Social Determinants of Health in the Context of Migration and at a Time of Economic Crisis
Dear colleagues, distinguished guests, ladies and
I am pleased to have this opportunity to address you today. As
the deputy director general of the international Organization for
Migration and an (ex) commissioner of the Social Determinants of
Health, I would like to focus my talk on the social health
determinants in the context of migration. In particular, I would
like to highlight:
- Why migration must be considered among the social determinants
of any health system?
- why social determinants of health are of key
relevance to the health of migrants and of a successful
outcomes of the migratory process?
- why especially now, during the financial and economic
crisis, we, as policy makers and health workers have a
duty to uphold the commitments made concerning the health of poor
and marginalized populations;
The overarching goal of the Commission on the Social
Determinants of Health comprised three major guiding principals, as
- improving the conditions of daily life, the circumstances in
which people are born, grow, live, work and age.
- tackling the inequitable distribution of power, money, and
resources, the structural drivers of those conditions of
daily life, globally, nationally and locally.
- measuring the problem, evaluating actions, expanding the
knowledge base, developing a workforce that is trained in the
social determinants of health and raising public awareness of
the social determinants of health.
Our report mainly focussed on the means that governments and
other key actors in a country can employ to systematically
eliminate the social, economic and political barriers that prevent
everyone from being able to enjoy healthy lives, to close the
health gap that exists between regions of the world, within the
same country including among people of the same generation. This is
a very ambitious goal considering today’s situation of
inequities in health status and access to health.
A child born in Japan can expect to live more than 80 years, in
Brazil 72 years, India 64; and in Botswana 39. Access to
health care also varies within countries: in some of the most rural
countries in China, only 30% of women receive ante natal care,
compared to 96% in urban areas. But these inequities in health
status and access also exist within communities when comparing
health status and access between nationals and certain migrant
groups. There are ample examples of studies among migrant
populations showing their inferior health status as compared to
their hosting community members. For instance, in the USA,
Hispanics and the black community bear a disproportionate burden of
disease, injury, death and disability when compared with non
Hispanic and non black populations.
How then should health systems take into
account migrant health needs?
Even if migrants may benefit from a "health migrant effect" when
they first arrive in their host community, this health benefit
wears off over time due to social determinants of health such as
low socio economic status.
The number of migrants is likely to be in excess of 200 million
today. The pattern of population movements are such that most
countries are simultaneously countries of origin, transit, and of
destination, at the same time, there has been a diversification of
migratory behaviour ranging from short term relocation, to long
term assignments, permanent migration or multi stage migration
itineraries and return back to the point of origin.
Migration processes can positively or negatively impact health
outcomes just as health status can affect migration outcomes.
Migration is in and of itself not a risk to health. Conditions
surrounding the migration process can increase the vulnerability to
ill health. This is particularly true for those who migrate
involuntarily, fleeing natural or man made disasters and human
rights violations; and those who find themselves in an irregular
situation, such as those who migrate through clandestine means or
fall in the hands of traffickers and end up in exploitative
situations. But also the many migrant workers who lack proper
immigration papers form an enormous large but vulnerable population
group. Migrant workers, in particular the undocumented workers, are
involved in degrading, dirty and dangerous jobs, exposing them to
occupational hazards, but have no health insurance. It is contrary
to notions of social justice that these vulnerable migrant groups
which are at high risk for abuse, exploitation and discrimination,
have the least access to health and social services.
Even if health services are available to migrants, they may not
be utilized due to lack of culturally or linguistically appropriate
approaches, lack of knowledge and information about their rights
and entitlements, or out of fear for deportation. For instance in
Geneva, Switzerland, as many other countries in Europe, free health
care is available for undocumented migrants, of whom 90% have no
health insurance. Yet, a recent study among undocumented
migrant women showed there is a serious under use of preventive
measures, such as a six fold under use of Pap test screening; high
percent of unintended pregnancies (75 % of pregnant migrants as
compared to 20% of the control group); and delayed prenatal care
(63% of undocumented began prenatal care during the first trimester
as compared to 96% of controls).
Health risk factors are often linked to the legal status of
migrants, determining the level of access to health and social
services. Further contributors include poverty, stigma,
discrimination, housing, education, occupational health, social
exclusion, differences in language and culture, separation from
family and socio cultural norms etc. In fact, migration health goes
well beyond the traditional management of diseases among mobile
populations and is intrinsically linked with the broader social
determinants of health and unequal distribution of such
determinants. For instance, in the UK black African infants are 60%
more likely to be of low birth weight as compared with white
infants and socio economic factors are important in explaining this
It is for this reason that multi disciplinary and multi
sector stakeholders should work in partnership to avoid
social exclusion and improve the health of migrants. The
Social Determinants of Health Framework looks to improve access to
health, but it goes beyond health care to understand and fight the
causes of ill health.
Especially in the case of migration, there is a need to develop
and strengthen partnerships between various
- Build capacity within public health systems of source, transit
and destination countries to prevent and better manage transmission
of disease and promote health of migrants. This includes
integration of migration aspects into health policies and
strategies, educating health care providers and educators, and
health and migration policy makers on how to address health issues
associated with population mobility and disparities in health
services between geographical locations.
- Develop and implement integration and prevention strategies to
decrease stigmatization, social exclusion, discrimination and
marginalization of migrant populations; offer language, culturally
and gender sensitive services; and facilitate ethnic community
participation the delivery of health services delivery and policy
- Ensure national policies and laws respect the rights of
migrants and improve access to health promotion, prevention, care
and treatment for all migrants regardless of their immigration or
- Support research to assess and document the health of migrants;
enhance national and international surveillance and information
systems and ensure inclusion of disaggregated health data
concerning migrant populations.
- Invest in training of health workers on the various social
determinants of health, including migration.
- Include ethical and human rights approaches to ensure
acceptable standards of treatment and research concerning migrants
What about the financial and economic
In the context of this discussion, it is unavoidable to mention
a few words about the financial crisis and its economic
effects both at global and national level
The challenge today is to prevent the financial crisis becoming
a social and health crisis. It must be highlighted that many
countries that depend on foreign aid from donor countries and from
remittances from members of the diaspora, stand the risk of a
decline in funding for development, including lack of funding of
health projects. I must point out that in 2008 it was
estimated that remittances of some USD 283 billion were made to
developing countries. Thus a reduction in remittances has the
realistic potential of affecting vulnerable communities in the
developing world who depend on these remittances.
During these economic downturns, migrant workers are often the
most vulnerable category of workers, in terms of job losses and
treatment in the workplace. A reduction in wages and poorer working
conditions will impact on the quality of life and health of
migrant. Further more, discrimination and stigma as migrants are
mistakenly perceived as taking the jobs of local workers, will fuel
marginalization which will have major negative impacts on
migrants’ well being as well as that of hosting
Some effects of the global crisis on migrant and migration have
already been observed. However, there is limited concrete empirical
evidence supporting these observations, given limited data on
migrants in general. For instance, a stop on new entries for
foreign workers has been put into place in some East, Southeast and
Central Asian countries. There have been instances of
discrimination and xenophobia against migrants who are mistakenly
perceived as taking the jobs of local workers; simultaneously,
reductions in regular labour migration flows have been recorded as
potential migrants choose to stay home and see out the crisis
there. And there have been reports of an increase in the return of
unemployed migrants to their country or community of origin.
As a consequence, a decline in remittance flows has already been
recorded in a number of developing countries of origin (e.g.
Morocco, Philippines, countries in Latin America, China). Migrants
may also be more reluctant to send money through formal channels
due to lack of confidence in banking systems.
While there is some evidence of a reduction in the flow of
irregular migrants, likely because potential migrants are informed
that job opportunities are scarce. In the medium term, however, an
increase in irregular migration is possible with the strengthening
of informal labour markets as employers make savings, as unemployed
migrants in destination countries overstay and seek to work without
authorization and as opportunities for regular labour migration
decrease resulting in emigration of more persons from countries of
origin more seriously affected by the crisis.
Flexible, coherent and comprehensive migration management
polices are needed, as well as reinforced international
cooperation, to maximize the benefits of migration, protect
migrants and take their needs into account in measures addressing
A strong degree of solidarity between countries of origin and
destination is called for to safeguard and continue to harness the
benefits flowing from the migration and development relationship to
both sets of countries as well as to migrants and their
In conclusion, I would like to emphasize that
migration is a fact of life in a world full of inequalities and
people searching for better lives; and as migrants are essential
for developed countries, to compensate for ageing populations and
skill shortages in some parts of the world, a vital challenge
facing governments and communities is integrating the health needs
of migrants into relevant policies and provide accessible,
acceptable and affordable health services, as a cornerstone of
primary health care, to all migrant populations, irrespective of
their legal status.. Such an inclusive approach can lead to
improved health for societies as a whole and contribute to their
stability and development. Especially in the context of migrant
health, social determinants offer an entry point towards achieving
health equity building on the values of primary health care, such
as promoting universal access.
It is therefore of great importance that the proposed resolution
on ‘reducing health inequalities through action on the social
determinants of health’, be adopted during the upcoming WHO
World health Assembly. The promotion of health is central to the
global development agenda and a responsibility of all governments.
In that respect, also the global forum on migration and development
needs to address health as a cross cutting topic to its work.
In the work of the Commission , we developed a new approach to
development: Health and health equity may not be the aim of
all social policies but they will be a fundamental
result; in fact growth by itself , without appropriate social
policies to ensure reasonable fairness in the way its
benefits are distributed , brings little benefit
to health equity .
The financial crisis has provoked an examination of societal
values and reinforces the importance of addressing social
determinants of health since poorer and marginalized people are
more likely to suffer disproportionately. Minimizing such
inequities during times of crises requires preserving levels of
health and social expenditure, in addition to using it better.
Revitalizing primary health care and addressing social determinants
become more important than ever if progress is to be made towards
reducing health inequities and achieving health targets such as
The message IOM sends is to guard against policies aimed at
sending migrant workers home as this is not the solution and can
have disastrous consequences for development given the scale of
remittances. Just as protectionism in trade needs to be avoided, so
should protectionism in human mobility be resisted, as migrants and
migration, and indeed human mobility, may be part of the solution,
not the problem.
I thank you all very much.