By Nyala Thompson Grunwald
Accessibility, affordability, acceptability. According to Yip-Ching Yu’s citation of the World Health Organisation, these are three key terms that -should- define healthcare in any situation, but more particularly so for those whose lives are being completely uprooted. Just in case this needs reiteration, proper care for a person’s physical, mental, sexual, emotional health is part of the fabric of society, and which should not, and cannot be withheld by capitalist values.
Healthcare is not a privilege to which one requires access, it is a necessity.
Therefore, using the term ‘accessibility’ as key to define the goals of clinical aid systems to migrants is/should be a temporary term, one that is only relevant while capitalist systems and values rule interactions between people. These values reduce any relief for migrants to purely transactional parameters. That is affordability. Legido-Quigley et al raise the issue that the core of all obstacles that migrants face when accessing healthcare are of a financial nature. What clinical services and medical treatments are available at a price or not determine what kind of healthcare migrant populations can avail of – insufficient, inadequate or rather “promotive, curative, preventative, rehabilitative”. This is acceptability.
But we’ve established that easy access to healthcare, free of cost, is a necessity, therefore acceptability goes beyond the above. Rather, acceptability refers to receiving treatment and care in ways that cater to one’s intersectionality. A person is a compound of cultures (I am not applying the colonial-prescribed definition of culture, here cultures refer to communities, identities, stories and experiences) articulated sensorily, cognitively that continuously define their person and body. Any person fabricates and occupies their own intersectional space, and this is essential to consider in any and all healthcare contexts.
Legally, there are distinct categories of migrants, and their access to social services of any kind depends on their status. I say legal to emphasise that these are nominations of a certain systemic lens. For purposes of clarity, the categories of migrants are as follows: irregular, regular, internal, asylum seeker, refugee, internally displaced migrants. Legally, statistically, these are the categories that structure the demographics of migrant populations. Following these legal nominations, the resources that are available – financial, social, medical – to migrants depend on the status in which they are classified:
“Legal entitlements to health services differ according to individual migration characteristics such as duration of stay, documentation status, and channel of entry”.
For instance, assigned female at birth migrants working in certain industries are more susceptible to economic, social, physical and mental forms of abuse, with less legal and medical protection against such harmful situations. How can the conditional access to healthcare services be justified? Minorities – systemic social and economic minorities mind you, not necessarily demographic minorities – are already at a forced disadvantage, and this is heightened by circumstances of migration.
In a further instantiation of the above quote, recently arrived migrants in Trinidad and Tobago have access to all medical centres and services at no cost, including maternity care and vaccinations. However, cancer treatments, treatments for chronic illnesses such as asthma, diabetes, depression…etc or testing and treatments for HIV/AIDS are not available. These services are not available for reasons of priority, distributing clinical services on an emergency basis, although this is not fully clarified on the United Nations Commissioner for Refugees infobase for migrant access to healthcare in Trinidad and Tobago. What is noteworthy here are not only the conditions – or lack thereof – to accessibility and affordability of healthcare for migrants but rather that there are more discrepancies and questions than answers, and this in every instantiation of organised healthcare for migrant access.
And I have time to read into this. What of those migrating, seeking to make a new home in another country for whatever reasons, accompanied by others with existing medical conditions? In need of certain clinical services? In an inherently unstable and uncertain situation, a person’s medical well-being and overall health, their very access to, affordability of and acceptability of must be secured.
Legido-Quigley et al’s article cited the commitment to universal health coverage reiterated by leaders across the world in 2015. This commitment was cited along with a commitment to sustainable development: “Universal health coverage is a guarantee that all people and communities can access high quality health services, while ensuring they are not exposed to financial hardship”. Two out of three goals stated – accessibility and affordability. The reality of this commitment is that its practical applications have not included all migrants, regardless of legal status. The barriers to enabling proper medical care to all relate to the networks within which healthcare services are embedded. Legality has already been mentioned, yet the organisation of medical services is intricately linked to issues of policy, economy, education, industry and more.
Hence the barriers to ensuring accessibility, affordability and acceptability of healthcare services stem from these networks. Legido-Quigley et al’s article posits that government legislation and policy is neither migrant inclusive nor collaborative between ministries. Furthermore, lack of funding – in staff, equipment, technology – impedes the provision of resources for healthcare services, in any country or across countries. It is worth noting that “the free movement of labour was the initial reason for implementing cross border care within the European Union”. While that is only one regional example, this demonstrates certain priorities, that healthcare is only worth securing collectively in exchange for labour and profit. Lastly, Legido-Quigley et al denote the insufficiency of cultural training and competence, removing valuable bridges to both the acceptability and accessibility of healthcare for migrant populations.
These are some of the barriers to realising whole accessibility, affordability and acceptability of healthcare for migrants. What are the solutions? Yip-Ching Yu suggests promoting intercultural pedagogy within staff training, to remedy the acceptability and comprehensive accessibility of medical and clinical services. Legido-Quigley et al argue for more inclusive policies across the board, in economic policy, social and political policy. Steps that, if taken, will effectively attack these challenges from the root, but is it enough? Both articles that this blog post draws heavily from are articles that analyse specific instantiations, in Asia and the European Union.
They have a global scope; however, they may not apply to the realities of all migrant populations. Here I would suggest that the key terms accessibility, affordability and acceptability are insufficient to encompass the something that needs to change. Those key terms, coined by the WHO in 2013, are vocabulary of accommodation, of borrowing on systemic negligence. Why not transfer these terms to the following: unequivocal, informed, motivated healthcare. Unequivocal in provision, mutually informed and dynamically motivated. The title of this blog post recalls the expression ‘shifting planes, shifting tides’: migrants live these perpetual shifts spatially, socially, economically, in so many ways that I cannot even begin to name.
Accessing healthcare as a migrant is itself a nameless struggle. So too is accessing healthcare as a non-white migrant, a migrant of any faith, a queer migrant, an assigned female migrant, a migrant who menstruates, a migrant of any ethnicity….and countless other cultures.
The intersectional space that each person embodies is amplified when that intersectionality moves, migrates.
Thus, medical environments must learn to shift, to motivate these realities unequivocally and informedly.
My thanks to David Turpin, volunteer with Feminitt Caribbean, for his valuable insight into this post.
References
Legido-Quigley Helena et al, ‘Healthcare is not Universal if Undocumented Migrants are not Included’, Migration and Health, The British Medical Journal 16/10/2019
International Organisation of Migration, https://www.iom.int/
United Nations Comissioner for Refugees, https://help.unhcr.org/trinidadandtobago/faqs/accessing-healthcare-in-trinidad-and-tobago/
‘Women on the Move: Migration, Care Work and Health’, Policy Brief, World Health Organisation Press 10/2017
Yip-Ching Yu Anny, ‘Health Care Access for Refugees and Migrants’, Health and Migration: A Collaborative Community, United Nations University Press 01/10/2019
Nyala Thompson Grunwald (she/her) is a Franco-Trinbagonian pannist, artivist with two bachelor’s in arts. Currently a postgraduate student based in London, Nyala’s research thus far focuses on decoloniality, and afrodiaspora in race, music, gender and culture.
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