Health Systems that Meet the Health Needs of Refugees and Migrants

Abstract

This article discusses strategies designed to assist European Union (EU) health systems respond to the urgent health needs of refugees and migrants, assessing the situation from both an EU and global perspective. The article provides an overview of the legal framework, political policies, actions taken and the funding issues facing European institutions and international organizations as they seek to strengthen their response to healthcare needs of refugees and migrants. This article argues that EU member states need to be committed to improving the health status of refugees and migrants and reinforce their capabilities to advocate for respect for their basic right to health.

Keywords

Refugees migrants healthcare policy

Introduction

The migration and refugee influx to Europe have become major political, social, and economic issues, raising significant human rights concerns. The global displaced population at the end of 2015 had reached 65.3 million people, according to United Nations High Commissioner for refugees (UNHCR, 2016). This was the highest number recorded since the aftermath of the Second World War and it comprised 16.1 million refugees outside their home countries; 5.2 million Palestinian refugees inside and outside Palestinian territories registered with the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA); 3.2 million asylum seekers outside their home countries whose applications had not yet been decided by the end of 2015; and 40.8 million internally displaced persons inside their home countries (European Stability Initiative, 2017). More than 2.5 million people applied for asylum in the European Union (EU) in 2015 and 2016, the last years for which good data are available (European Parliament, 2017c).

More than a million migrants and refugees crossed into Europe in 2015, sparking a crisis as countries struggled to cope with the influx, creating divisions in the EU over how best to deal with resettling people (BBC News, 2017). Taking a closer look to the figures, the International Organization of Migration (IOM) estimated that more than 1,011,700 migrants arrived by the sea in 2015, and another 34,900 by land. In 2014, by way of comparison, the total figure had been only 280,000 arrivals by sea and land (IOM, 2015). According to European Boarder and Coast Guard Agency (FRONTEX), the western and central Mediterranean areas, as well as western Balkans, are the routes most commonly chosen by refugees and migrants who enter Europe illegally (FRONTEX, 2017). According to the UNHCR, for the over one million Mediterranean Sea arrivals between January 2015 and March 2016 the top three nationalities of entrants were people from Syria (46.7%), Afghanistan (20.9%), and Iraq (9.4%) (EU, 2016). After this time, however, migrants from Western Africa became the majority of arrivals. The nationality breakdown varied by host country. In Italy, arrivals are mainly Guinean (13%) and Nigerian (13%), followed by migrants from Bangladesh (12%) and Cote d’Ivoire (10%). Greece received more migrants from Syria (36%), Iraq (10%), the Democratic Republic of Congo (7%), Pakistan (7%), and Afghanistan (6%) (IOM, 2017a). As has been well reported, migration is a very dangerous undertaking. According to the IOM, more than 3,770 migrants died trying to cross the Mediterranean in the year 2015 alone, the last year for which we have confirmed numbers (IOM, 2015).

Since the spike beginning then in April 2015, the EU has struggled to cope with the migrant and refugee crisis. Many national actors must help in this emergency. The management of the migrants’ and refugees’ situation is a shared responsibility, not just for EU member states, but also for the non-EU countries along the transit routes, as well as in the nations of origin for the migrants and refugees. This article aims to examine the EU policies and actions, seeking to measure whether the level of health services provided to refugees and migrants is similar to citizens of the host nation. Beyond this, this article will explore the strategies that will successfully help health systems respond to the critical health needs for the arriving populations.

Addressing the Immigrants’ and Refugee’s Health Issues

Refugees’ health is one of the leading global public health crises of this century (Syed & Mobayed, 2017). The families suffer from a wide array of health concerns, from the overtly visible to the subtle yet deeply serious. Refugees often have acute mental health problems and trauma symptoms, notably depression and post-traumatic stress disorder (PTSD), related to organized violence, torture, human rights violation, the trials of resettlement, and the often deeply traumatic migration experience (Burnett & Peel, 2001). Yet it is difficult to document all of these conditions, as O’Donnell, Higgins, Chauhan, and Mullen (2008) note, there exists but limited specific evidence on the health status of asylum seekers and refugees, making it hard to measure fully the exact impact of healthcare access difficulties. Hard evidence of poor health among refugees is mostly confined to readily visible issues, such as maternity problems or violent mental illness outcomes (WHO, 2014).

The refugees’ and migrants’ most common health problems have been detailed by the World Health Organization (WHO, 2017) with a general conclusion that their health problems are similar to those of the rest of the population, although some migrant and refugee groups may have a higher prevalence of particular afflictions. The most frequent health problems of newly arrived refugees and migrants include accidental injuries, hypothermia, burns, gastrointestinal illnesses, cardiovascular events, pregnancy- and delivery-related complications, diabetes, and hypertension. The difficult living conditions (unemployment, poor housing, discrimination, and social exclusion) faced by many of the migrants place them at higher risk for poor health. Owing to poor living conditions, suboptimal hygiene, and deprivation endured during migration, vulnerable individuals, especially children, are more prone to respiratory infections and gastrointestinal illnesses (WHO, 2017). Many migrants, especially children, pregnant women, older people, those who have experienced war, refugee status or bad living conditions, may have a much greater need for ongoing care and treatment. The new arrivals may also have different cultural or linguistic backgrounds, presenting challenges both for them and for healthcare providers in host nations.

According to WHO, the exposure of refugees and migrants to the risks associated with population movements—psychosocial disorders, reproductive health problems, higher new-born mortality, drug abuse, nutrition disorders, alcoholism, and exposure to violence—increase their vulnerability to non-communicable diseases (NCDs). The key issue with regard to NCDs is the interruption of care, due to either the decimation of the healthcare systems for flight of professional care givers in their home countries or the lack of access in the overburdened healthcare facilities in the host nations. A critical issue is that geographic displacement far too commonly results in interruption of the continuous treatment that is crucial for chronic conditions (WHO, 2017).

Are Health Systems Ready to Welcome Refugees and Migrants?

As migrants and refugees arrive, the health systems of host nations confront many challenges. Many migrants have come to the EU to escape war and atrocities, arriving with the hope of making a better life for their families in Europe. This hope is grounded in the fact that EU nations do have obligations under international law to accommodate these individuals. EU law specifies the conditions for asylum applicants and refugees, and foremost amongst these rights is access to healthcare. However, refugees’ and migrants’ health needs can absorb a lot of time and effort from the health systems, placing added demands on available extra.

These swiftly rising needs come within a context of economic crisis and budget cuts in the health sector for several receiving nations. Following the European and global economic disaster of 2008, health spending slowed significantly across Europe after many years of prior continuous growth (OECD, 2016). Indeed, from 2010 onwards many European countries have been facing dramatic reductions in health spending, with some suffering ongoing contraction over a number of years. Average annual increases in health spending growth across the EU members of the Organisation of Economic Co-operation and Development (OECD) climbed just above zero in 2013 after three successive years of reductions (OECD, 2015).

The provision of healthcare is entirely a responsibility for each EU member state. Yet the era of austerity has in some countries led to the implementation of new more free market-oriented strategies in the field of healthcare and social welfare, policies which have often unfavorable impact on the most vulnerable groups in the society, most of all, migrants and ethnic minorities. In times of economic crisis this may be understandable but, it will be argued here, such policies are short-sighted. Health systems need to shift the still widely held perception of health expenditure on ethnic minorities and migrants as primarily a “cost” rather than an investment, and to send the message that health contributes to inclusive economic growth that benefits all.

Access to healthcare should stand first within health system priorities, and refugees and migrants, it will be shown here, absolutely have a legally protected right to it. The WHO report EUR/RC65/13 (WHO, 2015a) puts people at the center of the healthcare systems. People-centered health systems reflect the values of solidarity and equity.

The OECD is calling for a “new generation of the health systems reforms” (OECD, 2017) to meet the needs of refugees and migrants. The crucial question remains: what are the irregular migrants’ and refugees’ rights to health? What is covered under the EU legal umbrella and what are the actions taken by the EU and the member states to address this issue?

The International Legal Framework

There is substantial evidence of inequities in both the state of health for these groups and overall accessibility and quality of health services available to them (WHO, 2010). The EU has made many commitments to address discrimination in all its forms, and fairness in health is a critical area of the EU’s concern with social justice. EU antidiscrimination activities had included building the legal framework for defense of these rights; supporting the development and exchange of best practices in fair health policies; launching health improvement pilot projects and conducting studies; and activity supporting the work of the EU’s Fundamental Rights Agency and other like institutions. The legal framework that ensures access to health services for migrants and refugees provides valuable, if under-utilized sources for EU member state policy makers and healthcare professional.

What is behind all these efforts is one basic principle: health is a human right (Directive 2008/115/EC). The right to health includes both freedoms and entitlements. Freedoms include the right to control one’s health and body (e.g., sexual and reproductive rights) and to be free from interference (e.g., free from torture and from non-consensual medical treatment and experimentation). Entitlements include the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health (WHO, 2015b).

Human rights should have no borders. This right is more than just a high-minded ideal; the principle is enshrined in Article 168 of the treaty on the functioning of the EU, which states that “a high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities” (C 326/47, 2012). The EU Charter of Fundamental Rights—Articles 21, 35—codifies everyone’s right to access preventive healthcare and the right to access necessary from medical treatment under the conditions established by national laws and practices (C 364/01, 2000). The charter also underscores the EU commitment to equal opportunities and antidiscrimination, guaranteeing access to healthcare (SWD/50, 2016).

The protection of these fundamental rights is ensured through EU laws and has been steadily advanced by actions taken both by EU institutions and through national laws and their attendant agencies. Moreover, the EU has explicitly singled out the right of people in vulnerable situations to necessary health attention. The EU Committee on the Elimination of Racial Discrimination, in its general recommendation No. 30 (2004) on non-citizens, and the EU Committee on Economic, Social and Cultural Rights, in its general comment No. 14 (2000) on the right to the highest attainable standard of health, both stress that member states should respect the right of non-citizens to an adequate standard of physical and mental health by, among other actions, refraining from denying or limiting their access to preventive, curative, and palliative health services (UN, WHO, Fact Sheet No 31, 2008). In 2007 the EU Council adopted conclusions on migrant health (Council of European Union, 2007). The right for legal migrants to have access to healthcare on the same basis as nationals is clear; refugees and/or undocumented persons, as some of the most vulnerable persons within a population, cannot be left aside.

The IOM has created an online database which makes all EU norms and instruments (regional and international) accessible covering the relevant rights and obligations of migrants (IOM, 2017b). The EU Return Directive 2008/115/EC covers access to healthcare of those irregular migrants who are subject to return procedures (both in detention centers and outside detention). The Return Directive obliges member states to provide emergency healthcare and essential treatment of illness to migrants, even those who are under return orders (Articles 14(1)(b) and 16(3)) of the directive. Article 10 of the EU treaty on the functioning of the EU (C 326/47, 2012) states that the Union shall aim to combat discrimination when defining and implementing all its policies and activities, including those relating to healthcare.

There is a vast legal underpinning in the EU, assuring migrants’ health rights. The European Parliament resolution on “Undocumented Migrant Women in the EU” (European Parliament, 2014) underlined the need for equal access to justice and services for all women, calling on national and European authorities to ensure that a woman’s immigration status does not prevent any woman from accessing decent housing, healthcare, education, and justice. The council conclusions on the common values and principles of EU health systems (C 146/1, 2006) stated in its founding declaration that health services must be underpinned by the values of universality, access to good quality care, equity, and solidarity. The EU Council conclusions on “Equity and Health in all Policies: Solidarity in Health” (Madrid, June 8, 2010, Article 8) further cemented the EU’s commitment to recognize these basic rights for all. The European Parliament resolution “Reducing Health Inequalities” in the EU (A7-0032/2011, March 8, 2011, points 5–22) similarly addressed the issues of vulnerable groups (European Parliament, 2011). The most basic documents of the EU make clear the shared and fundamental commitment to recognize and honor the rights of migrants to healthcare.

EU Actions

In 2015, the European Agenda on Migration responded to the need for swift and determined action in response to the human tragedy in the whole of the Mediterranean. This document continues to serve as a blueprint for the EU’s reaction to the ongoing crises (COM240, 2015). The agenda provides a comprehensive approach grounded in mutual trust and solidarity among EU member states and institutions (European Commission, 2015). The importance of prioritizing European solidarity remains a very important theme running through the discussion by regional policy makers, particularly in a climate of economic uncertainty and fiscal pressures that can impact disproportionately on the most vulnerable groups in society including refugees, migrants, and ethnic minorities.

At the national level, migration and health issues loomed large, especially in Greece and Italy. Greek authorities called for an open national discussion regarding the impact of migration on health and health systems, calling for an enhanced cooperative role by all EU member states on this common regional public health challenge. In 2014 the Greek government organized a session on “Migration and Public Health” at the Informal Health Council in Athens. On March 19–20, 2014, the Greek “Hellenic Center for Disease Control and Prevention,” in collaboration with the European Centre for Disease Control and Prevention (ECDC), hosted a workshop on the public health benefits of screening for infectious diseases among newly arrived migrants to the EU/European Economic Area (EEA). At the same time, Italy organized a conference on health to foster cooperation and to support initiatives in the area of migration and health in the Mediterranean areas.

In order to respond to the emergent needs of the Mediterranean member states, Cyprus, Greece, Italy, and Malta, the nations that most faced the emergency situation of migrants in the South Mediterranean Sea, together requested that the EU facilitates the process of exploring options for solutions through Union provisions (European Commission, 2017a). The Health Security Committee of the European Commission prioritized the health issues of the refugees and migrants and in coordination with the ECDC worked on recommendations and funding (COM292, 2011).

In 2015, ECDC (under European Commission the Directorate-General for Health and Food Safety [DG SANTE]’s responsibility) published a report on the public health needs of irregular migrants, refugees or asylum seekers across the EU’s southern and south-eastern borders. The conclusion of this report noted that migrants do not, as is sometimes argued, pose a significant health threat to the citizens of the EU. There is no evidence or expert opinion that suggests that migrants increase the risk of infectious disease epidemics in the host population in Europe. Indeed, according to Semenza et al. (2016), many newly arrived migrants in Europe are themselves vulnerable to infection upon arrival, and thus prevention and assessment of infectious diseases among newly arrived people are an essential humane response if we are to address the health needs of the refugees and migrants.

The same year ECDC developed an expert opinion statement to address the urgent health needs related to the influx of migrants into the EU. The advice of this body had been requested by the European Commission, which asked the ECDC to focus on migrants entering the EU, particularly those who may be irregular or were applying for asylum or refugee status and who originated from Africa or the Middle East. The options to address health needs of migrants concentrated on actions which could be taken at the point of entry or shortly after arrival (ECDC, 2015a). The ECDC conducted interviews with member states experts and a review of the relevant literature, highlighting the overall needs of the population in question. The report recommended reception centers/systems for newly arrived migrants in order to assure health assessments immediately upon arrival; adequate shelter to avoid crowding and ensuring good sanitation and hygienic conditions; health education and health promotion emphasizing the benefits of screening, immunization and other measures; screening for communicable diseases according to their countries of origin and countries transited during migration (ECDC, 2015b). The scientific advice urged disease screening; syndromic surveillance (pre-diagnosis assessment); public health follow-up; vaccination; general hygiene measures; preventing or minimizing overcrowding; health education and health promotion; access to healthcare, free of charge; and other measures, including anthelmintic treatments for gastrointestinal parasitic infections.

Above all, vaccination is an essential measure needed to help assure migrants’ and refugees’ health. The ECDC has already issued guidance on vaccination for migrant children and adults (ECDC, 2015c) and additional EU collaborative work in this area is needed. In response, the EU in 2017 pressed for the assistance of non-governmental organizations (NGOs) in helping to assure higher coverage in the EU for immigrant populations (European Commission, 2017b). This step would be good for the health of the migrants and refugees, and would be good for Europe and indeed for the world as a whole.

The European Commission adopted an action plan on the integration of third-country nationals on June 7, 2016 (COM377, 2016). The action plan provided evidence that ill health and lack of access to health services can be amongst the most fundamental ongoing obstacles to integration, with an impact on virtually all areas of life and shaping the ability of migrant to find employment, education or learn the host country’s language and interact successfully with public institutions. The action plan findings noted that third-country nationals can face particular problems in accessing regular health services, dealing with unfamiliar healthcare systems, or communicating effectively with healthcare staffs. The report found that the right to health is often challenged by immigrants’ problems linked to their legal status or by overt discrimination, or simply by language and cultural barriers.

The DG SANTE coordinates activities through the Health Security Committee: collating requests for vaccines and other health supplies from EU countries most affected so that other EU countries can help; improving the monitoring of communicable diseases via the Early Warning and Response System; bringing together national contact points for health with those in charge of civil protection and asylum; and accessing migration and integration funds (European Commission, 2017a).

In 2017, Eurostat published data on migrants’ integration, measured in terms of employment, health, education, social inclusion and active citizenship in the hosting countries. However, most EU member states could not provide reliable aggregated data regarding the health situation of their foreign populations or could not provide any such data at all. Therefore, a range of new indicators has been proposed which would allow for a better assessment of the situation (Eurostat, 2017).

EU Funding

The European Parliament has given dealing with migration issues top priority and called for the EU to do more to manage the situation. A vote on the EU’s 2017 budget (European Parliament, 2017a) in December 2016 secured a reinforcement package of Ä728 million for mainly migration-related funds. In April 2017, the European Parliament made available Ä3.9 billion in additional support for migration-related measures through a mid-term review of the EU’s 2014–2020 budget (European Parliament, 2017b). Regarding the legislative protection of the disadvantaged groups, including refugees and migrants, the council’s conclusions on the economic crisis and on healthcare noted that public health expenditures have been reduced in many member states since 2009. The body underscored the fact that investments in health promotion and disease prevention, with a particular focus on the disadvantaged groups, should be preserved, especially in times of economic crisis, since they have a short- and long-term positive contribution to improving the health of the population and reducing health inequalities (C 217/02, 2014).

The new multi-annual EU financial framework 2014–2020, which facilitates member states’ utilization of designated EU funding streams, aims fundamentally to reduce inequalities in health status, explicitly laying out the priorities for the European Regional Development Fund as a contributor to promoting social inclusion and combating poverty. The EU Asylum and Migration Fund, managed through DG HOME (Ä3.7 billion for the years 2014–2020), provides support to most EU member states for immigrant reception and asylum systems, capacity building, resettlement and relocation, pre-departure measures, integration at local and regional level, and return measures.

Moreover, the EU provided Ä7.2 million in 2015 to support EU countries facing particularly high influxes of migrants and refugees and the accompanying health-related challenges. Ä7 million was allocated in 2016 for sharing best practices on healthcare models for vulnerable migrants, as well as providing funds for training health professionals and immigration law enforcement officers. The 2017 budget included actions on migrants’ health, preventing diseases and fostering a supportive environment for healthy lifestyles (the EU “health in all policies” principle) (European Commission, 2017c). It was an important step forward in dealing with the humanitarian crisis.

In 2017, the DG SANTE supported with Ä1.3 million (European Commission, 2017c) the “assessment of the feasibility of establishing a European expert network for rare communicable diseases and other rare pathologies in the context of globalization and migration” (European Commission, 2017d) and “the health status of newly arrived migrants and refugees in Europe” (C1158, 2016). DG SANTE works with the ECDC, the WHO Europe and the IOM to better identify and address the needs of EU countries and refugees. It develops training programs for healthcare professionals. Through the EU Health Programme 2014–2020, funding is provided for the development of training packages for health professionals to improve access and quality of health services for migrants and ethnic minorities. These measures are helping and will continue to help healthcare professionals learn about diseases that they are not familiar with and provide information on cultural perspectives and specific needs among the people arriving (CHAFEA, 2015).

DG SANTE produced guidelines for maintaining immigrant personal health records and offered an accompanying handbook to help healthcare professionals in the receiving countries build accurate medical histories of incoming migrants and refugees, identifying the most immediate needs. A direct grant was provided to the IOM for the implementation of the personal health record practice across Europe (IOM, 2017c). In 2017, DG SANTE supported further implementation not only in the immigration frontline but also for those people in transit (European Commission, 2017b).

Other key projects funded by the EU Health Programme 2014–2020 included the 2016 best practices in care provision initiative for vulnerable migrants and refugees (European Commission, 2016), offering financial outlays for a pilot project for training modules for health professionals; a new program for border guards and trainers in migrants’ and refugees’ health; and a training program for first-line health professionals, border officers and trainers working at local level with migrants and refugees.

The EU Commission’s Consumers, Health, Agriculture and Food Executive Agency (CHAFEA), responsible for implementing the health program, has promoted a number of activities, including training in health services for migrants and ethnic minorities (e.g., MEM-TP, IOM Equi-Health), as well as sponsoring research and holding international conferences on migration and health. The conference on migrants and health actions funded under the health program 2008–2013 and 2014–2020 was organized to share best practices implemented in the framework of the health program actions addressing migrants’ health needs (CHAFEA, 2016). In addition, a project of Ä0.5 million, funded by the EU Health Programme, called for “supporting health coordination, assessments, planning, access to healthcare and capacity building in member states under particular migratory pressure (SHCAPAC)” with the general objective of supporting EU member states under particular migratory pressure deal most effectively with the health-related challenges (CHAFEA, 2015).

Moreover, the EU Health Programme’s contribution to fostering solidarity in health and reducing health inequalities in the EU 2003–2013 led to the publication of the report, “action on health inequalities in the European Union,” highlighting the reality that vulnerable groups, such as people living in extreme poverty; the disadvantaged migrants; ethnic minority groups; and people with disabilities and people suffering from illnesses that can carry social stigma, for example, HIV/AIDS or mental illness; often suffer the most striking inequalities in healthcare in the EU (European Commission, 2014).

The report noted that 17 countries of 27 EU member states reported progress in at least one of the measured 64 health inequalities reduction actions areas from 2003 to 2013. Most of the partners (70%) came from 13 countries (Italy, the UK, the Netherlands, Germany, France, Spain, Hungary, Sweden, Denmark, Poland, Austria, Czech Republic, and Finland). Eight countries from the EU-15 countries (the Netherlands, the UK, Belgium, Austria, Germany, Spain, Italy, and France) led in 51 (80%) of the reform actions funded. The Netherlands was the most frequent beneficiary, with 11 (17%) reform actions funded, followed by the UK (9 actions, 14%) and France (6 actions, 9%). Five other countries, Austria, Belgium, Germany, Italy, and Spain, each coordinated 5 actions. Greek organizations led in two reform action areas addressing migrant and ethnic minorities’ health issues.

As a conclusion the report outlined that in order to meet the needs of the vulnerable groups, member states needed to raise awareness and promote actions to improve access to of health services and preventive care for migrants and ethnic minorities and other vulnerable groups. Providing an overview of the global dimension of EU funding regarding the refugees and migrants issues, the EU has allocated a total of Ä17.7 billion from the EU budget to deal with the migration crisis for the 2015–2017 period, with Ä10.3 billion for funding outside the EU, including Ä2.7 billion in humanitarian aid, Ä0.6 billion for the trust fund for Syria (also known as the MADAD Fund) and Ä2.4 billion for the emergency trust fund for Africa (European Commission, 2017e). The humanitarian aid provided by the EU helps refugees and migrants in countries outside the EU, such as Iraq, Jordan, Lebanon, and Turkey. In order to support a facility for refugees in Turkey, the EU and its member states have already allocated Ä2.2 billion for both humanitarian and other socio-economic assistance. As of June 2017, contracts had been signed for 48 projects worth over Ä1.6 billion, with Ä811 million have already been disbursed (European Commission, 2017f). The EU is also a leading donor in the international response to the Syria crisis, with Ä9.4 billion in humanitarian and development assistance already allocated (European Commission, 2017e).

Policy Considerations

As noted, the right to healthcare is guaranteed under international and European human rights law. These standards apply to everyone regardless of their migration status. In general, member states must provide reception conditions which ensure a standard of living adequate for health and ensure that all people, regardless of immigration status, receive necessary healthcare.

Although this does not oblige EU member states to guarantee access to all health services on at exactly the same level as citizens, it does impose some minimum requirements such as access to emergency healthcare. At the very least, this should include access to necessary medical care for all, equal access to healthcare for children and antenatal, delivery, and postnatal healthcare for mothers. However, it is clear that practice varies widely between countries. There are currently no binding EU rules in force covering access to healthcare of irregular migrants in general. It is for member states alone to ensure that their obligations regarding fundamental rights as resulting from the European Convention on Human Rights and from their internal legislation are respected. It might therefore be useful to consider developing guidance at European level to support member states in this regard.

The EU is working on remedying the unequal healthcare situation of migrants and refugees. The European Commission has sought to promote universal access through coordination efforts, and it is working in close cooperation with its agencies and international organizations, especially the WHO and the IOM, to closely monitor the situation. Moreover, the EU Agencies, including the Fundamental Rights Agency, the European Asylum Support Centre and the ECDC, provide information and analysis. The EU has an effective system for rapid alert and information sharing on communicable diseases which brings together all member states, the ECDC and WHO. The European Commission seeks to promote universal access to high quality healthcare, through coordination efforts with member states and activities financed by the health program. EU asylum and migration funds are also available.

However, in the end, the responsibility for the organization and delivery of healthcare lies with the member states. Some member states have shouldered a higher burden than others regarding influx of distressed migrants. Tensions in the EU have been rising because of the disproportionate burden faced by some countries, particularly the countries where the majority of migrants have been arriving: Mediterranean countries and Hungary (European Commission, 2017d).

Health systems need to overcome economic constraints, estimate potential expenditure based on volume data and costs and most importantly focus on fair and equal access to healthcare for everyone. Part of the trouble is that collecting data is still at an embryonic stage. Still, member states have the competence to organize and finance health systems, funding research regarding the needs of different social groups.

Resolving the problems of vulnerable groups, including migrants and ethnic minorities, in all areas of life including housing, employment, and education, must be given more attention. Further action is needed, particularly the development of integrated policies at the national level to address the causes of health inequalities and more specifically the impact of current economic conditions on the migrants and ethnics minorities. Some recommendations on potential health reforms aiming to address these concerns are as follows:

More attention must be given to the new demands placed on hospitals and health centers brought about by changing demographics. Attention should focus on the areas with the highest percentage of refugees’ arrivals.

An adequate level of health financing must be assured, and scarce resources have to be allocated that take into attention the health needs of refugees and migrants.

Healthcare providers play a key role in reaching out to vulnerable groups. The use of immigrant doctors to deliver services in their own languages to immigrant groups, and the use of health mediators must be encouraged.

New training needs to be given to health workers ensuring that they are at best able to meet the health needs of refugees and migrants.

Close coordination between the healthcare institutions and the social care providers at all levels should be enhanced so that the wide array for socio-economic and cultural challenges that migrants face are addressed.

Hospitals must adapt to refugees and migrants needs.

The official documentations and protocols have to be translated to languages that are spoken by refugees and migrants in order to minimize insecurity and anxiety and identify immigrants’ actual needs.

The current situation finds many refugees and migrants located in camps. Primary care providers should be charged with acting as advocates, with health and social workers visiting the camps on a regular basis to provide preventive care, health promotion and education on hygiene.

Health family programs should be added to help immigrants successfully acclimate to their new homes.

National health systems should more directly target measures that would improve the health of migrants and ethnic minorities, but effective reforms cannot be achieved by the national governments acting alone. Collaboration across the EU in addressing the health issues linked to migration needs to be embraced. Integrated strategies are needed, but these must be secured into place at the local level, involving relevant organizations and stakeholders right down to the local governments. Those in positions of leadership and opinion-makers are most responsible for bringing attention and energy to the necessary reforms in this area, and partnerships between state authorities, patient organizations and civil society and health professionals. It is everyone’s responsibility, but everyone will benefit if we make a collective commitment to address these urgent health concerns.

Conclusions

Addressing the health needs of migrants and refugees is fundamental to the key principles of the EU regarding the freedom of movement and an abiding support for human rights. Member states are responsible for the provision of healthcare, but this provision needs to comply with the international commitments EU member states have signed. What is required is a spirit of solidarity and cooperation, a determination to take broader measures to integrate newly arrived people into the open European societies. Given the variety of approaches it might be appropriate to define major principles, base these on scientific evidence, and well consider the public health benefits brought about by ensuring the health of migrants, both for them and for the host populations.

The right to health for refugees and migrants needs to be much more widely recognized. EU member states need to be committed to improve the health status of refugees and migrants and these nations need support to reinforce their capabilities in this respect. The fundamental standards of health must always be honoured, for this is a basic right for all people.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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