Three Country Assessment on Health Screening of
Migrant Workers and its Impact on Right to Health
and Right to Work
Presentation on the Key Findings and Recommendations
Manuel da Quinta
23 July 2014
AIDS 2014, Melbourne , Australia
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Presentation outline
Assessment scope and methodology
Limitations
Background and rationale
Findings and analysis
Discussion
Recommendations
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Assessment
Scope and
Methodology
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.
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.
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Limitations
Only 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
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A 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 Emphasis on Migrants
AIDS
ILO Recommendation Prohibits mandatory testing, screening or
disclosure, prohibits discrimination in or
200, 2010
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
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
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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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Mandatory Medical Tests*
Receiving
Countries
General
P hyiscal
TB
E xamination* *
S kin
Disease
Drug
Gastro
Chest
Heart
Renal
Liver
Hepatitis HIV V DRL T P HA S ugar test/Ampheta P regnancy
Lung
Instentinal/
X -ray
Function
Function Function
mine
Abdomen
P yschaiartic
Ilness/M ental E plisepy Other
Health
Sending
Countries
Korea
Cambodia
Thailand
Cambodia
Japan
Cambodia
Kuwait
GCC states
(Bahrain,
Kuwait, Oman,
Qatar, Saudi
Arabia and the
United Arab
Emirates)
requiring
GAMCA
certification
Brunei
Durussalam
Malaysia
Indonesia
Taiwan
Indonesia
Hongkong
Indonesia
Singapore
Indonesia
India, Sri
Lanka,
Pakistan,
Bangladesh,
Philippines,
Nepal,
Indonesia and
other Asian
Countries
Unclear
* These tests are still required as of November 2013 based on the hiring policy and/or Ministrial policy of the host
country
Required
**General Physical examination includes Height, eyes, ears, weight, blood pressure and pulse check up and Blood
GroupType
Not 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
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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 screening
Only 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 headlice. 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
Referral from the
recruiting agency
Philippines
Migrants
receive results
Unfit
Permanent
Fit
Medical certification by
the testing facilities
Test results at
designated medical
screening facilities
Recruiting
agencies
Authentication of
results and
certification at
DoH
Unfit
Fit
Temporary
Temporary
Referred for
confirmatory
tests and
other
medical
treatment
Cambodia & Indonesia
Health
service
referral
Treatment ,
certification
and
deployment
Permanent
Revealed
without
details and
told to get
help
Training
and
deployment
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Finding 3: Lost to follow-up a challenge among
permanent “unfit to work” migrants
Limited information available on a
seemingly sizeable population
Lack of established mechanisms
 Of est. 800-1000 migrant workers
tested every month for GCC countries,
approx. 5-10% test “unfit for work”
(ASSAADAH, 2013) -- anecdotal
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
 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
Number of Unfit Cases per Month for Six Month Period (Jan-Aug
2013)
Total Unfit Cases by Disease Category
Total
Jan. Feb. Mar. April May June July August
HBsAg positive
anti-HCV positive
anti-HIV positive
TB or abnormal X-Ray
VDRL-TPHA positive
Positive Pregnancy test
Diabetes Mellitus
Hypertension
Total
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1
3
161
16
8
6
15
234
37
1
1
113
17
13
18
9
209
12
1
2
88
17
4
7
8
139
28
2
3
150
22
10
7
13
235
27
0
4
166
24
8
13
17
259
25 22 16
0 3
1
1 3
3
68 57 65
19 17 10
3 6
8
7 6
3
13 4 10
136 118 116
191
9
20
868
142
60
67
89
1446
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Finding 4: Varied deportation processes but most
compromise human rights
GCC deportations very traumatic and inhumane as reported by
migrants
Quarantined and detained if “unfit” on health grounds (4-30
days)
Not allowed contacts, communication or documents
Automatic cancellation of work permit & visa
Very 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 analysis
The 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
Focus on “unfit to work”
• Ensure safety & reliability of test
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 Appreciation
Migrant workers
Key informant interviews from relevant dept. of ministries of
health and labor/migration
Recruiting agencies
Achieve Philippines
CARAM Cambodia
Solidaritas Perempuan (SP) in Indonesia
CARAM Asia
JUNIMA including the UN regional and country offices of –
ILO, UNAIDS and UNDP
And all of you present here today!
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THANK YOU