Summer Institute on Migration and Global Health U C Berkeley, June 26 th , 2012

1. Summer Institute on Migration and Global HealthU C Berkeley, June 26th, 2012 Good Practices and efforts to address Migration and Global Health Issues: an Operational Framework • International Organization for Migration (IOM) • Dr.K.Wickramage • Head, Health Programs, IOM SRI LANKA

2. Contextualize migration health in view of global health goals Review some good practices in light of the four main ‘pillars’ of action set by the Madrid IOM-WHO Consultation Lessons learnt in implementation of the WHA resolution on health of migrants Learning Objectives & Presentation Outline • The WHA resolution and the IOM-WHO Global Consultation in Madrid • Putting WHA resolution into action – examples from around the Globe • The Sri Lanka Case Study

3. Global Migration Trends “Human mobility has been identified as one of the most important geo-phenomena of our era. Today, there are more people on the move than at any other time in recorded history” - GFMD • 1 Billion Migrants World Wide • 215 million international migrants (UNDESA) • 740 million internal migrants (UNDP) (includes 15 million refugees (UNHCR) • by 2050 ...405 million international migrants (World Bank)

4. Some of the countries/areas that are most affected by international migration are in Asia. Approximately 2.5 million Asian migrant workers leave their countries every year to work abroad. 760 every day leave SL!! Overview of Asian Migration Trends

5. Countries in Asia can be roughly classified according to their international migration status “mainly sending”...(COLOMBO process) “mainly receiving”.. (Abu Dhabi Process) “both receiving and sending” eg. Sri Lanka & Thailand Migration Status

6. Remittances to Asia (by year) 4.1Bn to 5.1Bn 2011

7. Migration Heath agenda addresses the physical, mental and social needs of migrants, and the public health needs of hosting communities through polices and practices corresponding to the emerging challenges facing mobile populations today” Migration Health for the Benefit of All. IOM Council Session,

8. Migration as a Social Determinant of Health MIGRATION • Policy and strategy • across sectors • Availability of • strategic data for policy change • Lack of targeted • health information • Gender norms • Service availability, • location, hours of • operation • Safety & security • Relationship with • “host” community • Community leadership • Sensitivity of services • Living and working • conditions • Stigma, xenophobia, • social exclusion • Language and cultural barriers • Health literacy • Immigration status • Health-seeking behaviours • service access barriers

9. Health consequences Mental Health Psychological Sexual & Reprod Emotional Functional Social impact Physical trauma Occupational risks Potential health consequences of migration substance abuse Infectious & unattended chronic conditions

10. determine health status via SDH lens...

11. HOW TO IMPLEMENT THIS STRATERGY?? World Health Assembly Resolution on Health of Migrants (WHA 61.17)Calls upon Member States: “to promote equitable access to health promotion and care for migrants”“to promote bilateral and multilateral cooperation on migrants’ health among countries involved in the whole migration process”

12. World Health Assembly Resolution on Health of Migrants (WHA 61.17)Calls upon Member States: “to promote equitable access to health promotion and care for migrants”“to promote bilateral and multilateral cooperation on migrants’ health among countries involved in the whole migration process”

13. IOM Conceptual Framework for Migration Health Action at Country level (Mosca & Wickramage) INBOUND immigration OUTBOUND emigration INTERNAL migration 4 pillars of WHA resolution Public Health aspects (e.g. communicable disease, NCDs, Mental Health, social and health burden…) Cross cutting issues Multi-sectoral action (e.g. health, labor, social protection, development, security ….) Economic and Financial Aspects (remittances, who pays?, resource costs for health system, insurance schemes, private/public..)

14. Migrant FLOWS* and STAGES of migration Pre-departure In transit • Resident Visa applicants Migrant and Mobile Populations At destination Families of left behind migrants Upon return • Out bound migration: Refers to the movement of people out of the country and encompasses categories such as Labor migrants, irregular migrants, trafficked victims, unregistered workers etc. • In bound Migration: Refers to people moving into the country, and encompasses categories such as students, foreign migrant workers, tourists, returning refugees and failed asylum seekers etc. • Internal Migration: Refers to the flow of people within a country’s internal borders, and includes categories such as free-trade zone workers, those workers in Board of Investment (BOI) industrial zones, seasonal workers, internally displaced people and students. • Families left behind – either spouses and/or caregivers, children etc of left migrants and mobile population. *Wickramage, Peiris, Perera, Mosca (2010)

15. Stakeholders by stage of migration Pre-departure In transit At destination Upon return

16. IOM Conceptual Framework for Migration Health Action at Country level (Mosca & Wickramage) INBOUND immigration OUTBOUND emigration INTERNAL migration 4 pillars of WHA resolution Public Health aspects (e.g. communicable disease, NCDs, Mental Health, social and health burden…) Cross cutting issues Multi-sectoral action (e.g. health, labor, social protection, development, security ….) Economic and Financial Aspects (remittances, who pays?, resource costs for health system, insurance schemes, private/public..)

17. Develop health information systems Standardization & comparability of migrant health data Migrant health research 1. Monitoring Migrant Health 4 pillars of WHA resolution

18. IOM Health Assessment Program - (Migrant Management Operational System Application) includes all health data for the US Refugee Admission Program for timely dissemination to CDC, US Dept of State. a. Migrant health information systems • understand morbidity trends (nutritional status of children under 5) • standardized data collection • comparability of data using ICD10 Classification • Electronic real time-transfer of quality information to partners MiMOSA

19. Research provides an EBM model for developing migrant health policies and programs Recommended objectives of migrant health research are, to increase data collection on health status and outcomes for migrants monitor migrants’ health seeking behaviours access to and utilization of health services c. Migrant health research

20. Development and review of - Global, Regional and National [policy & legal] frameworks on migration health Capacity building, Guidance and standards for countries Social protection in health for migrants 2) Policy and legal frameworks 4 pillars of WHA resolution

21. The International Convention on Protection of Rights of all Migrant Workers and Members of their Families, Articles 28, 43, 45 International Covenant on Economic, Social and Cultural Rights, Article 12.1, general comment no. 14 UN General Assembly Special Session on HIV/AIDS (UNGASS, 2001) – Call for strategies to facilitate HIV/AIDS prevention programmes for migrants and mobile workers. a. Global frameworks

22. 15 nations in Southern Africa: “SADC framework on population mobility and communicable diseases (CDs)” Provides guidance on the protection of the health of cross- border mobile population “Council ofEurope Committee of Experts on Migration, Mobility and Access to Healthcare” on migrants’ living conditions, entitlement to and access & quality of healthcare, as well as general guidelines for migrant health action in the EU Member States. a. Regional frameworks

23. Zambia In September 2010, a new HIV policy for the transport sector by the Ministry of Communications and Transport (MCT) addresses HIV for mobile workers in the transport sector. a. National frameworks

24. Model of a funding/insurance system for migrants in the Philippines Philippine Overseas Workers Welfare Administration (OWWA): Fully-funded by a mandatory membership fee of US$25 per contract for migrants going abroad as temporary workers. Memorandum of Instructions No. 006, Series of 2009 - establishment of Medical Rehabilitation Program for eligible mentally ill and physically disabled OFW members • b. Social protection policies for migrant’s health

25. a. Migrant Inclusive Health Policies b. Migrant-friendly health services 3) Migrant Sensitive Health Systems 4 pillars of WHA resolution

26. Mexico Developed and is implementing the Comprehensive Health Care Strategy for Migrants, with a designated focal point in the Ministry of Health responsible for its implementation. Includes Health Informational Booths (ventanillas de salud) Leave Healthy, Return Healthy (vatesanoregressasano) Repatriation of gravely ill countrymen Health promotion on the northern border Insurance schemes at low costs a. Migrant Inclusive Health Services

27. Spain: The Strategic Plan for Citizenship and Integration 2007–2010 (Plan Estratégico de Ciudadanía e Integración). Each region of Spain has a specific plan adapted to the local migrant typologies and needs. For example, in Almeria: sensitization and training of health professionals, community mobilization/campaign promotion of equitable access to health services. a. Migrant Inclusive Health Services/Policies

28. With the integration of migrants every body gains. We gain in economic growth, quality of life, in cultural diversity

29. b. Migrant-friendly services Health Assessment Europe – 1,700 Programmes USRAP, Resettlement to Canada, Australia, New Zealand, EU and other countries Asia – 50,000 refugees Nepal, Thailand, Malaysia Refugee Population Africa and Middle East – 38,000 Kenya, Ethiopia, Jordan, Iraq 90, 000 refugees in 2010 including 76, 000 of US refugees representing around 75% of USRAP caseload. Overall, about 600, 000 refugees assisted over the last 10 years IOM Major Refugee HA Operations 2010 Locations More than 40 countries worldwide

30. b. Migrant-friendly health Assessment Expanded Health Assessment • TB management (Lab, DoT) • Malaria and De-worming • Outbreaks Management • Pre-departure evaluation • Enhanced data management and data sharing • Enhanced HA Protocols • Preventive care • Surveillance • Profiling • Local system strengthening and Capacity building Core Health Assessment TB reach: Genexpert scale up….. Evolution of HA Programmes

31. 4. Strengthening inter-country coordination and partnerships IV. Partnerships, networks and multi country frameworks 4 pillars of WHA resolution

32. International migration dialogues UNGAHigh-level Dialogue on International Migration & Development 2006 Global Forum on Migration and Development The Global Migration Group a. Global level

33. July 2010, Bangkok, Thailand: 13 nation High Level Multi-Stakeholder Regional Dialogue on Health Challenges for Asian Migrant Workers –IOM, UNDP, WHO, JUNIMA, Joint UNAIDS and ILO IV.1.Strengthening inter-country coordination and partnerships • b. Regional level

34. Regional Dialogue on the Health Challenges for Asian Labour Migrants 13 – 14 July 2010 , Bangkok Joint Recommendations At national level: Strongly encourage and support relevant government ministries to review existing policies, laws and practices related to labour migration and health aiming coherence among policies that may affect migrant's health and their ability to access services. Identify and/or designate a focal entity for migration health within concerned ministries tasked to initiate inter-ministerial and cross-sectoral dialogue. Increase participation of migrant workers in all aspects of their health and welfare including policy formulation and programme implementation. Conduct advocacy and public education activities at national and community levels through participatory and collaborative efforts between NGOs, international organizations, governments in order to build support among stakeholders for migrant-inclusive policies, national strategies and action plans. Encourage the inclusion of key migration variables in national census and surveys, including those used in national housing, health, labour, education and migration statistics, in data collection and the proper use and confidentiality of data. • At bilateral, regional, intra-regional: • Governments examine the possibility of bilateral agreements with a view to ensure social protection, portability of entitlements, including health insurance and monitoring of the overall migration process. • Conduct multi sectoral advocacy among health and non-health networks and labour migration frameworks to build support among public, government and key stakeholders, including CSOs, for migrant-inclusive policies and adoption of regional and international conventions and standards. • Develop guidelines and minimum standards to assist countries of origin and destination, based on effective practices and existing models, for migrant workers, including health financial schemes and social protection in health, ie. mandatory health insurance, that will benefit migrants as well as their families, regardless of whether they are joining the migrant workers or whether they stay behind.

35. National migration dialoguesTanzania; Mozambique; South Africa; Kenya c. National level IV.1. Strengthening inter-country coordination and partnerships

36. World Health Assembly Resolution on Health of Migrants (WHA 61.17)Calls upon Member States: “to promote equitable access to health promotion and care for migrants”“to promote bilateral and multilateral cooperation on migrants’ health among countries involved in the whole migration process”

37. Migration, Health and Development in Sri Lanka Advancing and evidenced-based approach for Migration Health policy development via an inter-Ministry framework….

38. Migration Sri Lanka– Facts and Figures Emerging from a 30 year civil conflict between GoSL and LTTE 1. Post-war, 2. Epidemiological (NCD), 3. demographic, 4. economic(MIC), 5.labour receiving.. One in ten SL’s are working abroad,an annual outflow of 300,000 persons One in 5 of Sri Lanka’s total labour force (23.8%) is currently employed abroad. 49% percent of ILMs are women, and out of these, 86% are ‘domestic housemaids’. Over 93% were employed in the Middle Eastern countries. 730 of registered migrant workers depart Sri Lanka each day3. ILMs contributed 5.1bn USD (8% of GDP) to the Sri Lankan economy in 2011, with foreign remittances earning expected to increase to 7bn USD in 20162. 76% of the total remittance received to the country was from garment industry and employments overseas (Central Bank, 2008) Sri Lanka becoming a labour receiving country not just a labour sending one: 44,400 Resident visas issued for workers (9000 Chinese and 9000 Indians, mainly on construction related development projects)

39. High level political commitment is essential for meaningful programming at country level…

40. Ongoing policy process in Sri Lanka Migration • Approach adopted by Government: • Identified the need in addressing all three types of migration: outbound, inbound & internal • A Multi-stakeholder approach adopting an Inter-Ministerial process • An evidence-based research agenda to inform policy process enabled

41. Where does migration health ‘fit’? • DDG/PHS I • DDG/PHS II • Airport Health Authority • Port Health Authority • Family Health Bureau • Health Education Bureau • Epidemiology Unit 8. Policy directorate 9. Non-Communicable disease directorate 10. Mental Health Directorate • Department of Immigration and Emigration • Department of Registration of Persons Sri Lanka National Migration Health Taskforce • General Treasury • Department of Census and Statistics • Central Bank of Sri Lanka • Department of Probation and Childcare Services • National Child Protection Authority • Sri Lanka Women’s Bureau • Board of Investment of Sri Lanka • Sri Lanka Tourism Promotion Bureau • Sri Lanka Tourism Development Authority

42. Mapping – an essential first step! Problem/Issues identification – e.g. don’t limit to only labour migration! Stakeholder Mapping within GoSL* + Academia, NGOs, Civil Society, UN, Development partners *Selection of Technical focal points within each Government Ministry (contested). Political mapping – also involved in this step of stakeholder mapping. Mapping of existing domestic legal and policy frameworks linked to MHD Mapping for advocacy - regional forums (Colombo Process) and global fora (GFMD- Mexico) to push MHD agenda Service mapping(e.g. health, legal and social protections offered to Labour Migrant workers)

43. Inter-MinisterialCoordination Framework for Migration Health Development in Sri Lanka National Steering Committee on Migration Health (NSC) Migration Health Task Force (MHTF) Comprised of Secretary/ Director General level representatives of the key Ministries such as Ministry of Health, Ministry of Foreign Affairs etc. Meets 2-3 times per year (or as per need) to decide on National policy decisions and inter-ministerial coordination issues forwarded by the MHTF Comprised of technical focal points from each stake holder agency (Key Ministries, UN agencies, NGOs , Academics , Civil Society) that contributes actively to development and planning of the sectoral/ministry policies and programmes related to Migration Health. Meets once in 2 months Migration Health Secretariat (Housed within the Ministry of Health) The dedicated hub that coordinates the National migration health agenda for Government of Sri Lanka Wickramage, Peiris, Perera (2010)

44. determine health status via SDH lens...

45. WHAT IS THE SOCIAL COST? WHAT IS THE HEALTH CONSEQUENCE? Migrant and Mobile Populations I’m only presenting data from 1/5 national studies here due to time constratints…

46. Assessment of mental health and physical wellbeing of ‘left behind’ family members of international labour migrants: a national comparative study in Sri LankaWickramage, K., Siriwardana, C., Sumathipala, A., Siribaddana, S., Adikari, A, Peiris, S., Perera, S., Mosca, D. Aim and Methods : • This national study utilized both quantitative and qualitative research methods to determine the associations between health status of the left-behind spouse, children and caregivers, for comparison with families having no history of migration. A multi-stage random sampling method was used to capture 62% of the total migrant worker population in Sri Lanka. We surveyed a total 1,625 adults (from 410 migrant and 410 non-migrant families) and 820 children, matched for both age and sex, within a pediatric and adolescent group. Socio-demographic, and health status data were derived from a range of standardized pre-validated health instruments measuring quality of life and mental health status (adult and child). Anthropometric data on childhood development was also obtained. Univariateand multivariate analyses were used to estimate the differences in health outcomes between migrant and non-migrant families. Findings: • Children from migrant families have a higher risk potential to develop psychopathology and sustain poorer nutritional development outcomes than children from non-migrant households. • Just over two-in every five ‘left-behind’ children (44%) reported as having any psychiatric diagnosis. • A quarter of all left-behind children under 5-years were severely underweight (25.4%). • Nearly one-in-three migrant families were also single-parent households. Multivariate models revealed the association of emotional disorders and psychiatric diagnosis was strongest within single-parent households, and was exacerbated where the sole parent was the migrant worker [OR 0.75(0.34-1.64)]. • Significantly high levels of depression were found in caregivers [12.3% (CI: 12.23-12.31)] and spouses from left-behind families [25.5% (CI:25.47-25.60], than those comparative non-migrant group [7.32% (CI: 7.29-7.34)]; with physical health status profile also showing similar trends.

47. “families left behind” • The absence of parent has a negative impact on overall health and development of children left behind: • Growth and development: 25% of the children in the families with migrant parent are “under-weight” (- 2 SD Z-score) • Child-psychopathology: All domains in SDQ were higher among the children in migrant families (Wickramage. et al. IOM, 2011).

48. General health status – SF 36 score Mental and physical health of the left behind spouses and care-givers were also significantly poor (Wickramage. et al. IOM, 2011).

49. Prevalence of Common Mental Disorders of left behind families by standardised Scale for Depression using PHQ (Wickramage. et al. IOM, 2011).

50. Vulnerabilities faced by Sri Lanka International Labour Migrants. IOM, Sri Lanka (2012)