Migration, displacement and health systems

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Dr. Kim Ozano: Hello listeners, and

welcome to Connecting Citizens to Science.

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I'm Dr.

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Kim Ozano, and this is a podcast

where we discuss current research

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and debates on global health.

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Today's episode is the fifth in

a six part mini series brought

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to you by ReBUILD for Resilience.

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ReBUILD is a research consortium that

examines health systems resilience in

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fragile settings that experience violence,

conflict, pandemics, and other shocks.

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Today's focus is migration,

displacement, and health systems.

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A report by the United Nations High

Commissioner for Refugees has found that

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displacement has tripled in one decade,

from 40 million to 118 million, and this

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does not count for the climate refugees.

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So what does this mean for health systems

that have been shaped around issues

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of national and political borders?

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We find out from our guests and co-host,

who talk us through the importance

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of integration for health and social

outcomes, and the cultural changes that

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are needed to address discrimination

and exclusion in healthcare.

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We have with us today, Professor Fouad

Mohammad Fouad, who has conducted

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extensive research on migration and

health, focusing on multidisciplinary

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approaches to forced displacement,

health systems and humanitarian

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settings, and the political economy

of health in protracted crisis.

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Professor Fouad is also the IDRC chair

of the Forced Displacement Programme

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in the Middle East and the co-director

for the Refugee Health Programme

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at the Global Health Institute.

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His role as a member of several technical

working groups, which include the WHO

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Global Consultation on the Health of

Migrants and Refugees, and the Global

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Research Agenda on Health and Migration.

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Fouad serves as a Commissioner in the

UCL Lancet Commission on Migration

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and Health, and is a Commissioner

in the Lancet Commission on Health

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Conflict and Forced Migration.

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Also joining us today, we have Dr.

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Santino Severoni, the Director of the

Department of Health and Migration

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at WHO headquarters in Geneva.

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Dr.

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Severoni has over 24 years of experience.

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He has held senior roles at the

WHO regional office for Europe and

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worked globally in health sector

reforms, system strengthening,

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and complex emergency management.

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Since 2011, he has focused on public

health aspects of migration, leading

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efforts to implement global migration

and refugee compacts, and coordinating

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WHO's first world report on the

health of refugees and migrants.

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I also have the pleasure of

being joined by co-host, Dr.

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Joanna Raven.

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She is a reader and the Research

Co-director of ReBUILD for Resilience.

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Dr.

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Raven has worked in global health for

more than 25 years and has focused

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on strengthening health systems.

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She is also a health worker herself,

so she focuses on supporting the

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health workforce to deliver person

centered care that is of good

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quality and leaves no one behind.

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Hello Jo and welcome back to the podcast.

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It's great to see you again.

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I was wondering if you could kick

us off by setting the scene of

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migration and displacement globally

and the scale of the problem and

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what this means for health systems.

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Dr. Joanna Raven: So, first of all,

I'm really delighted to be here with

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such global experts, Foaud and Santino

to discuss such an important topic.

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As you've said, Kim, you've

highlighted that despite numerous

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migration initiatives and programmes

displacement continues to increase.

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In 2023, the number of forcibly displaced

and stateless people rose to record highs.

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And this is really a symptom of a

world in turmoil, marked by war,

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displacement, coups and natural disasters.

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More than 1 billion people are on the move

globally, which is staggeringly is about

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one in eight of the global population.

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Of this total 281 million people are

international migrants, and 84 million

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are forcibly displaced by maybe conflict,

by politics, by climate crisis, etc.

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And among those forcibly displaced,

35 million are children, and 1

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million were born into refugee life.

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And the number of people on the move is

expected to grow due to poverty, lack

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of access to basic services, lack of

security, conflict, the climate crisis,

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environmental degradation and disasters.

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But it's clear that refugees and migrants

often face worse health outcomes in

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countries of transit or in, in fact,

the ones they end up staying in.

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They face barriers to accessing health

services, including language, cultural

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differences, discrimination, and

restricted use of health services.

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Migration, displacement, and health

systems is a really, really complex

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topic and we're really lucky to

have Fouad and Santino to really

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unpick this, this complex area.

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I'd like to hear your thoughts, Fouad,

on why migration and displacement are

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important to consider in health systems.

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Dr. Fouad Mohamed Fouad: Jo, thank

you very much for inviting me.

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So, um, why migration is

important in public health and in

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health systems, I think because

people in general need health.

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Unfortunately, the entire current

health system has been shaped around

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the issue of national health systems.

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So, people considered as resident or

citizens, actually those people have

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clear access to health, but for people on

the move, actually, it's another issue.

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And although there's a lot of efforts

in the last decades to improve the

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access of migrants into health, there

is a lot of barriers and we can see now

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these barriers growing up more and more.

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One of the major issues is the issue

of politics, not a social issue.

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Migration is substantially a political

issue and therefore, we cannot avoid

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considering that in the discussion.

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You see now in the news, every

time talking about migration,

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anti-migration and all these issues.

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And this is specifically what affect

people's access to their rights.

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Migration is a very historical issue.

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Since the dawn of history, people move.

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It's not a new and people move for

the same reason, war economy, looking

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for food but now just in the last two

centuries, we consider that is a problem

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and this problem increasing more and more.

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Dr. Santino Severoni: You made

a very powerful introduction.

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If I'm allowed to provocate and

to oversimplify, I might translate

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all these complexity into two

main reason why this is important.

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The numbers that Jo you just mentioned.

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If we put together displaced internal

migrants, international migrants,

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refugees, asylum seekers, we are

talking about one every eight people

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around the world to be on the move.

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So one billion people today is moving.

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It was alluded at the speed

of displacement because of the

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geopolitical instability we

are sadly observing nowadays.

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Second point, this means that if we are

looking at the efficiency of the system,

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the efficacy of the health systems.

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A health system is able to do its job

if it's able to address the health needs

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of all of the population who serves.

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And if you're going to look at our

society today, our society, because of

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these figures, is a diverse society.

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It will continue to evolve,

so health systems need to

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follow the demographic changes.

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COVID proved to us that exclusion

means public health failure,

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inclusion means cost effectiveness

and public health success.

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Dr. Joanna Raven: Thanks for

those introductory remarks.

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I want to touch upon now the challenges

that the health systems face in trying to

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manage these different and diverse groups.

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Fouad, you started talking about the

national and political borders and I also

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think about these parallel structures that

are often set up in different countries.

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Can we elaborate on those and

discuss what these challenges are?

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Dr. Fouad Mohamed Fouad: Well, exactly.

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This is an issue.

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The current health system, it serves

its population, and in a specific

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country, inside political borders.

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Let's imagine that people crossing these

borders, there are some sort of thoughts

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and ideas about how to address that within

the emergency phase or short term phase.

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Well, we know now that people

are moving in protracted time.

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The average, as per World Summit in 2017,

that people move, the average length of

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migration is 17 years or 19 years now.

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So what does it mean?

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It means that this is very protracted.

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Now, how to serve healthcare for those

people in, in such sort of context?

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Again, one of the issue is, as Santino

mentioned, is the issue of integration.

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I mean this is very basic, but

integration is not just a technical issue.

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Integration has many implications.

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One of the top is the legality, the

politics, the issue of economy, so

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how to address other systems, then we

can try to respond to people's needs.

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So, unfortunately, addressing

migration needs created , a

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sort of parallel systems.

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Look to Middle East, Lebanon, for

example, Jordan, there's a national

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health system by the country, but

also there's another part of the

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system for Palestinian refugees, like

UNRWA, the UN Agency for Palestinian

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Refugees, and there's a sort of separate

or third parallel health system.

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There is a sort of informal health

sector run by refugee health workers,

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run by local organisations that work

aside from the national health system.

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So it creates that sort

of, more complexity when

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thinking about integration.

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Dr. Santino Severoni: Health systems are

usually coming from different directions.

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Around the financial crisis in 2008,

politics discover that the topic of

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migration could be very powerful in

terms of being utilised in the political

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campaigns for certain political vision.

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The legal framework, is utilised

to integrate or to exclude people.

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To define who are the people which

are entitled to social services

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and which level of services.

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So the first issue is the mechanisms

the countries are utilising to

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identify who are the people and how

those people can access the service

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that the state made available.

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The other element is related to

availability of data, helping

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us to understand the situation.

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Research, because it's incredible to

believe, but until a few years ago,

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public health sectors were not paying

attention to the issue of migration.

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We were paying attention to the issue of

migration only in the case of emergency.

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So when health was becoming a sort of

side effect of the migratory process.

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But research is also important to

show what is the cost of intervening

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and the cost of not acting in order

to sit in front of decision makers,

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government, politicians, ministers,

and providing them the solid

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information to help policy making and

decision making process effective.

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Dr. Fouad Mohamed Fouad: Actually, I

want to ask Santino giving his very

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extensive experience, but before

that, I would do some disclosure,

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that I didn't at the beginning and

this might to point at the question.

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So I am myself a forced displaced person.

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I moved out of my homeland because

of war and I sought refuge, but

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actually I'm not officially refugee.

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I didn't register at UNHCR.

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I just could consider myself forced

displaced and migrant worker.

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I myself, also a doctor, tried, in many

cases to have access to health in the

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country where I was, but I found really

very difficult to navigate the system.

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So my question to Santino, when we have

a different national systems, where many

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refugees move out to these, countries

with different national health systems,

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how WHO could play a role in coordinating

a change on the national health

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system or national health systems

in these neighboring countries.

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Dr. Santino Severoni: If I'm looking to

the current work we are having as a WHO on

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the topic of health and migration, I think

what we are doing today is a strategy to

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move governments to identify entry points,

then to build up areas of collaboration

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and really engage countries to move on.

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The tremendous challenge we do

have that when we started his work,

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unfortunately, this was not long ago.

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So all of this is a new topic for WHO.

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This means a new topic also for

member states, but there are a lot

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of progresses, and to answer your

question, I will say, yes, it's possible

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to change things, but this need to be

done, even if the challenge posed by

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the health and migration issues are

universal, but then there is a necessity

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to address local answers because

everybody looking at their own reality.

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So you need to tailor the debate,

the technical assistance intervention

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to the specific country needs.

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It's really a strategic approach,

means sharing resources.

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Maybe those close to the border,

sharing human resources for health,

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sharing facilities, creating revolving

economic financial mechanisms

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to allow people to enjoy service

across the two borders when needed.

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In this, I'm a bit sad because even

if I'm visiting many countries, it's

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really very limited initiative, very,

very embryo initiative, because what

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is prevailing still very much the idea

of protecting, managing borders, so

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having a fence around the country.

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So those are, in my view, cultural

changes which require time and

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from our side requires persistence.

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You're speaking from the high authority

of also having a life experience.

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What does it mean?

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The process you went through

and now you are teaching.

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I think we need to start with young

generation and we need to be persistent

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in order to generate a critical

mass of people better understanding

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this topic because still we are

navigating into a situation where

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this information, kind of inconsistent

narrative are poisoning the reality.

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We believe this so important

to really support countries to

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undertake changes or helping the

system at a local level to move on.

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We have a health system review tool,

which is a complex process we are building

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together with a country authority.

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And we make clear that we

want to stay in the backstage.

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We want to have the Ministry

of Health taking the lead.

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Why this?

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Because in a multi-sectoral issue like

health and migration, this is already

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an empowerment process because we are

encouraging Ministry of Health to face

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the other line ministers and to have

a leadership role and to defend the

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importance of factoring the health

dimension into national actions.

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But also it's an opportunity, in

many cases, we see health and other

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sectors learning from each other

because they're living there in the

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same country, same government, but

they don't know that different things

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are taking place in the country.

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We need to engage with the health

diplomacy and patients and negotiation

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to make them to understand the

benefit of applying this tool.

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Once this tool is applied, we see

country getting super excited because

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it's helping them to understand what are

the strengths and weaknesses in their

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systems and then to act not emotionally.

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So this is a tool that we are

applied to high income countries,

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middle low income countries.

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there is a financial element

that is beyond the health sector.

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The big challenge is that there are

a number of countries which today are

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hosting displaced population, a large

population of refugees, and they're

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renting a global civil service to all

countries around the world because

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they're assisting these people, but

they don't have enough international,

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particularly financial support in order

to fuel their own national mechanism.

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So those are a little bit the,

the, the complexity of what at

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least we observe around the world.

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Dr. Joanna Raven: It will be great

to have some examples of good

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practice from different countries.

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Dr. Fouad Mohamed Fouad: In Lebanon

in one of the ReBUILD research

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components, we developed what we

called the learning sites and learning

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site is improving localisation to

build the capacity where people can

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put this strategy for their health.

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And we tried actually to consider

that as a very collective work.

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So in one example that we did in Lebanon,

where not only the host community, the

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Lebanese, engaged in the learning site

experience, but also many refugees, like

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we have a Syrian refugee doctor who is

the vice president of the municipality

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health committee and has a voice similar

to the Lebanese hosting population.

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We try to go beyond one example, we

build, research in four countries

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and so we try to see if this model

could be replicated in other contexts.

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Dr. Santino Severoni: In terms of

country practice, we have a platform

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in our website where you can track

those country practices, also to

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learn what countries are doing.

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And we see about almost one third

of the world countries, today are

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actively engaging into implementing

in the health sector element of public

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health aspect of population movement.

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So we see a lot of practice,

a lot of initiative.

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Among all of them, what I like very

much is what's going on at the moment

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in Columbia, where the provision of

the national health insurance to 1.

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5 million migrants from Venezuela and

all the health financing mechanisms

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to tailor or to activate the extended

coverage has been uncovering some

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policy setting dysfunctionalities

or health system dysfunctionalities.

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So at the moment in the country,

they are proposing a health sector

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reform based on what they're

learning providing health insurance

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coverage to migrants from Venezuela.

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So very, very interesting.

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The entire population benefiting

from a more equitable and

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more fair health system.

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Or, what Philippines has been doing.

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Philippines is a big supplier of migrants

in all sectors, also healthcare workers.

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So what they did is pretty

unique because they developed a

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very comprehensive programme of

training, informing for migrants

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moving abroad in different sectors.

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And this has a huge impact in terms of

alerting migrants, informing them what are

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the public health risks, and how they need

to behave, but also build up a connection

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with the country in case of help.

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So they are not stranded in

case they are in need of help.

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Last, it's Turkey, Germany, what happened

a few years ago with Syrian refugees.

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Utilising people, displaced refugees,

forced migrants in, working in the

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systems of the country's hosting them.

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So the primary care expansion in the

Turkish health system have been employing

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Syrian healthcare workers, cultural

mediators, translators, bringing a

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new dimension of innovation and the

efficacy of the national system.

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The same happened in Germany in trying

to identify a fast track to recognise

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healthcare workforce skills and to

include them into the national system.

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So those are encouraging, initiative

which are aiming more in uncovering

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the value of inclusion rather than

building on separation and exclusion.

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And I like very much what you are

doing Foaud, if I'm thinking to

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the academic world, the idea to

bring this topic into public health

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teaching at the undergraduate and

postgraduate level, I think it's a must.

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Because it's totally anachronistic to have

future health care workers, generations,

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which they don't have basic understanding

of the complexity of this topic.

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Either you want to be a clinician, either

you want to be a nurse, or you want to

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be a policymaker or a public health care.

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You have to confront with

a diverse world tomorrow.

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So those are instruments which need to be

teached undergraduate and postgraduate.

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Dr. Kim Ozano: you so much.

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I've really enjoyed listening

to the conversation.

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I've learned so much.

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I really like Santino this, this

call to consider cultural changes

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and how this requires time.

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So we'd like to end the podcast with

advice that you would give to people who

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really want to start working in the field

of migration and displacement, whether it

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be for research or at a practical level.

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Dr. Joanna Raven: I think integration

of refugees and displaced people into

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the local health system is vital,

not to have parallel systems running.

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And to do that, we need to support

the lower levels of the health system

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to provide services in an integrated

way, as we've heard from Lebanon

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and the ReBUILD examples, but very

importantly, use evidence from research

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studies to do this in the best way.

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Dr. Kim Ozano: Reinforce that

integration and use of evidence.

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That's great.

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Fouad, pleas

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Dr. Fouad Mohamed Fouad: One is to

focus on the protracted long term needs.

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The mentality of a humanitarian

is to address the emergency phase.

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And we know that's not the, the reality.

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So it's important now

to develop programmes to

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address the chronic diseases.

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A second quick one is also about

integration, but not just the services.

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It's about the education itself.

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There is a huge needs, as Santino

mentioned, to have migration

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and health in undergrad

curriculums even in high school.

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Dr. Kim Ozano: Thank you very much.

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Look towards that long term

needs, and move beyond the

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humanitarian emergency response.

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Santino, take us home with

one final piece of advice.

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Dr. Santino Severoni: Building on what

Fouad mentioned, I think it's time to

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innovate the medical faculty curricula.

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I'm a clinician myself, I would love

to have a little bit more teaching,

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when I was a younger student at the

medical school or at the specialisation.

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So I think it's important,

especially with a change in society.

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The other element is a

bit of a kind of a dream.

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Allow me to use a famous phrase, I

have a dream, to see disappearing the

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political manipulation from this topic

and really to discuss and work and address

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public health aspect of migration by

addressing technical discussion, public

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discussions, not political sentiments

or manipulation of this information

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that will be very useful for everybody.

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Dr. Kim Ozano: Thank you very much.

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Innovation and medical teaching

and really to start engaging in

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public health discussion and and

move away from the political focus.

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So that's some wonderful advice.

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I hope our listeners have

enjoyed our wonderful guests, Dr.

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Santino Severoni, professor

Fouad Fouad and Dr.

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Joanna Raven.

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Don't forget listeners that this is

the fifth of the six part miniseries.

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So do check out the other four episodes

and stay tuned for the next one.

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So until next time, bye bye.