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The migration crisis is one of the most pressing global challenges, as worldwide displacement is now at the highest level ever recorded. Latest global estimates by the UN Commissioner for Refugees (UNHCR) show that 59·5 million people are forcibly displaced as a result of persecution, conflict, generalised violence, or human rights violations.1 The estimated refugee population reached an unprecedented 19·6 million individuals worldwide in 2015—half of them being children—and the number is steadily increasing, with Syria as the leading country of origin of refugees.1,2 A lengthy drought preceded the Syrian crisis that led to a large movement of people into cities and contributed to instability. Recent evidence suggests that risks of such droughts in the region are more than doubled as a result of climate change.3
More than a million refugees and migrants arrived in the European Union in 2015.4 The growing influx of vulnerable populations poses many challenges to host countries, not least with regard to preparedness and resilience of health systems and access to health-care services. Furthermore, increasing numbers of refugees are likely in future as a result of a complex combination of driving forces, such as faltering and unequal economic growth, population increases, conflicts and environmental change. The need to develop more effective approaches that respond to the health needs of displaced populations and address the root causes of displacement is therefore imperative.
A refugee is someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country”.5 Refugees experience conditions of vulnerability, marginalisation, and poverty, in addition to high stress of displacement, which seriously affect the health of these populations, including women, children, and older people.
Evidence suggests that refugees often have acute mental health problems and trauma symptoms, notably depression and post-traumatic stress disorder (PTSD), related to organised violence, torture, human rights violation, resettlement, and traumatic migration experience.6 Victims of torture and other forms of violence experience a range of physical problems and disabilities, including malunited fractures, soft tissue injuries, musculoskeletal symptoms, neuropathies, head injuries, and epilepsy.6 Refugees have a high burden of malnutrition and anaemia, treatable non-communicable diseases exacerbated by lack of access to regular medication, and infectious diseases, including hepatitis A and B and parasitic diseases.7,8 The threat of imported disease could contribute to public apprehension about refugees in receiving countries. It is important to emphasise that no systematic association exists between migration and importation of communicable diseases.9 In addition, refugees are particularly vulnerable to sexual and gender-based violence.10 Displacement also complicates the delivery of maternal and obstetric care increasing the risk of unsafe childbirth and maternal and neonatal morbidity and mortality.8
Despite this high burden of disease, access to health care for refugees is mostly restricted in host countries with great variation in entitlements.7,11 Although most welcoming countries offer in principle some kind of medical screening upon arrival, many refugees do not benefit from these services and the quality of screening programmes is questionable and often overlooks mental health problems.7 Legal restrictions also impede refugees’ access to health care. Asylum seekers are typically granted restricted access to health care, often limited to emergency medical care, pregnancy and childbirth care, and immunisation services.7,12 In many European and other countries in the Organisation for Economic Cooperation and Development (OECD), access to essential health-care services is conditional on confinement in detention facilities as part of processes to facilitate asylum claims and identification of individuals.13 Yet, a recent systematic review showed an independent adverse effect of detention on the mental health of asylum seekers, including PTSD, depression, and anxiety.13 In addition, host countries often impose waiting periods before they grant refugees access to health-care services which delays care.14 Exclusion from health care is exacerbated by the undocumented status of many refugees and uncertainties about entitlements for failed asylum seekers.
Practical barriers impede access to health-care services for refugees—eg, inadequate information and awareness about the availability of services, insufficient financial means, restricted access to transport, culturally insensitive care, and inadequate provision of interpreters.7 Various OECD countries also charge migrants user fees for health-care services, further restricting access to health care.12
Initial restriction of access to care for refugees leads to delayed care and increased per person health expenditures.15 Provision of preventive care, including primary and secondary prevention of cardiovascular disease and antenatal care, could generate savings for health-care systems by alleviating the burden of stroke, myocardial infarction, and adverse birth outcomes.16 Overall, robust evidence argues against claims that granting universal health coverage (UHC) to refugees increases health-care expenditure.15 Furthermore, poor access to health-care services interacts with discrimination and limited social rights thereby reinforcing exclusion as a root cause of ill health among refugees.11
Access to essential health services for refugees should be recognised as a fundamental human right.16 As such, host countries must address refugees’ exclusion from health-care services and their unmet health needs. Donor countries should support efforts to improve access to secure essential health-care services, including for those displaced within or close to their countries of origin who can be most vulnerable to ill health and violence. Greater efforts are needed to strengthen the resilience of health systems to foster equity and efficiency in refugee health. As the global community moves towards the ambitious goal of UHC in the post-2015 sustainable development era, serious consideration should be given to the right of refugees to access timely, appropriate, and quality health-care services.
We declare no competing interests.
Etienne V Langlois, Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.
Andy Haines, Departments of Social and Environmental Health Research and of Population Health, London School of Hygiene & Tropical Medicine, London UK.
Göran Tomson, Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet, Stockholm, Sweden.
Abdul Ghaffar, Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.