ORIGINAL ARTICLES AND REVIEWS
Loredana IngrossoI; Tanja SchmidtII; Jamila SherallyII; Matteo DembechII; Sara Barragan MontesII; Rita Sa MachadoII; Giuseppe AnnunziataIII; Giovanni RezzaI; Santino SeveroniII
IDipartimento di Malattie Infettive, Parassitarie ed Immunomediate, Istituto Superiore di Sanità, Rome, Italy
IIEuropean Office for Investment for Health and Development, WHO Regional Office for Europe, Venice, Italy
IIIInternational Centre for Migration Health and Development, Geneva, Switzerland
BACKGROUND: Migrants have problematic access to health-care; non-institutional organizations (NGOs), as well as institutional bodies may play a role in facilitating their access to mainstream health care.
AIM: Our research reviews actions that address the need of migrants in terms of health care in order to understand how, where, and who participates in this effort.
METHOD: Data were from desk or web research, declaration from organisations and their websites, information from WHO Country Offices.
RESULTS: 154 NGOs were identified in the WHO European Region. 58% were direct health care providers while the remaining provided either mediation services or were part of a network organization. 173 national institutes (GOVs) were found; less than the 20% were directly or indirectly involved in health care, whereas the majority were involved in research, policy development, international relations and human rights.
CONCLUSION AND RECOMMENDATION: Some gaps, a certain fragmentation and lack of coordination were identified. WHO can play an overarching role in the exchange of expertise and harmonisation of the efforts in this field.
Key words: migrants, health care, access health care, NGOs, WHO European Region
The "Public Health Aspects of Migration in Europe" (PHAME) project, established by WHO in collaboration with the Italian Ministry of Health in April 2013, aims at improving the responsiveness to the health needs of undocumented migrants, by strengthening public health preparedness, improving the quality of services delivered, increasing trust between health professionals and patients, and optimizing the utilization of health structures in countries receiving migrants [1, 2]. Migrants, either undocumented or documented have gained increasing attention as a vulnerable group , as they are exposed to health risks that are higher than that of the general population because of the practical obstacles (language barrier, bureaucracy, fear of expulsion) which prevent them from accessing mainstream health care in destination countries [4-7]. Such situations not only affect migrants in everyday life but also pose a challenge to public health, possibly contributing to the reappearance of old diseases (like tuberculosis)  or the appearance of new diseases in non-protected populations. Non-institutional organizations (NGOs) already play an important role in this field by bridging the gap between mainstream health services and the people in need. Their activity, however, depends on a vast array of variables like the scope of the NGO, their distribution on the territory, the availability of funds, etc. At the moment, some attempts have been made in the EU to group various organizations under a common umbrella (i.e., "Mighhealthnet"  and "Nowhereland" ). However, a comprehensive overview that provides information regarding the main NGOs working on health service provisions related to migration in Member States of the entire WHO European Region does not exist.
This report presents the results of a mapping exercise conducted between May and July 2013 to document key NGO actors that provide health care services to migrants, irrespective of their legal status. It includes the countries of the WHO European Region with the aim of developing a useful tool for coordination, networking and the reciprocal exchange of practices and experiences amongst its key stakeholders in the region.
At the same time, a similar exercise has been conducted to investigate the role of institutional actors by constructing a data-base that will provide a comprehensive overview of governmental centres, universities and foundations that are active on the subject of migration and health.
Currently, there is a fragmented picture of the main stakeholders working on public health issues related to migration. Furthermore, limited coordination exists among these key actors and there is little coherence between policies and strategies among the different countries. There is a need for improved coordination. Sharing experiences, best practices and know-how is an important step in addressing the migration phenomenon both internally within individual Member States as well as within the European Region, at large.
The aim of this desk review was to identify the major actors, both Institutional and non-institutional, that facilitate migrants' access to national and local health services. This document will help to draw a comprehensive picture in order to identify missing spots or possible duplications in the action of NGOs and institutional bodies.
Two independent people (TS, JS) were in charge of collecting information while a third one (LI) analysed the data.
Data on NGOs of the WHO European Member States were gathered from different sources:
desk research, accessing relevant websites and reports of non-institutional organisations that provide health care services to migrants covering the countries in the WHO European Region;
in addition, several databases/directories were scanned by country to identify relevant organizations: The Practice Database of the Nowhereland Project http://www.nowhereland.info/?i_ca_id=416; The Mighealthnet Project http://mighealth.net/index.php?title=Main_Page; The Forced Migration Online Organizations Directory: http://www.forcedmigration.org/research-resources/organizations?SearchTerm=&b_start=0&submit=Search; The directory of the Faham refugee: http://www.refugeelegalaidinformation.org/refugee-resources; The directory of w2eu.info-Independent information for refugees and migrants coming to Europe; http://www.w2eu.info;
formal declarations from identified organisations obtained through telephone interviews and email exchange.
The identified data were presented in an excel sheet by country, and provided information on:
name of organisation/contact person; contact details; type of service provider (direct service provider, mediation service provider, network); type of health services offered; geographical location; relevant publications/research activities. The various NGOs were classified as Direct, Mediation or Network in order to identify those that have direct interaction with - and offer services to migrants (Direct) - or that, by all means facilitate migrants' integration into the life of the new country from the health, educational and bureaucratic point of view (Mediation). NGOs belonging to a network or constituting a network may offer either direct or mediation services.
To better understand how the different NGOs assist migrants in the matter of health care, we analysed in more detail the activities of the NGOs belonging to the first dataset, which provided a detailed description of the NGOs' activities but did not include data obtained at a later stage from the WHO country offices (found below the complete list of WHO county offices interviewed).
Data on institutional organizations of the WHO EURO Member States was gathered from three sources:
search on Google using the following search terms: migration + health + the country name; migrant + health + the country name; migration institute + the country name; migration + centre + the country name; migration + research + the country name. Google Translator was used to translate migration and health and the name of the country into the official language spoken in the country;
websites found through Google were then checked to see if English versions were available. The websites which did not contain an English version were translated by a member of the staff that spoke the concerned language, or were disregarded (the latter was only the case for a couple of websites);
often, international associations and organizations working on migrant related issues provided a list of partner institutions on their website. This gave access to further sources of information.
For both institutional and non-institutional organisations, WHO European Country Offices were contacted when limited or no information was available. This applied in particular to Austria, Azerbaijan, Belarus, Bosnia-Herzegovina, Estonia, Kazakhstan, Kyrgyzstan, Latvia, the Former Yugoslav Republic of Macedonia, Moldova, Montenegro, Russian Federation, Tajikistan, Turkmenistan and Uzbekistan. The WHO EURO Country Offices assisted upon request, providing either direct information on existing institutions, links to other websites, or further contact details (of the Ministry of Health for instance).
Data on each country was collected and presented in the form of an Excel sheet providing basic information on each institution. The institutes were categorized as: state institute; university institute; independent research institute; others (associations, part of an international network etc.). Among the last category (others), we grouped all the institutions/associations that eluded a clear identification: think-tank organizations and some NGOs were possibly included in this category as well. State institutions included: ministry of health, human right, labour, civil, social or foreign affairs, border guards control, state run hospitals, national and regional centres for prevention and control of AIDS/TB.
A note was made of the institutes that dealt partially and specifically with health. Additionally, information was collected on international collaborations and organizations.
The survey regarding institutional (GOV) and noninstitutional organizations (NGOs) active in the field of migration was performed in all of the 53 countries belonging to the WHO EURO Region (see Table 1 for the complete list of the investigated countries and Figure 1 for comprehensive results).
A total of 154 NGOs were identified in 48 countries of the WHO EURO Region. Diverse religious or faithbased organizations, professional associations, charities and humanitarian organizations were identified. Their activity spans from providing information, to serving as an alternative health care provider, or acting as a mediator between the migrant and mainstream health care providers. We therefore classified them, in accordance to their role in supporting migrant health, as "direct", "mediation", "Network", or a mix of them (see Table 2a for their description in terms of typology's activity and Table 2b for their relative percentages). Of these 154 NGOs, 49% (76), were direct health care providers spanning from basic to specialist health care (among them 18 were offering mediation service as well). The remaining (78) were either providing indirect services to migrants, facilitating their access to the country's available health or social services (mediation) (63), or being part of a network (15), were mostly involved in advocacy or more generally worked for increasing awareness and acceptance of migrants and only very seldom were in the position to offer activities related to health.
To better understand how the different NGOs assist migrants in the matter of health care, we analysed in more detail the activities of the NGOs in a restricted dataset (see methods for details).
In this setting (Figure 2), we found 66 NGOs categorised as "direct" providers: 61 of them were health-related, and their activities were basic health care (62%), specialist treatments (69%) and health promotion (72%), while emergency care and referral to mainstream health care were less represented (20% and 7%, respectively; Figure 2). Basic health care did not include first aid care (emergency). Among the specialist treatments those related to mental health were the most represented (67%), followed by dental (14%), and health reproductive care (0.15%). Under the generic term of health promotion we included all activities regarding health education, such as vaccination campaigns, mother-to-child assistance, prevention of unwanted pregnancies, campaigns for the prevention of sexual transmitted diseases, etc.
Furthermore, direct, but not health related support, was offered quite frequently by NGOs and was represented both by legal and social advice (53%, data not shown).
After direct request to WHO Country Offices regarding the countries missing at the first search (Austria, Azerbaijan, Belarus, Bosnia-Herzegovina, Estonia, Kazakhstan, Kyrgyzstan, Latvia, the Former Yugoslav Republic of Macedonia, Moldova, Montenegro, Russian Federation, Tajikistan, Turkmenistan and Uzbekistan), we were able to add 51 more NGOs. 39 of them categorised themselves as mediation, 6 as direct/mediation, 3 as network and 2 as direct. However this search apart from definition, did not provide further details about the specific NGO's activity; therefore we cannot include them in the analysis.
Finally, among the 53 countries of the WHO European Region, 7 countries (Andorra, Azerbaijan, Kazakhstan, Monaco, Rep. of Moldova, San Marino and Uzbekistan) do not seem to have any active non-institutional organisation devoted to migrant support. However, given the nature of our review, we cannot exclude that such organisations indeed exist and possibly have a role in supporting migrants.
The second desk review was aimed at identifying the institutional organisations (GOVs) that, in the investigated countries, address the issue of migrants and, possibly, to identify those active in the field of direct health support.
Through our investigation we were able to identify 173 GOVs dealing with migrants at various levels; we regrouped them either as state institutes or universities (both represented the 33.5% of the total) or as independent research institutes (19.6%) and others (16%).
Universities and other independent research institutes were mostly conducting research on the sociological and economic impact of migration as well as on any other issue related to the integration of migrants in the host country. Other common focus areas of research included policy development, international relations and human rights.
When we examined the type of activity that the GOVs were involved in, we found that less than 20% of them were directly or indirectly involved in health care; while the majority (over 40%) were involved in research or other common initiatives regarding communication, education, governance and data collection (Figure 3).
In summary, among the 173 GOVs (cumulated data obtained from the desk top search review and from the active request to the WHO Country Offices), only 10 institutions distributed in 5 countries (Italy, Kazakhstan, Malta, Montenegro and Turkmenistan) provide direct health services to migrants, while another 26 institutions, spread in 14 countries, have activities that are only indirectly related to health, such as epidemiological research or data collection on demographic determinants of health in migrants (Figure 4).
As for the NGOs related desk review, some countries (Andorra, Cyprus, Iceland, Monaco, San Marino and Uzbekistan) apparently do not have any institutional organization involved in the field of migration. However, we cannot exclude that some information is missing due to the nature of this search.
As additional results of this review, we were able to list several associations/initiatives that operate at the international level and that have a wide perspective on migration and health such as: EUPHA (www.eupha.org), European Public Health Association (umbrella organization for public health associations and institutes in Europe), ICMHD (www.icmhd.ch): International Centre for Migration, Health and Development (based in Geneva), and Mighealth .
The EUPHA section on Migrant and Ethnic Minority Health aims at increasing and spreading knowledge regarding ethnic differences in health and health care, on their determinants and on interventions aimed at reducing such differences. EUPHA also aims at setting methodological standards for European countries in order to promote the exchange of information and to provide a basis for comparative studies. In addition to these academic aims, EUPHA seeks to increase political attention at the national and European level regarding the impact of migration on health and health care systems.
The ICMHD is a non-profit institution based in Geneva, Switzerland. It is a research, training and policy centre founded in 1995 with the purpose of improving, protecting, and advocating for the health and welfare of people on the move. ICMHD is a WHO Collaborating Centre for Health-Related Issues Among People Displaced by Disasters and a UNFPA Implementing Partner. It also works with other UN agencies as well as with universities, research and training institutions throughout the world.
Mighealth is a project that aims at giving professionals, policy makers, researchers, educators and migrant and minority groups easy access to a dynamically evolving body of knowledge and a virtual network of expertise. In 16 countries, the project has set up and publicized a "wiki" (an interactive web site) in the local language. The wikis contain information about individuals, organizations and resources dealing with migrant and minority health. They are linked to each other and to a central (English-language) site.
From the data gathered by two independent searches in the field of migrants' assistance and support, it may be stated that migration is a phenomenon that is closely monitored by a wide range of organizations, including national and international NGOs, and institutional organizations. Such interest is testified by the large numbers of NGOs (154), institutional organizations (173), and international platforms (3) that are active in this field and in almost every country of the WHO European Region.
Does this mean that migrants are well provided in their humanitarian, social, educational and health needs? This is certainly more difficult to assess. Depending on the law, country responses to migrants' needs in terms of health is different from place to place. Consequently NGOs in different countries may have to cover a wide range of roles: from immediate health support acting as a surrogate of national care assistance to a link with mainstream health care or social services redirecting people to them. Given the nature of our search we were not able to use a structured questionnaire. Therefore to understand the role of NGOs, we asked them to categorize themselves according to their activity (direct/mediation) and their structure (belonging to a network); such broad categorisation is useful to gauge how much of an NGO's activity goes into support for primary needs of migrants, and how much effort is given to help convey the migrants' requests or needs into the mainstream health services of the country where they temporarily or permanently reside, legally or not. Actually, direct interaction with migrants (health involved or not) corresponds to only 50% of the NGOs listed in our database.
Network organizations appear to be active mostly in advocacy and defence of migrants' human rights, as well as in fighting for a more welcoming policy and better governance of resources.
Henceforth, according to our results from a limited dataset, only 37% of NGOs are able to give direct support, which usually means health care support, either basic or specialist. When specialist care is offered, mental care is usually well represented, and we may speculate if this represents an answer to a migrant's specific needs or if it depends mostly on the more feasible arrangement of human resources and facilities. Among specialist care, dental and reproductive health also receive a certain attention. These data, however partial (they do not take into account the 8 direct NGOs added to the total after the WHO Country Offices), may be regarded as representative of the general picture of the health care offered by NGOs in the various WHO European Countries.
The database resulting from our search may indeed represent a starting point for a more organic collection of information that are now incomplete, unevenly collected or missing. For instance, we do not know if our database is exhaustive. We do not have homogeneous information on every NGO's activity, their geographical distribution inside each country, their target in terms of migrants' population, i.e. absolute and relative numbers of people addressed, their legal status, country of birth, religion or any other epidemiological indicator like age and sex. Such information may well represent a future target of research now that a preliminary database has been obtained and is ready to be fully exploited.
The picture on the side of institutional activity is quite different: we observed that the vast majority of institutional bodies of the 53 country states are engaged in governance, data collection and research (Figure 3) while only a few countries seem to have identified the need to develop institutional bodies dedicated to migrants' needs in terms of health and direct support. This picture may result from the existence, in some of the countries under observation, of a health system favouring universal access to treatment and care, which may be inclusive of migrant populations. However, such a result may also reflect a different approach to undocumented (illegal) migrants and the dilemma stemming from providing health support to someone that entered the country against the law.
At the international level, three networks were identified that focused (partially) on migrant health. However, despite a broad and inclusive approach none of them have developed a specific activity in the field of migrants' access to health.
In conclusion, WHO can play an important overarching role in the exchange of expertise in health related migrant issues and this mapping exercise may well be the first step toward a comprehensive public directory through which institutes can get in touch with each other. Other options may include the creation of a platform or the further development of existing networks such as EUPHA. Finally, blank spots in terms of action or geography may be individuated and possibly covered by future plans.
We gratefully thank Fenicia Vescio for data organization, Stefano Boros for graphic assistance and Grace Lassiter for language revision.
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Address for correspondence:
Dipartimento di Malattie Infettive, Parassitarie ed Immunomediate, Istituto Superiore di Sanità
Viale Regina Elena 299
00161 Rome, Italy
Received on 16 March 2015.
Acceptedon 2 July 2015.
Conflict of interest statement: No competing financial interests exist.