From February 21^st to 23^rd, delegates from over 40 countries met in Colombo, Sri Lanka to identify gaps and accomplishments so far and to reach consensus on key policy strategies to reset the agenda on migrant health. Representatives from governments, academia, NGOs and civil society organizations, the International Organization for Migration (IOM) and the WHO discussed three thematic areas within a rights based, people centered and equity framework: Global Health, Vulnerability & Resilience and Development.

Sri Lanka, the host country, and one of the few in the world to have a comprehensive health policy for migrants is cognizant of the contribution migrants make to the economy and is committed to safeguarding their right to health. Sri Lanka has taken significant steps to bring migration and health on the global health discourse through the UNGA high level meeting on migration and forced displacement held last year in New York and regional platforms such as the WHO Regional Committee for South-East Asia  (SEARO) and the Colombo Process (a forum of Asian labour sending countries to facilitate dialogue and cooperation relating to labour mobility).

Migration is a social determinant of health that impacts on the health of migrants, their families and host communities. The Regional Director of IOM for the Asia-Pacific, Dr Maria Nanette Motus acknowledged the urgent need for global Compacts and inter-country engagement in strengthening bilateral social protection agreements between source, transit and destination countries.

Pursuing the vision of the 2030 agenda to leave no one behind, by reducing vulnerabilities and addressing key health needs of migrants, will safeguard not only migrants but also host populations from long-term health and social costs, facilitating integration and creation of a more equitable and inclusive society. Cross border initiatives are needed to ensure that migrant health is addressed without discrimination throughout all phases of the migration cycle. Every single day we read  disturbing reports in the media on how migrants’ health and human rights are jeopardized or worse, while migrating – so they hope – to a better future. This is a global responsibility.

 ‘We’d like to see migrant health as a litmus test of the coherence of the SDGs and ultimately of the actual implementation of universal health coverage’.

Dr Maria Nanette Motus, Regional Director of IOM for the Asia-Pacific Region

Strengthening the resilience of existing health systems is a priority to provide migrant sensitive health services through the implementation of well-managed and coordinated migration policies, including financial risk protection and equal access to quality services. The need for evidence and its relevance in enhancing migrant-inclusive policy development was voiced by the Director-General of IOM, Mr William Lacy Swing: ‘We need to be guided by evidence, not uninformed opinions; we need to be guided by science and pragmatism, not fear and misinformation.’  That might not be exactly in sync with our ‘post-truth’ times, but remains true more than ever.

The Consultation was a meaningful platform for multisectoral dialogue and to secure political commitment in an environment of increasing challenges to integrating migrant health needs in national and international policies and strategies. The highlight of the consultation was the launch of the ‘Colombo Statement’ which calls for mainstreaming migrant health into key national, regional and international agendas aligned with the implementation of WHA resolutions and SDGs. This will pave the way for sustained international dialogue leading up to the adoption of the Global Compact for safe, orderly and regular migration and the Global Compact on refugees in 2018.

The need to work hand in hand with migrant communities, governments, civil society, the private sector and academia amidst competing priorities and increasing anti-migrant and anti-refugee sentiments was reiterated throughout the consultation and well echoed by the WHO Regional Director of SEARO, Dr Poonam Khetrapal Singh: ‘Together we have the power to bend history to our benefit. Together we can ensure that the right to health is secure for all including migrants and refugees.’

Or as somebody used to say not so long ago, when the world still felt like a better place: “Yes we can!”

“Am I audible? Am I visible?” Abheena Aher (National Programme Manager, Global Action for Trans Equality, India) asked the audience at the recent Prince Mahidol Award Conference   in Bangkok, equating the invisibility of those excluded from society to transparent glasses through which people see without acknowledging the individual or human being.

From a personal perspective, this statement and indeed the whole conference were a real eye opener. Having never before felt ‘excluded’ in society, the event provided me with the opportunity to hear about the harsh realities of social exclusion from the marginalized individuals who find themselves invisible to the rest of society.

The event brought together 888 participants from 72 countries, from members of minority groups to politicians to researchers, academics and activists, to deliberate on ‘addressing the health of vulnerable populations for an inclusive society’. The most compelling presence was that of the 44 civil society and NGO representatives on stage. This is an important and timely topic when increasingly nationalist policies seem to threaten the existence of diverse and cohesive societies. It is also an opportune time to address the health of vulnerable populations in the context of the SDGs which focus on leaving no one behind.

Existing and emerging causes of vulnerability

In his keynote speech, Amartya Sen classified some causes of vulnerability as biological, economic, structural, knowledge related and relational. Biological vulnerability refers to having diseases with unknown or imperfect or very expensive cures (here, the resistance to antibiotics was cited as a new vulnerability). Economic vulnerability arises from living in poverty making people more susceptible to illness. Structural vulnerability arises from deficiencies in sanitary and other facilities which can have disastrous effects on health. The inability to make use of existing knowledge also makes people vulnerable, such as adopting behaviors like smoking, regardless of the evidence available showing its detrimental effects on health. Finally, relational vulnerability stems from stratifications in society relating to social barriers such as historically established caste systems in India or more modern divisions related to class and occupational disadvantage. All these barriers cause social inequity. Therefore, the problem of inequality has to be seen as a pervasive challenge that demands a much broader change well beyond the medical realm.

It is also not only about being a member of just one disadvantaged group; intersectionality often predisposes individuals to extreme vulnerability. The dimensions that drive vulnerability (gender, religion, sexual orientation, disability status, ethnicity, employment status and location) can co-exist, more often than not, and create adverse outcomes for such individuals. Therefore, tackling issues of one disadvantaged group may not be adequate to holistically address the underlying causes of social exclusion.

Achieving Universal Health Coverage (UHC)

“No one should say that UHC is unaffordable or they don’t know how to do it.”

Gro Harlem Brundtland, PMAC 2017

Dr Brundtland highlighted the experiences of Thailand, Sri Lanka, Delhi-India, Ethiopia and Rwanda to substantiate how countries at all income levels can move towards UHC. She espoused progressive universalism  as the path to make progress towards UHC, in which everyone receives a package of primary healthcare services free at the point of delivery. However this would require a redistribution of resources to cater to the needs of vulnerable and excluded groups as generally their health needs are greater.

Meeting the needs of vulnerable communities is integral in realizing the goal of UHC through adopting a people-centred and human rights-based approach. Communities must be empowered to be at the center of the solution rather than be passive recipients of interventions that are not resonant with their needs. They should be properly informed of their rights: right to health, right to education, right to equal opportunities, right to organize themselves and right to voice their opinions.

Making vulnerable populations more visible

One of the major barriers to addressing the needs of vulnerable groups is scarcity of data. These groups will remain invisible as long as we do not capture them in information systems. By counting we give them, they are given an identity that they have been denied.

As summed up by one of the panelists, common across all socially excluded and vulnerable groups regardless of the country they come from are the need for visibility and the opportunity to participate in decision making that affects their life. It’s not only about creating people centered care through effective laws and policies but also addressing attitudes that determine actions towards these marginalized populations. What is needed to address vulnerability and social exclusion is a combination of top down approaches from responsive and accountable governments and bottom up approaches through community engagement and active citizenship.

‘Social inclusion is often not about doing more, it is about doing things differently’- Mr. Monthian Buntun, Conference synthesis

The Conference proposed several actions in support of social inclusion. First and foremost is the role of the State to devise mechanisms across sectors to tackle social inclusion and monitor progress and ensure equal opportunities in markets, services and spaces for all.

The health sector can bring about change in transforming education to create a more socially accountable health workforce. Inclusion of students from socially excluded groups in the health workforce can ensure more dignified and respectful services to respective populations. We need to support collaborative governance for health to create effective dialogue between the community and the healthcare providers.

We must start by putting vulnerable communities at the centre of the solution to drive change that will ultimately realize a transformation in addressing the health needs of vulnerable people.

The effect of gender roles and norms on men’s health
Worldwide, men’s life expectancy remains lower than women’s. Key factors contributing to this include poor health seeking behaviors of men compared to women resulting from an interplay of factors of masculinity and workforce participation that drives men to ignore health issues. In Sri Lanka, this poor health seeking behavior has manifested in lower rates of utilization of non-communicable disease screening facilities provided through healthy lifestyle centers. Making services more inclusive by extending them to workplaces can make access easier for men. Men are also more at risk of dying due to alcohol and smoking related diseases. The prevalence of use of both substances remains significantly lower among women. In Sri Lanka, for example, according to the STEPS Survey of 2015, the prevalence of current smoking among males was 29.4% and only 0.1% among females. Regarding alcohol consumption, 34.8% of males were current drinkers and only 0.5% of the females were current drinkers. It is clear that the use of these substances negatively impact on the health of men; targeted programs are necessary to provide assistance to quit their addictive behaviors. Research has shown that the top ten causes of ill-health affect men more than women.

In many contexts, the social and economic roles performed by men and women are different, and therefore the health risks they are exposed to over their life course differ. The intersection between gender, economic power, and social roles, for example, are contributing to different health outcomes between men and women. What this means is that men’s health is often more affected by working conditions, violence, and smoking, while women’s health is often more influenced by the burdens of caregiving to different generations with paid work and housekeeping.

The role of discourse in men’s health
In addition to considering how gender roles and norms affect men’s health, it is also important to consider the role of the language and how men are perceived by different actors. Actions and discourse of health service providers, managers, policy makers, and researchers, for example, can negatively affect men. Because we often fall into the trap of talking about women as victims who are acted upon, and men as agents who act, we often fail to recognize that the social forces that expose women to health risks (patriarchal gender norms that limit the possibilities for women’s agency) act equally on men, and equally constrain their choices. Even when the effect on these forces on men is recognized, the discourse fails to reflect it.

This discourse is a result of a gendered worldview in which men are afforded power and agency, but also, therefore, considered as perpetrators and risk-takers, and inappropriate subjects for sympathy, care and support. In other words, men are subject to social and cultural forces which make it difficult for them to protect themselves from risk without jeopardizing their masculine identities, but are also disadvantaged by global and national (often patriarchal) discourse that fails to consider them as victims acted upon by cultural and systemic forces. In Ghana, for example, public discourse on domestic violence often highlights men as perpetrators rather than victims. Data from the Domestic Violence and Victims Support Unit (DOVVSU), however, shows that a significant number of men have been abused by their wives. 2,807 men reported domestic abuse cases against their wives in 2015, while 3,143 reported domestic abuse in 2014 (Domestic Violence and Victims Support Unit Report, 2015).

It is important that we consider discourse in relation to how health services are provided. In South Africa, despite substantial evidence of the poor treatment outcomes of men with HIV, men are still neglected as a key-population for HIV interventions, in local and global treatment guidelines and funding opportunities. Because maternal and child health (MCH) constitutes a window of opportunity to initiate HIV testing and care, many HIV and sexual and reproductive health (SRH) services are provided in MCH contexts – contexts in which men might feel unwelcome or uncomfortable. In addition, most health services are provided by women, further alienate men who feel uncomfortable discussing sex with women. In South Africa, this phenomenon is exacerbated by the politicization of the sexuality of men (particularly black men) who, in the context of the HIV pandemic and racist social structures that are the legacy of apartheid, are considered as spreaders of disease and perpetrators of sexual violence. The vulnerabilities that are a result of these intersecting forces is further exacerbated by the poverty and inequality that affect such a large proportion of the South African population.

Health policy makers need to start considering the challenges men face in accessing care, for example by making health facilities more male friendly – distinguishing men’s SRH services from MCH services, and keeping health facilities open later so that men who work can still access them – as well as by explicitly recognising the needs and vulnerabilities of men in the discourse used in policy documents. In addition, the discourse we use matters, because it can undermine or reinforce pervasive paradigms of understanding. As health researchers, we need to be careful in the language we use, and encourage policy makers to do the same.

Note:  This blog is based on an online discussion about gender in health systems with 14 members of the new cohort of the Emerging Voices. The blog presents reflections made during those discussion.