Three Country Assessment on Health Screening of Migrant Workers and its Impact on Right to Health and Right to WorkPresentation on the Key Findings and Recommendations

Manuel da Quinta23 July 2014AIDS 2014, Melbourne , Australia

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Presentation outlineAssessment scope and methodologyLimitationsBackground and rationaleFindings and analysisDiscussion Recommendations

Assessment Scope and

Methodology Focus on the perspectives and experience of sending countries:• Cambodia, Indonesia and the Philippines

Data gathering and analysis using triangulation

Support of in-country NGO partners of CARAM Asia and ILO country offices

Assessment findings and recommendations to be used for a planned dialogue between ASEAN and the Arab States in 2014.

To develop an understanding of the health screening of

migrant workers in

ASEAN and its impact on their

right to work and right to

health throughout the migration cycle.

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LimitationsOnly included documented migrant workers

Mostly focused on land-based migrants

Limited time for field investigation, restricting a comprehensive and detailed analysis of different sectors and all existing programs

5A case against mandatory health screening of migrants Violates migrants’ integrity, dignity and private life, especially if performed without the latter's informed consent

Violates right to work

Ineffective public health measure• costly• discriminatory• undermines public health efforts for HIV prevention and treatment • passive and people less likely to be in-charge of their health• can create a false sense of national security

Ineffective determinant of health status and/or ability to perform work

• the worker may have a false negative test due to the window period• a negative test speaks little as there can be an exposure after the test itself• having a past or current health condition does not necessarily mean NOT being

able to perform work

International Labor Standard on HIV and AIDSILO Recommendation 200, 2010

Emphasis on Migrants

Prohibits mandatory testing, screening or disclosure, prohibits discrimination in or exclusion from migration on the basis of real or perceived HIV status

Migrants should have universal access to HIV education, information, treatment, care and support in countries concerned

Provides for training, safety instructions and any necessary guidance to be given in a clear and accessible manner

Ensure a safe and healthy work environment for migrant workers

all measures apply to countries of origin, countries of transit and countries of destination

Universal access to HIV prevention, treatment, care and support services for all workers working under all forms or arrangements, and at all workplaces, regardless of legal status or occupation

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Finding 1: Pre-departure medical screening is mandatory, including for HIV

Certification: “Fit to Work”

The most significant - if not - the ONLY determining factor, for overseas employment eligibility in all three countries

Other Categories of Certification“Temporarily Unfit”“Unfit”

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Receiving Countries

General Phyiscal Examination**

TB Skin Disease Hepatitis HIV VDRL TPHA Sugar

Drug test/Amphetamine

Pregnancy Chest X-ray Lung Heart

FunctionGastro Instentinal/Abdomen

Renal Function

Liver Function

Pyschaiartic Ilness/Mental Health

Eplisepy Other Sending Countries

Korea Cambodia

Thailand Cambodia

Japan Cambodia

Kuwait IndonesiaGCC states (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates) requiring GAMCA certification

India, Sri Lanka, Pakistan, Bangladesh, Philippines, Nepal, Indonesia and other Asian Countries

Brunei DurussalamMalaysia

Taiwan Indonesia

Hongkong IndonesiaSingapore Indonesia

Unclear

Required

At the time of the study, Ministry of Labor and Vocational Training was conducting mandatory testing of HIV for Cambodian Migrants going to Thailand. The director of the Dept. of Occupational Saftey and Health confirmed that the test was still required as of October 2013

Mandatory Medical Tests*

* These tests are still required as of November 2013 based on the hiring policy and/or Ministrial policy of the host country**General Physical examination includes Height, eyes, ears, weight, blood pressure and pulse check up and Blood GroupType Not required

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Finding 1.1: HIV counseling and testing procedures are not informative or confidential In the FGDs, referring to the pre-departure medical screeningOnly few aware of the medical tests

taken

No one received pre-test counseling and limited post-test counseling for positive migrants

No one received their test results personally (Cambodia & Indonesia)

Detailed medical test results including for HIV were disclosed to the recruiting agencies (in all countries)

“…our recruiting agencies told us that we had to take some medical tests. We were taken in groups to a health center. There they took our blood, urine, checked our eyes, did our x-ray, measured our weight and height. They also checked for head-lice. Then a doctor (lady) took us to a separate room, told us to be naked and checked our breasts, stomach, buttocks for skin disease. We were also told to take out our family planning implants (before going abroad)…they said that because of the heavy work we would have to do in the destination country, we needed to take it out…” a female migrant, Indonesia

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Finding 2: Minimal referral for “unfit to work” migrants

Test results at designated

medical screening facilities Recruiting

agencies

Unfit FitPermane

nt

Revealed without details

and told to get help

Temporary

Health service referral

Treatment , certification

and deployment

Migrants receive results Authenticatio

n of results and

certification at DoH

Unfit

Referred for

confirmatory tests

and other medical

treatment

Fit

Permanent

Temporary

Medical certification by the testing

facilities

Philippines

Cambodia & Indonesia

Training and

deployment

Referral from the recruiting agency

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Finding 3: Lost to follow-up a challenge among permanent “unfit to work” migrantsLimited information available

on a seemingly sizeable population

Lack of established

mechanisms to follow-up and provide services

NGOs providing limited support including for HIV service referral

Health service delivery model for migrant workers not adequately designed and implemented

Of est. 800-1000 migrant workers tested every month for GCC countries, approx. 5-10% test “unfit for work” (ASSAADAH, 2013) -- anecdotal

PASEI deploys about 70% of the total OFWs from the Philippines. Among whom, approx. 20% receive “unfit to work” certification on health grounds (PASEI 2013) -- anecdotal

Of the 13,072 Cambodian migrants sent to Thailand between 2012-Oct 2013, 380 (2.9%) “unfit to work” (undisclosed recruiting agency Cambodia)

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Unfit Cases by Disease Category by a GAMCA certified clinic in Jakarta

Jan. Feb. Mar. April May June July August

HBsAg positive 24 37 12 28 27 25 22 16 191anti-HCV positive 1 1 1 2 0 0 3 1 9anti-HIV positive 3 1 2 3 4 1 3 3 20TB or abnormal X-Ray 161 113 88 150 166 68 57 65 868VDRL-TPHA positive 16 17 17 22 24 19 17 10 142Positive Pregnancy test 8 13 4 10 8 3 6 8 60Diabetes Mellitus 6 18 7 7 13 7 6 3 67Hypertension 15 9 8 13 17 13 4 10 89Total 234 209 139 235 259 136 118 116 1446

Total Unfit Cases by Disease Category

Number of Unfit Cases per Month for Six Month Period (Jan-Aug 2013) Total

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Finding 4: Varied deportation processes but most compromise human rightsGCC deportations very traumatic and inhumane as reported by migrantsQuarantined and detained if “unfit” on health grounds (4-30 days)

Not allowed contacts, communication or documentsAutomatic cancellation of work permit & visaVery little social or legal support (Philippine OFWs supported by their embassies)

Need employer “exit-visa” Many handcuffed to the airport

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Discussion and analysisThe need for migrant-sensitive Health Systems Strengthening…

Laws and policies related to migration, and health screening are not harmonized

Low health system capacity to respond to migrants’ health needs

Regulating and monitoring health facilities for quality assurance a challenge

Integrated Health service delivery to meet a broad range of health needs, ensure quality and scale of services provided

Testing and rejecting/deportation VS testing and treating – a missed opportunity

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2. Sending countries’ practice on mandatory medical screening including for HIV

Changes must begin at home! Need clear guidelines and evidence-based service delivery model

for medical screening among migrants including for HIV (e.g. VCT or PICT, integrated or stand-alone, etc.)

Must ensure that medical screening practices are evidence informed and human-rights based (i.e. information, counseling, referral for services, etc.)

Must strengthen quality assurance and regulatory mechanism of medical screening facilities

Diplomatic approaches and political interventions needed to address mandatory health screening, related travel restrictions and consequences for employment abroad

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3. Host country imposed medical screening guidelines and standards

Health screening guidelines and standards, such as of GAMCA and FOMEMA not specific enough

Lack of scientific to decide “fit to work” or “unfit to work” – need better indicators

“…any spots or marks on one’s chest x-ray is labeled as TB, including marks and scars not even related to TB, from past infections due to pneumonia and so, one is “unfit to work…”GMACA certified medical screening facility in Manila

Guidelines and standards on the testing protocols unclear (such as for provision of information, VCT, service , referral services, etc.)

Clinics do not follow national protocols and guidelines – making it difficult to standardize and regulate

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4. Enhancing a corporate social responsible among recruiting agencies, a potential opportunity?

Recruiting agencies largely problematic for migrant workers

Turning “enemies” into allies…

Need to build their knowledge and awareness on the human rights of migrant workers and the positive roles they can play for public health and social benefits

Retain information on migrants throughout the migration cycle

Potential opportunity to develop tri-partite partnership between CSOs, recruiting agencies and medical screening facilities to provide referral services and follow-up support for health and social services

Better cooperation and coordination among recruiting agencies and government agencies to establish mechanism to report on migrants’ health issues

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Draft Recommendations• Develop and implement in-country and cross-border mechanisms at

national, provincial and community levels to better understand and monitor migrant health concerns for strengthening health service delivery

• Ensure outright prohibition of mandatory testing of HIV in sending countries.

• Remove existing laws and policies that require or allow testing to be used as a screening tool for employment eligibility

• Develop protective laws and policies which facilitate migrant workers’ access to needed health and other services including for redress in case of rights violation

• Ensure that testing practices mandatorily comply with international guidelines for health screening, including for HIV testing. As a basic minimum standard, it should: • Protect confidentiality• Strengthen counselling• Link to related services and referrals• Ensure safety & reliability of test

Focus on “unfit to work” and deportee migrants

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• Conduct operational research to better understand effective health service delivery for migrant workers, particularly to reach the vulnerable migrant workers including deportees and “unfit to work” migrant workers.

• Adopt a strict regulatory practice and strengthen monitoring mechanism to ensure quality assurance and adherence of standards of operation and testing standards and procedures by the medical screening facilities.

• Make health awareness, health promotion education including for HIV prevention and treatment and SGBV mandatory for all pre-departure orientation, trainings and briefings during medical screening.

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• Mobilize migrant community and empower them to:• Provide legal counselling and services to migrant workers in their native

language concerning work safety and workers’ rights, protection of those rights and job opportunities

• Ensure that all migrants, regardless of their migration status and nationality, work in sectors and occupation that meets labour standards, including those related to occupational health and safety

• Leverage on testing as an opportunity to provide health information and services for migrant workers with health problems, especially “unfit to work” and “permanently unfit to work” including those deported on health grounds. More specifically:

• Establish mechanism to ensure a contact-chain is maintained between medical screening facilities and migrant workers for confidential pre and post-test counselling and service referral

• Develop and implement mechanism for information sharing regarding epidemiological data collected by the medical screening and recruitment agencies with relevant government institutions and NGOs. This must be done without disclosing the names and details of the migrant workers

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• Develop and implement a referral mechanism between recruitment agencies and NGOs providing services to direct and refer migrant workers with health problems to needed services

• Support NGOs to set up outreach and follow-up mechanisms to ensure access to early treatment and other services for unfit to work migrant workers

• Sensitize and train recruitment agencies on migrant workers’ health, safety, and well-being as well as on their rights. Mobilize champion recruitment agencies including those with pre-existing mission of social-corporate responsibilities to facilitate migrant workers’ access to information and services regarding health and well-being.

• Review and address the shortfalls of medical screening guidelines imposed by host-countries and develop more scientific and evidence based approaches to interpret the findings of medical screening and decide which migrant workers are fit to work. Sending countries can negotiate the setting up of joint committee to review such guidelines with receiving countries and make the required changes.

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• Receiving countries must stop detention and deportation of migrant workers on health grounds.

• Strengthen support mechanisms and referral for responding to migrants’ health and social protection needs within host countries. This includes:

• Increase the number of attachés and strengthen the involvement of embassies in dispute settlement in host countries

• Make information regarding available services in host countries widely available for prospective and current migrants

• Establish online peer-support groups in the host countries for enhancing community resilience and lesson sharing

• Increase resource allocation for addressing migrant health issues, including for HIV prevention and treatment, through countries own internal resources as well as by efforts to mobilize donors from varied sectors such as through the GF mechanism for health.

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Acknowledgement and AppreciationMigrant workers

Key informant interviews from relevant dept. of ministries of health and labor/migration

Recruiting agenciesAchieve PhilippinesCARAM Cambodia

Solidaritas Perempuan (SP) in IndonesiaCARAM Asia

JUNIMA including the UN regional and country offices of – ILO, UNAIDS and UNDPAnd all of you present here today!

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THANK YOU