practices in developing and delivering health services that respond to the needs of refugees and migrants. Through the assessments and similar activities, the Regional Office has supported Member States to develop adequate health system capacities to respond to the health needs of refugees and migrants, including through the strengthening of national capacities to monitor health system inequities and to generate evidence on vulnerability profiles and needs. 10. The Regional Office has also assisted Member States in strengthening health information systems for improved data collection on refugee and migrant health, collecting and distributing information in cooperation with existing initiatives, and has identified and mapped good practices in refugee and migrant health monitoring. In taking these initiatives, the Regional Office has worked closely with other United Nations agencies such as the Office of the United Nations High Commissioner for Refugees and the International Organization for Migration (IOM). 11. At the global level, in the context of the Strategy and Action Plan, the Regional Office has played an instigating and catalytic role in mobilizing and supporting Member States to achieve consensus on the resolution on promoting the health of refugees and migrants adopted by the World Health Assembly in May 2017 (resolution WHA70.15), as well as the framework of priorities and guiding principles. It has also supported the development of the global compact on refugees and the global compact on safe, orderly and regular migration, by sharing experiences and participating in working groups. The Thirteenth General Programme of Work 2019–2023 also includes migration health within its emergency component. Implementation at country level 12. In accordance with the request of the Regional Committee in adopting the Strategy and Action Plan, implementation within Member States and the Region has now been reviewed by means of a questionnaire sent to all Member States. This requested information on a few high-level indicators designed to provide a snapshot of implementation of the nine strategic areas within the Strategy and Action Plan. 13. Forty Member States responded to the questionnaire. Of these, 32 reported having a national health policy, strategy and/or plan with at least one explicit component on migration and health (Fig. 1). Eight Member States reported that they did not have such an explicit component, but of these, five indicated an intention to do so in the future. EUR/RC68/8(F) page 6 Fig. 1. Does the national health policy, strategy and/or plan have at least one explicit component on migration and health? 14. The Member States mainly referred to the health of refugees (23) and asylum seekers (23), followed by labour migrants (16) and irregular migrants (16) in their national health policy strategies and/or plans. 15. All of the key strategic areas (SAs) of the Strategy and Action Plan were addressed in national health policies, strategies and plans. SA 6 (23 countries) was the most commonly addressed strategic area. This was closely followed by SAs 2, 4 and 9 (22), SAs 1, 5 and 8 (17), SA 7 (16) and SA 3 (14). 16. Half of the Member States (20) had conducted at least one assessment within their national health systems on the health needs of refugees and migrants. Of the other half, five had plans to do so. 17. Nineteen Member States had conducted at least one assessment within their national health systems on health service coverage for refugees and migrants. Twenty-one had not, of which seven had plans to do so (Fig. 2). Fig. 2. Has at least one assessment been conducted within the national health system on the health service coverage for refugees and migrants? 18. Twenty-six Member States had developed a regional or national contingency plan for large arrivals of refugees. Fourteen had not, of which five had plans to do so. Of the 26 Member States with a plan, nine had tested it. 19. Half of the Member States (20) reported that they routinely collect and include data on migration-related variables in existing local/regional/national datasets. Of the other half, 8 had plans to do so (Fig. 3). 32 8 Yes No 19 21 Yes No EUR/RC68/8(F) page 7 Fig. 3. Does the Member State routinely collect and include data on migration-related variables in the existing local/regional/national datasets? 20. Twenty-five Member States had involved non-health sectors and stakeholders in conducting assessments of the health needs (including social determinants of health) of refugees and migrants. Fifteen had not, of which one had plans to do so (Fig. 4). Fig. 4. Does the Member State involve non-health sectors and stakeholders in conducting assessments of the health needs (including social determinants of health) of refugees and migrants? Implementation at regional level The Migration and Health programme 21. The Migration and Health programme, formerly known as Public Health Aspects of Migrants in Europe (PHAME), was established in 2011 to support Member States to strengthen the health sector’s capacity to provide evidence-informed responses to the public health challenges of refugee and migrant health. The programme provides support to Member States under four pillars: technical assistance; health information, research and training; partnership building; and advocacy and communication. The programme promotes a collaborative intercountry approach to migrant health. It facilitates cross-country policy dialogue and encourages homogeneous health interventions along the migration routes and in destination countries, to promote the health of migrants and refugees and protect the health of the host communities. 22. Under the guidance of the programme, WHO country offices in Greece, Serbia and Turkey have appointed national professional officers to support these Member States in developing a migrant-friendly health system. 20 20 Yes No 25 15 Yes No EUR/RC68/8(F) page 8 The Knowledge Hub on Health and Migration 23. The Knowledge Hub on Health and Migration is a joint effort between the Regional Office, the Ministry of Health of Italy, the Regional Health Council of Sicily, Italy, and the European Commission. The aim is to build expertise and competence on the public health aspects of migration and to make knowledge and information in this area widely available. 24. As part of the work of the knowledge hub, a first summer school on refugee and migrant health was held in Sicily in 2017, organized by the Regional Office with the support of the Ministry of Health of Italy and the regional health authorities of Sicily, and in collaboration with the European Commission, the European Public Health Association, IOM and the University of California, Berkeley. The five-day course was offered under the umbrella of the WHO European Knowledge Hub on Health and Migration. 25. The school hosted 76 participants from 25 different countries, including 30 nominated delegates from 16 Member States. It provided an opportunity for participants to improve their understanding of the main health issues and needs of refugees and migrants, and of the broader public health and health system implications of large-scale migration in origin, transit and destination countries. The school also offered a platform for bridging research, policy and practice; sharing practical, real-world knowledge and experience; and fostering debate and critical thinking. 26. The course included a combination of plenary presentations, workshops, interactive discussions and panels. The theoretical information was complemented by a simulation exercise in which school participants joined an Italian coast guard boat responding to a simulated migrant boat emergency, enabling them to obtain greater understanding of the local model and infrastructure for responding to refugee and migrant health needs. Based on evaluations provided by participants, the school was considered to be a success, and options are being explored to make it an annual event. Migration and Health Knowledge Management 27. The Regional Office, in collaboration with the European Commission Directorate- General for Health and Food Safety, has established the Migration and Health Knowledge Management project to address knowledge gaps in the area of migration and health in the Region, and to support the development and uptake of evidence-informed guidance to ensure that activities meet the health needs of migrants and refugees. 28. The project is developing technical guidance recommendations across six priority issues in migrant health: child health, elderly health, health promotion, mental health, mother and newborn health, and noncommunicable diseases. For each priority issue, knowledge and good practices will be shared in various formats for immediate use and application. Interactive webinars on various topics related to refugee and migrant health are being conducted to complement the technical guidance and provide unique, thought-provoking perspectives. EUR/RC68/8(F) page 9 Lessons learned, recommended policy options, and ways forward 29. Migration is a major social, political and public health challenge for the European Region and for policy-makers developing coherent policies that address the health needs of all migrants and refugees, in accordance with the Strategy and Action Plan. 30. The ability of the state to provide health care for refugees and migrants varies according to the level of development of health service infrastructure and the funding of health care for the general population. Health systems should incorporate the needs of migrants into health financing, policy, planning, implementation, monitoring and evaluation in a systematic way. In line with the SDGs, resolution WHA61.17 on the health of migrants and the WHO people- centred health systems approach, care should be culturally informed and provided by culturally sensitive staff, both clinical and administrative. Wherever possible, refugees and migrants with health professional backgrounds should be incorporated into the workforce. 31. The utilization of services, particularly primary care, should be improved through: the provision of technical support for registering and making appointments; provision of language support and patient advocacy services; provision of free transport to and from appointments, when required; longer appointment times to allow for interpretation and explanation; provision of flexible opening hours and appointment times; gender-specific requests being met and respected; the development and delivery of high-quality training for professionals, including in the relevant cultural sensitivities; and increased awareness among health professionals of mental health issues for refugees and migrants, particularly minors. 32. Linguistic barriers to quality health care should be addressed through the adoption of an intersectoral approach to the provision and distribution of health information in a range of languages; the provision of professional interpreters, free of cost to the patient and health professional; the provision of clear labelling of prescriptions in relevant languages; and documentation of the languages spoken by, and literacy levels of, patients. 33. In addition, accurate communication and public information on health matters is of paramount importance to reduce discrimination and stigmatization, eliminate barriers to health care and offer the requisite conditions for mobile populations to enjoy a healthy life. Relevant guidelines should be shared widely, including with refugees and migrants themselves. Communication should also take place with local agencies and media, and with the local health workforce who should be trained in crisis communications and media relations. 34. Although specific services may be needed in urgent situations, in general the health needs of refugees and migrants should not be addressed separately from those of the rest of the population. The provision of universal health coverage is central to the response to the health needs of refugees and migrants. 35. National contingency planning should be fully integrated into national health policies, strategies and plans, based on comprehensive needs assessments. In this regard, focal points for refugee and migrant health within ministries of health play a major role. Effective integration of nongovernmental organizations is also important, particularly in early responses. EUR/RC68/8(F) page 10 36. Intersectoral health policies in the context of the SDGs and Health 2020 are vital to the response to the full range of health determinants. Intersectoral approaches were discussed at the high-level conference on promoting intersectoral and interagency action for health and well-being in the WHO European Region, held in December 2016 in Paris, France. Within the health sector, consideration should be given to the efficient use of resources, effective responses to health needs, and, in particular, the provision of primary health care with well-trained staff capable of dealing with psychosocial issues. The shift from an emergency to a longer-term response, and procedures for screening/case finding/triage should also be considered. 37. Full consideration should also be given to implementation of the International Health Regulations (2005), including national guidelines for communicable disease preparedness, surveillance and control. 38. At the operational level, practical support is required to improve access to services. Legal restrictions on access to health care for asylum seekers and refugees should be removed, regardless of migration status, and coordinated multisectoral action should be extended beyond the medical system to include sectors such as housing, employment and education. 39. Robust evidence and good surveillance systems are required to develop informed policies, enhance service delivery and support the work of health and non-health workers in areas such as screening practices for communicable and noncommunicable diseases and addressing the needs of unaccompanied minors. The evidence on refugee and migrant health issues should be strengthened by: development of information and monitoring systems that promote comparative work across subsections of migrant and non-migrant populations; coordination of data across governmental and nongovernmental agencies; examination of the health effects of different phases of the asylum process; assessment of the long-term health impacts of initiatives relating to integration in housing, employment and education; analysis of the correlation between integration policy and good health outcomes in maternity and mental health; development of non-stigmatizing concepts for research and monitoring; and improvement in the understanding of migrants’ own priorities, which may be at odds with those of professionals. Conclusions and plans 40. Evidence to date suggests that the Strategy and Action Plan has been partially implemented by Member States, but that much work remains to be done prior to the next evaluation point in 2020. It will be vital to incorporate assessments of health needs and health coverage into effective national health policies, strategies and plans, and to ensure that national and local focal points for refugee and migrant health have the authority and capacity to secure change. 41. All groups of migrants, including refugees, should be included in a national health policy strategy and/or plan. Contingency plans for large-scale arrivals also need to be developed and tested. Such national and local planning should proceed with the full involvement of all sectors, including civil society, and should be informed by the improved collection of information on migrant-related variables. EUR/RC68/8(F) page 11 42. At regional level, the Migration and Health programme will continue to work with Member States to: support implementation of the Strategy and Action Plan; help countries to fill potential gaps in health service delivery; continue to carry out joint public health and health system assessment missions; and provide policy recommendations on preparations for large influxes of refugees and migrants, using the WHO toolkit for assessing health system capacity for crisis management. 43. Ongoing work in Gaziantep, Turkey, to increase capacity to respond to the public health needs of Syrian refugees will continue as needed, as will collaborative work with the Regional Office Division of Health Systems and Public Health and Division of Health Emergencies and Communicable Diseases, in coordination with the Ministry of Health of Turkey. 44. The Knowledge Hub on Health and Migration and the annual summer school on refugee and migrant health will continue to be developed. Recent initiatives include the designation of the University of Pécs, Hungary, as the WHO Collaborating Centre for Migration Health Training and Research, to serve as a technical and scientific resource for the Migration and Health programme of the Regional Office. Other well-established universities and research institutions across the European Region are planning to become collaborating centres in this area, which would strengthen the work of the Regional Office in supporting countries. EUR/RC68/8(F) page 12 Annex. Definitions 1. Definitions of migrants, refugees and asylum seekers are diverse and inconsistent across the WHO European Region, implying both political sensitivities and specific challenges, including those related to access to health care. Entitlements and access to health services for different groups are determined by national regulations and legislation. In this document, the term “migrant” is used as an overarching category in line with resolution WHA61.17, and the terms “refugee” and “asylum seeker” are included and applied in accordance with the 1951 Convention Relating to the Status of Refugees and as recommended by the International Organization for Migration and United Nations High Commissioner for Refugees. When considering global and regional migration trends, it can also be useful to distinguish between two types of migration phenomena: structural long-term migration patterns resulting from global inequalities; and large-scale arrivals resulting from war, conflict and natural disasters. = = =