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Migration, Displacement and Health Systems
Episode 68 • 23rd August 2024 • Connecting Citizens to Science • The SCL Agency
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In this fifth episode of our six-part miniseries (see notes for 'useful links' to other episodes), we examine the intersection of migration, displacement, and health systems in fragile settings. With over 1 billion people on the move globally, including 84 million forcibly displaced, this episode addresses the challenges and opportunities that migration presents to health systems.

Our co-host, Dr. Joanna Raven, joins us alongside Professor Fouad Fouad and Dr. Santino Severoni, to share their experiences and insights on how health systems can respond to the needs of migrants and refugees through integration, cultural changes, and evidence-based practices.

Chapters

00:00 Introduction to the discussion on migration, displacement, and health systems resilience in fragile settings

01:00 Meet the Experts: Professor Fouad Mohammad Fouad and Dr. Santino Severoni

02:56 Global Migration and Displacement: Setting the Scene

07:56 Challenges Faced by Health Systems

09:13 Integration and Parallel Health Systems

13:11 WHO's Role and Strategic Approaches

17:11 Examples of Good Practices from Different Countries

21:48 Final Thoughts and Advice for Future Work

24:12 Conclusion and Next Episode Teaser

In this episode:

Dr Joanna Raven - Reader in health systems, Liverpool School of Tropical Medicine

Jo has worked in global health for more than 25 years, focusing on strengthening health systems. Jo is a researcher with a passion for co-designing and implementing health system research with local stakeholders including community members, health workers, health managers and decision makers. As a health worker herself, Jo’s work focuses on supporting the health workforce to deliver people-centred care that is of good quality and leaves no one behind.

Dr. Fouad Fouad - Professor of Global Health and Social Sciences, Liverpool School of Tropical Medicine

Fouad has extensive research on migration and health, focusing on multidisciplinary approaches to forced displacement, health systems in humanitarian settings, and the political economy of health in protracted crises. Fouad is also the IDRC Chair of the Forced Displacement Program in the Middle East and the Co-Director of the Refugee Health Program at the Global Health Institute. His role as a member of several technical working groups, including the WHO Global Consultation on the Health of Migrants and Refugees and the Global Research Agenda on Health and Migration, underscores his expertise and influence in the field. Fouad served as a commissioner in the UCL-Lancet Commission on Migration and Health (2018) and is currently a commissioner in the Lancet Commission on Health, Conflict, and Forced Migration.

Dr. Santino Severoni - Director of the WHO Department of Health and Migration, World Health Organization

Dr. Severoni is the Director of the Department of Health and Migration at WHO headquarters in Geneva. With over 24 years of experience, he has held senior roles at the WHO Regional Office for Europe and worked globally in health sector reforms, system strengthening, and complex emergency management. His career includes serving as WHO Representative in Albania and Tajikistan. Since 2011, he has focused on public health aspects of migration, leading efforts to implement global migration and refugee compacts and coordinating WHO’s first World Report on the Health of Refugees and Migrants.

Useful links

Want to hear more podcasts like this?

Follow Connecting Citizens to Science on your usual podcast platform or YouTube to hear more about current research and debates within global health.

The podcast cuts across disciplines, including health systems strengthening, gender and intersectionality, tropical diseases (NTDs, TB, Malaria), maternal and child healthcare (antenatal and postnatal care), mental health and wellbeing, vector-borne diseases, climate change and co-production approaches.

If you would like your project or programme to feature in an episode or miniseries, get in touch with the producers of Connecting Citizens to Science, the SCL Agency.

Transcripts

Speaker:

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.

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