As part of the ongoing Global Health Systems Research Symposium 2016, the Asian Development Bank (ADB) in collaboration with Emerging Voices of Global Health organized a session on “Healthcare beyond borders” on the first day of the symposium in Vancouver. Our world is an increasingly mobile and inter-connected world; around 1 billion people globally live outside of their place of birth– 650 million are internal migrants and 250 million are international migrants. The world is witnessing the highest level of migration since World War II.
Discussions at the ADB session left me with some thought-provoking questions. The session was intended to help participants develop a more informed understanding of the current direction of efforts towards achieving universal health coverage (UHC), and to share potential problems in efforts to provide health services for mobile populations. It was to think of ways in which to give a voice to different perspectives at the individual and institutional levels, and to think of creative solutions for providing health coverage and access to migrants.
The session started with the acknowledgment that to date, the UHC debate has largely focused on citizenship. Country level policymakers have been striving to cover their citizens first, before thinking of non-citizens. Indeed, in a resource-constrained setting, this would seem natural. However, in this increasingly mobile world, it is important to think about how to provide health coverage and financial protection based on where one lives, not where one comes from – to expand the UHC debate to imply ‘health for all’, not just for citizens of a country but health for all – everywhere.
Azusa Sato from the ADB outlined the migrant movement in Asia Pacific – the trends, employment and health issues faced by mobile populations, the systems and policies currently in place, and the role of ADB in addressing these issues. Two important insights were the broad approaches adopted by some sending and receiving countries in providing access to the migrant workers; the first approach termed – “UHC approach”, is relatively holistic, inclusive and does not differentiate nationals from non-nationals. The second approach called “worker and/or employer sponsored approach” requires compulsory contributions to cover the migrant employees.
Speakers and participants wrestled with various countries and regional level challenges in the first half of the session. Kenneth Ronquillo from Department of Health, Philippines shared the myriads of health risks faced by overseas Filipinos; this population comprises 16% of all the HIV/AIDS cases since 1984 in the Philippines; they face issues related to mental, sexual, reproductive, and occupational health in the destination countries; irregular and informal migrants are not able to access even basic health services. Inez Mikkelsen from ADB’s pacific regional department shared that there are small island populations with very few health centers in the pacific region, and the demand for off-island health care has outstripped the resources in the pacific region in the last few years; increasing numbers of pacific residents must obtain care off shore—in Australia, New Zealand, Philippines, or United States. Off -island health care is relatively expensive due to the additional cost of transportation and the higher cost of care.
Goran Zangana – an Emerging Voice (EV) from Iraq mentioned that due to internal conflicts and the war on terror, many geographical boundaries (borders) are irrelevant in Iraq and its surroundings; there is an overwhelming number of internally displaced populations and migrants from the neighboring countries in Iraq. He further stressed that the idea of UHC beyond borders should not be confined to migration due to work but should encompass migrations because of any reason. Deepika – an Emerging Voice from India reflected on operational challenges in holding the private sector accountable in a large-scale national level subsidized health insurance scheme for the poor in India, of which internal migrants are an important sub-population.
Possible solutions for the aforementioned challenges were discussed in the second half of the session. Gorik Ooms, now at the London school ( always a delight to listen to his “can do” & “must do” arguments for a fairer world, especially in times like these ) first raised the question, “is health a human right or citizen’s right?” We know the answer to that one. He then shared the historical perspective of the rights of (some) citizens, rights of humans as citizens of some states, and the rights of humans by being “part of the human species”. He also posited that the world might now require a form of ‘world health insurance’ to realize the right of health. Often it is said that first a World War III (we hope not!!) will be needed before we can get to these global solidarity schemes, but Gorik wasn’t that pessimistic. As for the (few) cynics in the room, even they thought we’re on track for the (US) reasons you know.
Eduardo Banzon from the ADB highlighted the example of the European economic integration and European health insurance card, and asked, “Is economic integration of countries a “must do first” before global UHC? The European participants in the room all gently nodded but instantly also thought that ‘economic unions don’t have eternal life either’, reflecting on the euro predicament in recent years. He further reflected on the portability of social security benefits including health insurance through the multilateral agreements. Barbara McPake from the Nossal Institute shared her perspective of supply-side harmonization to meet demands of mobile populations and suggested balancing insurance-based resource flows with direct funding for disadvantaged parts of the system.
Carlos van der Laat from the IOM reflected on the policy responses to migrant health issues, and shared IOM’s success stories in monitoring migrant health, establishment of partnerships and networks, policy and legal frameworks, and IOM’s interventions for making health systems ‘migrant-sensitive’. Juan Carlos (from University of Utah, not the former king of Spain) shared his reflections on insurance portability in Latin America and the Caribbean within the context of free trade of services, and elaborated on the unilateral (independent from agreements) definition of beneficiary, local laws forcing migrant workers/investors to choose insurance schemes, and agreements to provide services to poor populations from other countries.
I highlighted the need to collate evidence on the political, economic, and health benefits of UHC beyond borders. Bringing in the perspective of patients, I stressed the need to enhance patients’ knowledge of their entitlements and building their trust in the new health system. Felipe Sere – an Emerging Voice from Uruguay asked, “if the health should be delivered as a product or a right?” Commenting on the ways of engaging with private sector, he inquired “should health insurance be run on the same principles as of car insurance?” Which made us wonder, as he was clearly on to something, why he refrained from comparing health insurance with the Samsung Galaxy Note 7 insurance J! Soonman Kawan from the ADB summarized the session by asking if the term “beyond borders” only means beyond geographical boundaries or in the true sense, if it also encompasses different population groups with varying citizenships within countries.
To conclude, this session brought an interesting discussion on the extension of global health values of equity, social inclusion and justice, beyond borders. The key message to emerge was, is there a way that the global health community – within the current economic and political trends – can collectively engage in making health a human right and not a citizen’s right?
Declaration of conflict of interest: we have no competing interests