Recommendation CM/Rec(2011)13
of the Committee of Ministers to member states
on mobility, migration and access to health care

(Adopted by the Committee of Ministers on 16 November 2011
at the 1126th meeting of the Ministers’ Deputies)

Preamble

The Committee of Ministers, under the terms of Article 15.b of the Statute of the Council of Europe,

Considering that the aim of the Council of Europe is to achieve a greater unity between its members and that this aim may be pursued in particular by the adoption of common rules in the public health field;

Recalling the Action Plan adopted at the Third Summit of Heads of State and Government of the Council of Europe (Warsaw, 2005) wherein it is stated that: “We are aware of the importance of population movements within Europe and from other continents to Europe. Management of this migration is a major challenge to 21st-century Europe”;

Recalling also the statement in the Action Plan: “We shall systematically encourage intercultural and interfaith dialogue, based on universal human rights, as a means of promoting awareness, understanding, reconciliation and tolerance, as well as preventing conflicts and ensuring integration and the cohesion of society”;

Having regard to the 8th Conference of European Ministers of Health and the Bratislava Declaration on Health, Human Rights and Migration (2007);

Recalling Part I of the European Social Charter (revised) (ETS No. 163) which provides that the Parties thereto accept as the aim of their policy, to be pursued by all appropriate means, both national and international in character, the attainment of conditions in which the right of everyone to benefit from any measures enabling them to enjoy the highest possible standard of health attainable may be effectively realised;

Recalling Article 11 of the European Social Charter (revised) on the right to protection of health and Article 3 of the Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) on the equitable access to health care;

Having regard to its Recommendation Rec(2006)18 on health services in a multicultural society;

Having regard to its Recommendation Rec(2001)12 on the adaptation of health care services to the demand for health care and health care services of people in marginal situations, and noting that the definition of persons living in marginal situations applies to many migrants;

Having regard to its Recommendation Rec(2000)5 on the development of structures for citizen and patient participation in the decision-making process affecting health care;

Having regard to the Parliamentary Assembly Recommendation 1503 (2001) on health conditions of migrants and refugees in Europe;

Building on the achievements of the Council of Europe in elaborating policies on managing migration, notably thanks to the Committee on Migration, Refugees and Population of the Parliamentary Assembly and the European Committee on Migration (CDMG);

Noting the relevance of the World Health Organization’s resolutions and decisions, in particular the document “International Migration, Health and Human Rights” (2003) and Resolution WHA61.17 of the World Health Assembly (2008) entitled “Health of migrants”;

Noting the relevance of the International Organization for Migration’s contribution to the field, in particular the publications Migration and the right to health: A review of European Community law and Council of Europe instruments (2007), Migrant health for the benefit of all (2004) and the Concluding Statement of the European Union-level Consultation on migration health “Better health for all” (2009);

Recognising the European Union’s contribution to the field, in particular the Portuguese Presidency conference on “Health and migration in the European Union – Better health for all in an inclusive society” (2007), the European Commission Communication “Solidarity in health: Reducing health inequalities in the European Union” (2009), the Spanish Presidency document “Moving forward equity in health” (2010), the Employment, Social Policy, Health and Consumer Affairs Council conclusions on “Equity and health in all policies: Solidarity in health” (2010) and the European Parliament resolution of 8 March 2011 on reducing health inequalities in the European Union;

Bearing in mind the contributions brought to the field of health and migration by relevant non-governmental organisations, in particular the International Centre for Migration Health and Development, Doctors of the World and the Platform for international co-operation on undocumented migrants;

Recognising that both migration and public health are global issues, calling for global responses; many of the factors behind global health threats are also the factors which drive migration;

Recognising that while migration itself, under normal circumstances, may not be a risk to health, conditions surrounding migration can increase vulnerability;

Considering that appropriate and supportive handling of heterogeneous forms of migration requires diverse, non-standardised measures for the different groups concerned, and that the level of security for migrants can generally be increased through specially targeted measures based on determining the entitlements ensured to each group concerned;

Recognising that managing diversity and the integration of migrants should be driven by the fundamental values of human rights, the rule of law and democracy,

Recommends that governments of member states, having due regard to their specific national, regional or local structures and respective responsibilities, and in partnership with all other relevant organisations involved in improving, maintaining and restoring health:

i. in accordance with national legislation regarding the collection and use of personal data, collect information on the demographic, social, educational and economic characteristics of migrants and their legal situation in the host country;

ii. systematically monitor migrants’ state of health and investigate the causes of discrepancies;

iii. review all policies and practices affecting migrants’ living and working conditions in order to minimise risks to their health;

iv. having regard to the organisation, general principles and financial capacities of the social security system of the member state concerned, provide migrants with adequate entitlements to use health services and ensure that these entitlements are known and respected;

v. promote knowledge among migrants about issues concerning health and the health system, and take measures to increase the accessibility of health services;

vi. overcome language barriers by appropriate measures, including interpreting services and access to translated information materials wherever necessary;

vii. improve the adaptation of health service provisions to the needs, culture and social situation of migrants;

viii. improve the integration of health care with other social services for migrants;

ix. promote appropriate training and education programmes;

x. stimulate high-quality research on all aspects of health services for migrants;

xi. harmonise efforts to promote the health of migrants at European level;

xii. foster a closer relationship between migrants and health services, involving them in all activities concerned with their health;

xiii. support the widest possible dissemination of the recommendation and its explanatory memorandum, where appropriate accompanied by a translation;

xiv. take necessary steps to implement the guidelines contained in the appendix to this recommendation, in collaboration with health professionals, professional bodies, and all governmental and non-governmental agencies concerned with migrant health.

Appendix to Recommendation CM/Rec(2011)13

Guidelines

In this recommendation, the term “migrant” is used in a very broad sense, referring not only to those who change their country of residence voluntarily but also to asylum seekers, refugees and victims of human trafficking. Since the consequences of migration may also extend beyond the first generation, second and later generations are also discussed. In the case of Internally Displaced Persons, internal migrants are also included.

The length of time for which an international migrant resides in the host country may range from a few months to a lifetime. Therefore temporary or seasonal workers, as well as young people taking courses in a foreign country are included. Lastly, this recommendation pays attention to the needs of migrants upon their return to their country of origin (even though they may already be citizens of the country they are moving to), as well as undocumented or irregular migrants.

This use of the term “migrant” is broader than that found in some other documents, but it is more convenient to use one broad term than to refer each time to a long list of categories.

Reference to “health systems” or “services” should be understood throughout as referring not simply to health care, but also to health promotion, health education and preventive measures (for example screening or vaccination programmes).

A. Improving knowledge about migrants and their situation

1. In order to monitor the situation of migrants and provide the necessary basis for research and interventions designed to safeguard their health, governments should ensure that adequate data are collected on the numbers of different categories of migrants, their age, sex, country and/or place of birth, employment, level of education and economic situation, as well as the laws and policies affecting them.

2. Co-operation should be encouraged at international level with the aim of harmonising the form in which these data are collected.

3. In all activities concerning data collection, national legislation regarding the collection and use of personal data should be respected. Measures should be taken to ensure the confidentiality of personal information and to prevent any kind of abuse of the data collected. However, in this field there is an inherent tension between considerations of non-discrimination and the need to identify, analyse and remedy problems affecting particular social groups. An appropriate balance should be struck between these opposing considerations.

B. Migrants’ state of health

4. Governments should take steps to systematically monitor migrants’ state of health across a wide range of indicators. This can be done by including migrants in periodic surveys of the health of the whole population, or by undertaking special surveys. Where necessary, data on variables such as country of origin and migration status can be combined with health information by linking data sets.

5. These data should be analysed to identify the ways in which migrants’ health differs from that of the native-born population, and to explore the factors underlying these differences.

6. In keeping with the principle of “health in all policies”, governments should examine the ways in which adjustments to policies in various sectors could have a beneficial effect on migrant health. Examples include adapting industrial safety regimes to the needs of a diverse workforce; combating processes of social exclusion in education, employment and housing; reducing stress by tackling racism and xenophobia and ensuring decent living conditions for asylum seekers.

C. Entitlement to health service provision

7. Governments should do their best, having regard to the organisation, general principles and financial capacities of the social security system of the member state concerned, to provide migrants with adequate entitlements to use health services which meet their needs. Unnecessarily complex or laborious procedures for obtaining health service provision should be simplified.

8. Special attention should be paid to the entitlement of migrants to health service provision in the following cases:

    a. migrants who have not stayed long enough in a country to qualify for health care coverage;
    b. migrants whose insurance premiums are not paid by an employer;
    c. asylum seekers;
    d. irregular migrants;
    e. migrants held in reception and detention centres;
    f. particularly vulnerable migrants with special assistance needs (for example victims of trafficking or torture, elderly migrants or children).

9. Mechanisms should be put in place to ensure that legislation concerning migrants’ entitlement to health care is properly implemented and that it is fully observed by all concerned.

10. Individuals or agencies responsible for health care should not be required to inform the authorities when irregular migrants come to them for help. An exception to this rule should apply to cases where there is reason to suspect that a serious crime has been committed. Irregular migrants should also receive concrete assurances that, apart from this exception, they will not run the risk of denunciation if they seek medical help. Individuals or agencies providing health care to irregular migrants should not be liable to prosecution.

11. Measures should also be taken to ensure that not only migrants are well informed about their entitlement to use the health system, but that health care professionals at all levels are also aware of these rights.

D. Accessibility of the health system

12. Programmes for migrants should be aimed at improving knowledge about health and illness, the way the health system works and entitlements to health services. In order to be effective, such programmes should be carefully designed and targeted. Efforts to improve “health literacy” should take into account migrants’ own concepts and values concerning health, and an “outreaching” approach may be required.

13. Barriers to the accessibility of health services may have to be removed in order to help migrants find their way in the health system. The issue of language barriers should be addressed following the guidelines under paragraphs 15 and 16 below, and services should match the needs, culture and social situation of migrants. Practical difficulties such as inconvenient locations or opening times, and overly complicated registration or admission procedures, should be reduced as far as possible.

14. Training and education programmes should make health care professionals aware of barriers to access within the health care system (for example inappropriate referrals for secondary care, inadequate diagnostic procedures or discriminatory assumptions about the treatments which are suitable for migrants).

E. Quality of health services

15. The provision of high-quality interpreting services, as well as translated versions of written information, should be promoted by relevant authorities in order to improve both the accessibility and the quality of health care for migrants.

16. Consideration should be given to all available methods of reducing language barriers, including translation by telephone and video, face-to-face interpretation, the provision of “intercultural mediators” and helping migrants to learn the language of the host country. Dependence on informal, untrained interpreters, in particular family members, should be avoided.

17. Efforts should be made to improve the relevance and appropriateness of health services for migrants, making use of the insights and experience that have been gained over the past forty years in a wide range of countries.

18. Existing health services have been developed to meet the requirements of the majority population and may not be well adapted to meeting the needs of migrants. Offering the same services to all users in a diverse population may result in many users receiving a lower standard of care.

19. Services should be “culturally competent”, meaning well matched to the needs of migrants from diverse backgrounds. However, it is not only health care professionals who should be culturally competent, but also organisations as a whole. Many aspects of the structure and activities of organisations may need to be changed in the interests of effective care provision. For example, recruitment policies should ensure as far as possible that the diversity of the general population is reflected in the health services workforce.

20. In addition, the use of the term “culturally competent” should not be taken as implying that only cultural factors need to be considered. Many aspects of a patient’s social position, personal and group history, and legal and political situation in the host country, should be taken into account in order to provide care that is appropriate to his or her needs.

21. Good practice in health care for migrants may involve adapting existing diagnostic and therapeutic procedures or inventing new ones. The challenge of meeting the needs of migrants can generate innovations which also contribute to the improvement of care for other users.

22. The quality of existing health services for migrants should be critically evaluated to identify areas needing improvement. Relevant indicators are: drop-out rate, poor adherence to treatment or therapy and premature termination of treatment, or low levels of satisfaction among staff and/or patients. The effectiveness of treatment may also be evaluated quantitatively, although larger resources are generally required to do this.

23. On the basis of these evaluations, the nature of problems could be identified and good practice should be developed for improving service provision, making use, where relevant, of the experience that has been gained from solving these problems in other countries. New practices should be evaluated to see if improvements have really been achieved.

F. General measures to promote change

24. Collaboration between ministries or relevant authorities is recommended in order to incorporate health promotion and health education for migrants into integration programmes, and to ensure observance of the principle “health in all policies”. In particular, a high level of co-ordination between health and social services may be required because the health problems of migrants are often rooted in social or practical difficulties that require interventions by non-medical agencies (for example social care or the legal system). Measures such as care management or “one-stop services” may be necessary to overcome the problems migrants have in accessing both systems.

25. In the short term, training programmes should be promoted to sensitise health care workers to the issues involved and improve their competence in caring for migrants. In the long term, such issues should be promoted as compulsory elements in the basic training of doctors, nurses, psychologists, managers, policy makers and all other professions involved in health services.

26. Research should be conducted to identify the areas where action is required, to determine the measures that need to be taken and evaluate the success of measures that have been implemented to improve the conditions affecting migrants’ health, their access to the health care system and the quality of health care provided to them

27. Governments should consider joint measures to address the fragmentation of effort and lack of communication between the Council of Europe member states on the topic of migrant health. In order to stimulate multi-sectoral and interdisciplinary co-operation, consideration should be given to setting up a focal point or centre of excellence in each country which could act as a meeting or centralisation point for information, initiatives and discussions on migrant health.

28. Measures should be taken to promote participation of migrants in all activities concerning the provision of health care services, including decision-making processes. Migrants themselves should play a significant role in designing, evaluating and carrying out research on migrant health and health care, as well as in developing and implementing the measures developed on the basis of this research.

29. To support change in this area, it is necessary that not only the actors directly involved, but also the general public (who ultimately have to provide the necessary political support) should be adequately informed about issues concerning migrant health.

30. In implementing these guidelines, governments should ensure that measures are sustained,
co-ordinated and evidence based. Short-term measures and incidental projects cannot deliver the sustainable, universal and structural changes that are needed.

31. To bring about sustainable change, national governments should enter into partnerships with all stakeholders and actors concerned, as well as with migrant organisations, since change at each level needs to be supported by associated changes at all other levels. This involves not only policy development at the national level, but at the level of regional and local authorities, service providers, insurance companies, professional bodies, licensing and regulatory bodies and research organisations, etc. Non-governmental organisations may also have an important role to play in all parts of the health system.



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