Toward global health equity:
addressing social determinants of
health for stateless populations
Rebecca Yang, MPH
APHA 2022
Disclosures
Research conducted in collaboration with the Institute on Statelessness and
Inclusion, OBMICA, Phiren Amenca, Nubian Rights Forum, and Development and
Justice Initiative.
Funded by the Harvard Humanitarian Initiative Spark Grant. No conflicts of
interest to disclose.
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APHA 2022
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Statelessness refers to individuals “who are
not considered as nationals by any state under
the operation of its law”.
INTRODUCTION
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Estimated 12 million stateless individuals
Those who cannot or have not yet obtained birth
registration are considered at risk of
statelessness, because birth registration is
essential for proof of nationality in most
naturalization processes.
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Limited evidence suggests that lacking nationality results
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in inability to access care.
Health disparities for stateless communities worsened
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BACKGROUND
during the pandemic.
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Further research is needed to more clearly advocate for
the right to health for stateless populations and coordinate
with international organizations and national policymakers.
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CASE CONTEXTS
DOMINICAN REPUBLIC
MONTENEGRO
KENYA
INDIA
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METHODOLOGY
PREPARATION
Background research,
development of semistructured interview
questions.
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DATA COLLECTION
ANALYSIS
Interviews conducted on-site in Kenya
and Montenegro, remotely in DR and
India.
Key informants: community leaders,
NGOs, public health officials, healthcare
providers.
Qualitative coding for
distillation of common themes.
Development of
recommendations at health
systems & policy level.
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METHODOLOGY
PREPARATION
Background research,
development of semistructured interview
questions.
11/07/2 02 2
DATA COLLECTION
ANALYSIS
Interviews conducted on-site in Kenya
and Montenegro, remotely in DR and
India.
Key informants: community leaders,
NGOs, public health officials, healthcare
providers.
Qualitative coding for
distillation of common themes.
Development of
recommendations at health
systems & policy level.
A P HA 2 02 2
8
METHODOLOGY
PREPARATION
Background research,
development of semistructured interview
questions.
11/07/2 02 2
DATA COLLECTION
ANALYSIS
Interviews conducted on-site in Kenya
and Montenegro, remotely in DR and
India.
Key informants: community leaders,
NGOs, public health officials, healthcare
providers.
Qualitative coding for
distillation of common themes.
Development of
recommendations at health
systems & policy level.
A P HA 2 02 2
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BACKGROUND
METHODS
Citizenship stripping for tens of thousands of Dominicans of
Meetings conducted with OBMICA remotely.
Haitian descent.
1 NGO representative, 1 formerly stateless individual
Increased border securitization, hospital raids, arbitrary
detentions, and deportations of pregnant women of Haitian
DOMINICAN REPUBLIC
descent.
FINDINGS
Anti-Haitian rhetoric worsened during pandemic. Narrative of
Pandemic related restrictions disproportionately impacted
“pregnant Haitian women” overburdening Dominican health
economic livelihoods of stateless communities.
systems.
Exclusion from nationwide vaccination plan contributed to
Priority treatment for Dominican nationals over those of Haitian
vaccine hesitancy and misinformation spread.
descent.
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BACKGROUND
METHODS
Primarily Roma who never registered, or those with expired
In collaboration with Phiren Amenca on-site in Podgorica and
refugee status (granted after fall of Yugoslavia and Kosovo
Budva, Montenegro
wars of 1999).
3 NGO representatives, 2 formerly stateless individuals, 2 health
Historical Roma discrimination with low levels of social
providers, 3 MoH officials
MONTENEGRO
integration and educational attainment .
FINDINGS
Free health services for Montenegrin nationals only. Medical
Continuity of care is difficult because stateless patients cannot
exams can be free depending on physician discretion and
be registered in EMRs .
informal connections. Costs of medications, lab tests are
rarely waived.
Many Roma prefer home births , which are more difficult to prove
birth registration.
Contradicting information about true health service costs, but
Gender based violence is underreported.
cost is the main barrier to health access .
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METHODS
Nubians were not recognized as Kenyan nationals at time of
In collaboration with Nubian Rights Forum on-site in Nairobi,
independence.
Kenya
Increasing Islamophobia results in more stringent vetting
5 NGO representatives, 2 formerly stateless individuals, 1 health
procedures for Nubians.
provider, 1 public health official
KENYA
BACKGROUND
FINDINGS
Infectious diarrhea and typhoid are most common communicable
Pandemic related restrictions disproportionately impacted
diseases. Hypertension is most common NCD.
economic livelihoods of stateless communities.
Contradicting information about true health service costs. Many
Gender based violence increased during the pandemic.
with documents do not have health insurance due to cost .
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Preference for private health facilities despite increased cost.
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BACKGROUND
METHODS
The 2019 NRC update in Assam excluded 1.9 million individuals of
Conducted in collaboration with Development and Justice Initiative
mostly Bengali ethnicity. The 2019 Citizenship Amendment Act
remotely
excluded Muslims from citizenship pathways. Arbitrary detention
1 NGO representative
INDIA
of Bengalis.
FINDINGS
Individuals excluded from NRC spend most resources on legal
Malnutrition and lack of menstrual hygiene in younger population.
services for reinstating nationality, with little left for health.
Increased suicide rate for denationalized individuals.
Aadhar digital identification is not required to access
Reports of poor healthcare access at detention centers .
healthcare services. Preference for private health facilities due
Muslim Bengalis blamed for the pandemic – “CoronaJihad”
to accessibility and lenient documentation requirements.
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KEY THEMES
Discrimination and stigmatization of stateless communities adversely
impact health.
There are significant health access barriers for individuals without
proper documentation.
Deficiencies in monitoring true COVID impacts make it difficult to assess health
impacts on stateless populations.
Pandemic restrictions disproportionately impacted economic
livelihoods of stateless populations.
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Health as a human right for stateless individuals
cannot be viewed in isolation from its upstream
determinants. For many, poverty and legal processes
for birth registration are significant upstream
CONCLUSIONS
take precedence over health.
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Resolving statelessness is a key prerequisite for
addressing social determinants of health and
advancing health equity for stateless populations.
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RECOMMENDATIONS
Restructure existing funding mechanisms to incentivize long term, structural investments in health for stateless
populations and those at risk of statelessness.
Simplify processes for birth registration to increase access to health, employment, and social protections for
those at risk of statelessness.
Invest in more robust civil registration and vital statistics systems (CRVS) to accurately capture disease burden in
stateless populations.
Revise recipient identification processes for social protection and humanitarian assistance for inclusion of stateless
and unregistered populations.
Solicit input from community leaders and frontline representatives when drafting health policies and interventions that
impact stateless populations.
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