Pre-migration health assessments help Australia manage disease and improve lives. Greater collaboration between countries could boost public health, write Belinda Martin and Paul Douglas.
Australia granted 13,760 humanitarian visas to offshore applicants in 2016-17. This number will increase to a planned offshore program of 18,750 in 2018-19, and there is a continued need to ensure that the health and well-being of these immigrants is safeguarded during the settlement process, as well as mitigating against discrimination.
In a paper in Public Health Research & Practice, published by the Sax Institute, we outline how collaboration between like-minded national governments can improve pre-migration health assessments (PMHAs) through information sharing, collaborative learning and increased capability in countries of origin. The role of PMHAs is not only to screen for illness and disability, but to put measures in place to more effectively address these before, during and after arrival.
A PMHA is the medical examination required to assess an applicant’s health against a legislative requirement so they can be granted a visa to enter a country. In the Australian context, its main purpose, historically and now, has been to reduce or eliminate the risk of diseases being brought into the country, and to reduce the burden of significant extra costs being imposed on the Australian health system.
Australia has had a form of migration health screening since the Immigration Restriction Act 1901, traditionally post-arrival, which became the basis for the “White Australia” policy that only began to be dismantled after the end of the Second World War. As part of the drive to recruit increased numbers of British migrants in the mid-20th century, assessment of visa applicants’ health status before they undertake migration developed during the 1950s. Longstanding links between Australia and Britain offered the health infrastructure to enable this screening in Britain prior to departure. PMHAs have expanded globally since.
There has been growing recognition, especially in refugee and humanitarian entrants, that PMHAs present a unique opportunity to address the broader health needs of individuals, rather than merely assessing health as a legislative requirement for inadmissibility. In line with this, in 2012 Australia amended its policy so that refugee applicants could still be granted a visa, even if they required government-funded health and community services that would incur excessive cost to the public system. This expanded the PMHA beyond its original intent, and has allowed it to contribute meaningfully to enhanced public health.
The effectiveness of PMHAs for healthy refugee and humanitarian settlement hinges on robust evidence-based screening, and high-performing clinical practice and pre-migration interventions, in addition to post-arrival continuity of care. Having robust processes and effective outcomes in this respect prevents anti-migrant attitudes and discrimination through public confidence that there is not a negative impact on health through migration.
This can be challenging to achieve within the shifting complexity of differing refugee cohorts, coupled with growing volumes and ambitious political resettlement time frames. Understanding health issues in settling refugees is important so that we can appropriately respond to their needs and manage any risks through a continuum of care-based on evidence.
Undiagnosed, misdiagnosed or underdiagnosed conditions can affect refugees’ health before migration and delivery of services during settlement. Responsibility for the delivery of PMHAs resides with a panel of local health professionals in countries of origin, who are mostly employed by the International Organization for Migration (IOM). However, accountability for mitigating risks remains a sovereign responsibility for each receiving country.
Risks are mitigated through a combination of targeted on-site audits, regional training and desktop auditing. Australia’s on-site auditing rate is relatively low, with about 20% of the panel audited annually due to resourcing constraints. It therefore is dependent on other inputs to ensure it is working effectively.
The nature of migration is rapidly changing. It is more complex and multi-directional than ever before, raising implications for global public health where population movements serve as a “bridge” for passage of disease between countries, and the management of these risks. Existing approaches to manage these risks have not always kept pace with growing challenges associated with volume and complexity of modern migration patterns.
Many of these issues cannot be solved by one country alone, and key learning and resources can be leveraged by working together to address our common challenges. International collaboration between countries with similar programs, through shared learning and resources for improved health outcomes, helps us to understand more fully and respond to pre-migration health issues.
Following a call from the IOM to have a more standardised and consistent approach to PMHA globally and between countries, Australia, Canada, New Zealand, the United Kingdom and the United States have worked together for more than a decade within the Immigration and Refugee Health Working Group (IRHWG). In recent years, this group has evolved from information sharing into an action-oriented group which advances specific cross-agency projects and initiatives that deliver concrete outcomes benefiting all five members. Recent achievements include jointly hosting panel training in Asia for 420 panel physicians, as well as working to understand unexpectedly low rates of tuberculosis detected in the course of PMHAs among applicants from the Indian subcontinent.
As part of this intergovernmental collaboration, Australia gains more in clinical outcomes through leveraging IRHWG clinical expertise to improve both the quality of health screening and services delivered to refugees, and also diagnostic capability, than it would from committed resources alone.
Collaboration alleviates resource constraints by stretching Australia’s capacity beyond what could be achieved from budgeted resources, using shared IRHWG auditing and training workloads globally to expand the reach of PMHA coverage.
IRHWG countries face similar challenges, so monitoring and comparing differences in focus, policy and practice results in collaborative learning and policy gains for Australia. The inclusion of a skin condition assessment, and treatment for scabies and lice, is a recent PMHA policy change for Australia-bound refugees. This change was influenced by the policies of other IRHWG countries and by evidence of a high prevalence of untreated skin conditions leading to ill health in Syrian refugees in Jordan.
The collaborative effort between IRHWG members has been a catalyst for laboratory and treatment infrastructure, as well as training and education activities that may have otherwise not been possible. Through our collective capabilities, data and resources, we have been able to improve the service, security and efficiency of our respective PMHA programs and give confidence to the Australian public that threats to public health are appropriately managed, while decreasing the requirement for onshore follow-up and screening.
IRHWG members have traditionally centred their policy in terms of “threats” to public health, so it will be a challenge to consider how IRHWG will meaningfully contribute to global public good health in the future. The convergence of more rigorous international protocols across IRHWG members presents a unique opportunity to indirectly contribute to meeting global health elimination agendas. Improved, synergised screening protocols across IRHWG members enable local panel physicians to meet the public health standards of receiving countries, while maximising program effectiveness through capacity building and delivering the highest standards in host countries.
As long as disparities and prevalence discrepancies exist, national health programs in host countries and policies of receiving countries will continue to be challenged to manage the health concerns in migrating populations. Inconsistent and sovereign-based approaches will continue to lead to adverse impacts for individual migrants, as well as the host and receiving countries.
It is possible through collaborative efforts that the net result is the ongoing improvement of public health practices in host countries, through the capacity-building endeavours of PMHAs.
Belinda Martin and Paul Douglas work for the Department of Home Affairs and represent Australia on the IRHWG.
Read the full paper in Public Health Research & Practice, published by the Sax Institute: Intergovernmental collaboration for the health and wellbeing of refugees settling in Australia.