Migration and health

Definitions

Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 2006).1
This definition applies equally to migrants as it does to non-migrants. Health is also a basic human right and an essential component of sustainable development; being and staying healthy is a fundamental precondition for migrants to work, to be productive and to contribute to the social and economic development of their communities of origin and destination.

The concept of migration and health encompasses the idea that there are various factors and conditions that influence the health of migrants. These factors and conditions are referred to as social determinants of health. Migration, among other factors, is considered a social determinant of health for its potential to impact health. There are various levels of social determinants of health, which range from the general socioeconomic, legal, cultural, environmental, and physical environments to individual factors such as lifestyle, age, hereditary, and behavioral factors that impact the health of migrants (see Figure 2). There may be differences in the disease profiles and health risk factors between migrant and host populations, or inequalities in the access/uptake of preventive interventions and in treatment outcomes based on migration. 

The relationship between migration and health is complex, and its impact varies considerably across migrant groups, and from person to person within such groups. Conditions surrounding the migration process may exacerbate health vulnerabilities and risk behaviours such as the case of a victim of sex trafficking through transnational networks. Conversely, it can be an enabler for achieving better health trajectories, such as the case of a newly arrived refugee as part of a humanitarian settlement programme accessing treatment for a chronic disease. Due to the lack of legal status, stigma, discrimination, language, cultural barriers and low-income levels, irregular migrants may be excluded from accessing primary health care services, vaccination campaigns and health-promotion interventions.  

In terms of “migration health data”, the concept may be broadly defined as those data relevant to characterizing the health and social determinants of migrant populations, and around population mobility and health. These may include: quantitative data, such as epidemiological profiles on health status and disease burden; or, qualitative data that describes risk and resiliency factors or mapping health service access.

As the numbers of people moving between countries increases globally, the variety of motivations and conditions for mobility, as well as the socioeconomic context and political climate in which this mobility occurs, adds to the complexity of responding to health challenges faced by migrants in their sending, transit and receiving countries. 

In addition to the phases of the migration process, some migrants are also placed in detention, jails, and other closed facilities due to national migration policies. Detention most often affects asylum-seekers, refugees, displaced populations, trafficked persons or irregular migrants. Health-related vulnerabilities can increase due to various factors such as the lack of access to health services, inadequate hygiene and sanitation within densely populated living spaces, inadequate nutrition and violence. The length of detention has been associated with the severity of mental disorders and psychosocial issues.  

Some migrant workers, especially those with low level skills, are employed in sectors often amongst the most dangerous, difficult and demeaning (3Ds), with low wages, hazardous and harsh working conditions, and a lack of status recognition, social protection and occupational health rights. Migrants’ access to health services has increasingly been a key indicator of people-centred, rights-based, inclusive and equitable health systems that aim at reducing health inequities, but the social exclusion of vulnerable migrant groups continues to be common in the absence of explicit affirmative policies. 

Data sources (New! COVID-19)

WHO provides a list of sources of health data, although not specific to migration and health. Potential data sources on migration and health may be derived from various sources such as:  

Traditional or routine data sources at the national level:

Civil registration, vital statistics and population censuses: Administrative data sources and censuses provide information on the births and deaths (and cause of deaths) of people. If information on a person’s length of stay/date of entry into a country, citizenship status and country of birth are captured, such data may identify whether someone is a migrant, and be used to analyze health outcomes based on these variables.

Household surveys: Demographic and Health Surveys (DHSs) are nationally representative household surveys that provide data on a wide range of health and nutrition-related information. Such surveys include migrant variables/identifiers, such as length of stay/date of entry, citizenship, and country of birth, which can be used for further to analyze health outcomes. Such surveys are usually tailored to the needs of a particular country while containing several basic components that are comparable across all countries. 

Although DHSs provide data on rural-urban migration, only a few stipulate whether people move internationally. A 2012 review of 85 national DHSs found detailed information via a dedicated migration module to only be present in 12 surveys.  For children, their migration status can sometimes be identified through their mothers' migration status. In cases where a separate section on international migration appears in the questionnaire, children who left the household to go abroad can also be identified, along with their basic characteristics. 

The Living Standards Measurement Study (LSMS) is another household survey programme focused on generating high-quality data for evidence-based policy making. The migration module of LSMS surveys typically includes questions on place of birth, most recent place of residence, reasons for moving, number of times moved and types of migration (including inter-district, rural-urban and international migration).  

Health Institution-based records: National Hospital Registries provide data on health-related information pertinent to hospitalization, and National Epidemiological Disease surveillance systems provide information on diseases, conditions and outbreaks that may affect public health. However, most providers and insurers do not routinely collect data by legal status or on the national origin of the cases registered. Name-based algorithms have been used as an aetiological tool to “data-mine” such registries to provide valuable information on health status. Such approaches in Cancer registries have been utilized as an effectively compare disease burden among migrant groups.

Vertical disease control programmes: Increasingly, national disease control programmes such as Tuberculosis, HIV and Malaria control programmes are collecting data on migrant and mobile population groups, as human mobility is a critical element  in achieving disease control and elimination targets. Regional cooperation efforts to combat disease spread via migration routes have led to establishment of ‘cross-border’ data collection and joint-monitoring mechanisms to be established. One example is the Mekong Basin Disease Surveillance programme.

Foreign employment bureaus and migrant worker welfare agencies: These sources may capture data on health insurance claims of migrant workers (indicating morbidities), mortality (in case of migrant worker deaths) and data on deportations based on medical grounds.  

Non-traditional or agency-based sources:

The Migration Integration Policy Index (MIPEX) measures policies to integrate migrants in 38 countries in Europe, Asia, North America and Oceania, and includes data on health-related policies collected through MIPEX’s Health Strand questionnaire, which was developed by IOM’s Equi-Health Project, in collaboration with European Cooperation in Science and Technology (COST), Adapting European Health Systems to Diversity (ADAPT), and the Migration Policy Group (MPG).   

The MIPEX Health strand is an example of a metric (38 indicators) that aggregates multiple indices defined by a broad expert group (over 100 experts involved in the development, piloting and implementation), for 48 Member States as bench mark for measuring the equitability of a country’s policies relating to the health of migrants and including policies related to data collection and research (IOM, 2016).

BioMosaic is a software application that allows combining and visualizing immigration statistics, and health and demographic data. It was developed by the United States ’ Center for Disease Control and Prevention’s (CDC) Division of Global Migration and Quarantine in collaboration with Harvard University and the University of Toronto. BioMosaic shows foreign-born populations, census demographic data, and health-data indicators to the US county level. Targeted health communications, or public-health interventions, can be developed with the application by identifying foreign-born populations clustered in specific areas, or link census data on social determinants of health, such as income, education, language proficiency and access to healthcare.  

Research studies and reviews on the health of migrants at national level: Undertaking empirical research and systematic reviews provides vital health-related information on migrants that if meaningfully applied can catalyze policy formulation and inform practice interventions. For example, the Government of Sri Lanka in partnership with IOM published a compendium of migration health research that presented key data on health of migrant and mobile population groups by disease (e.g. Malaria) and by migrant typology (inbound, outbound, internal migrants and families left-behind). Such research led to formulation of a National Migration Health Policy and Action plan for Sri Lanka. In addition, the Refugee and Migrant Health Special Issue of the  journal PLOS Medicine provides articles on the latest research across different health topics. 

IOM sources:

Migration health assessments capture a range of health information by migrant type. For example, in 2016 IOM provided annual reporting of 400,000 health assessments of immigrants and refugees that it undertakes on behalf of governments and migrants. IOM also generates empirical analyses of findings for select population groups such as refugees. The information can be used to better understand the prevalence of diseases such as tuberculosis and conditions such as malnutrition among populations examined, and enable health authorities in both sending and receiving countries to better address the health of migrants. At the European level and in collaboration with the European Commission Directorate-General for Health and Food Safety (DG-SANTE) and relevant Member States, IOM captures data from health assessments of migrants in the EU through the Re-Health Project.

Migration Health and Development Research Initiative (MHADRI):  Launched in 2016, MHADRI is a network of migration health academics, researchers, civil society, and other actors who work on researching the relationship between migration and health. It was launched by IOM's Migration Health Division (MHD) in partnership with several academic institutions and researchers. MHADRI’s network and activities provide a platform  to share, collaborate, develop, advocate and disseminate research on the link between migration and health to inform policy development and programming.  IOM was appointed MHADRI Secretariat in 2017.

Migration Health Research Portal: IOM’s Migration Health Division has developed an online portal as a repository of all migration health related data stemming from IOM’s global health programmes. The Portal contains data in the form of technical reports and publications that are disaggregated by country, health issues and type of migrant group. Whilst the portal focuses on data from IOM related projects and interventions, it will expand as a global repository of all peer-reviewed publications on migration and health using rigorous bibliometric methods.

Country Migration Profiles: A Migration Profile is a country-owned tool, prepared in consultation with a broad range of stakeholders which can be used to enhance policy coherence, evidence-based policymaking, and the mainstreaming of migration into development plans. IOM has collaborated with the European Commission (EC) to create an online repository for Migration Profiles. However, only few have included a health component within their profile. Better guidance and investment is needed to provide governments with the tools to map migration health country profiles, as per methods and sources outlined in this brief. 

Data strengths & limitations

No singular metric can be used as an aggregate measure of the health of migrants. A global health indicator framework for measuring and monitoring the health of migrants does not exist and specific guidance on what data to collect and how to collect has not been developed.  The need to enhance health information systems and enable rigorous methodologies and capacities for collection of data on migration health, across all migrant groups at the national level remain a challenge for both developing and developed nations. 

A review led by IOM in 2009 of European research on migration and health identified areas for which better information on gathering migration and health data are needed, and the first Global Consultation in Migration Health held in 2010 outlined key policy questions and priorities to address in collecting migrant health data. The Global Knowledge Partnership on Migration and Development group (2015)  has proposed a structural, process, and outcome indicator model that provides a “rights-based approach” to evaluating the degree to which governments have integrated concerns, such as access to health services and decent work conditions, into their policies and practices. The framework provides a basis for which data may be systematically collected but no evidence exists of whether the indicator framework has been applied at the national level. 

As noted previously, several limitations in harnessing migration health data exist. First, data on the health of migrants and mobile population groups are not routinely collected by health information systems at sub-national, national, regional and global levels. Even with the DHS, countries can opt out of asking questions on mobility. Second, differences in definitions of migrant typologies, data sources and coverage hinder comparisons between countries. Third, some migrant groups are excluded from national health systems due to domestic legal and policy frameworks limiting or prohibiting their access to health care. For countries that do provide access, this is often only limited to emergency life-saving care, but not primary health care or reproductive health services.  Multiple barriers ranging from personal trauma or lack of translation services may inhibit migrants to fully navigate or utilize such health services.

Supporting countries to adopt a more rigorous module of questions on migration and mobility for all household members in DHS surveys or disease specific surveys would provide greater depth of data to analyze the associations between migration and health, and enable national comparisons. 

• 1The World Health Organization (WHO)’s Preamble to the Constitution of WHO, definition of health. This definition has not changed since the Constitution entered into force in 1948.