Migrant diversity and determinants of health care access and use

Access to and use of health care are key determinants of health, and significantly contribute to individuals’ health outcomes in interaction with behavioural, biological, environmental, genetic, psycho-social and socio-economic factors. ¹ The current magnitude and diversity of global human mobility across and within country borders have considerable implications and challenges for policies and the provision of health care in migrant receiving contexts. ² In this issue of the journal, Saunders et al. ³ examine the utilisation of health care among international migrants to the United Kingdom in comparison with the UK-born population, through cross-sectional analysis of two recent nationally representative surveys, and encompassing a wide range of health care domains. They show that lower health care utilisation among migrants compared to the UK-born is evident in all domains except in inpatient maternity care, but was eliminated except in dental care after adjustment for sex, age and long-term health conditions. They also report that recent migrants were less likely to utilise health care than the UK-born, and that only in primary care did migrants’ utilisation rise to a level higher than among the UK-born, after around 25 years of residence in the UK.

Other studies too have pointed to ‘a healthy migrant effect’, that is the selective migration of younger and fitter people with better health outcomes and lower levels of health care use compared to receiving country populations, although it is important to take into account the diversity in migrant categories and their reasons for migration. ⁴ For instance asylum seekers or trafficked migrants experiencing trauma at various stages of the migration process are most likely to have different health needs than many economic migrants or students. Evidence suggests that initial favourable health circumstances among some migrant groups decline over time as a result of factors such as changes in health behaviour associated with the incidence of non-communicable diseases - for example diabetes, heart disease and stroke - as well as structural disadvantages affecting access to a healthy life style and living conditions in the receiving society. ⁵ Saunders et al.’s finding regarding increasing health care utilisation by migrants’ length of residence in the UK supports such evidence.

Lower levels of health care utilisation, particularly among recent migrants, as shown by Saunders et al., may also derive from direct barriers to accessing health care among some migrant groups. There is qualitative research evidence that these barriers include inadequate or confusing information on health care systems and settings that is available to new migrants, insufficient interpreting and translation support for migrants with limited fluency in English, lack of affordable and reliable transport to reach health care settings in economically deprived areas where many recent migrants live, and cultural insensitivity among some frontline health care practitioners. ⁶ Migrants in vulnerable circumstances that increase susceptibility to poor health, including those with insecure immigration status such as visa overstayers, refused asylum seekers, and migrants who have been trafficked into the UK, are particularly disadvantaged in these respects. They are also the migrants who are most likely to be excluded from national household-based surveys.

Further, increasing stratification of the right to health care through recent changes in immigration rules in the UK means that some National Health Service (NHS) services, such as inpatient and outpatient hospital care, cannot be accessed free of charge by migrant groups deemed as not eligible. ⁷ These charging regulations and the sharing of patient details between government departments for the purpose of immigration enforcement, have deterred some migrants, including pregnant women, from seeking health care, with negative consequences for their health outcomes. ⁸ Currently, access to primary health care remains free for all irrespective of immigration status, but there is evidence that some general practices refuse to register patients if they lack documentation on identity or residence. ⁹ While data on emergency care utilisation was not included in the surveys analysed, as Saunders et al. also note there is evidence of increased attendance at hospital accident and emergency departments by migrants, as emergency care is excluded from charging on public health or humanitarian grounds. ¹⁰

The present Covid-19 pandemic has brought barriers to health care access and use for some categories of migrants even more sharply into focus in the UK and in other countries. Even though in the UK testing and treatment for the virus are exempt from charging, including for undocumented migrants, there is evidence that the hostile environment resulting from requirements for proving entitlement to both free NHS care and crisis economic support funds in general is disproportionately affecting vulnerable migrants at present. ¹¹ Moving forward and beyond the pandemic, utilisation of linked NHS and administrative data at national and local levels, together with results from large scale surveys such as presented by Saunders et al., in a way that explores the diversity of characteristics and health needs of migrants, are imperative for effective policies and practices towards providing equitable health care and positive health outcomes for all population groups.