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Climate Change Panel Seeks To Improve Communication, Open Doors To Private Sector 


Illegal Migrant Status and the Littleness of the European Health System

Values such as respect for human rights, human dignity and equality are at the heart of European Union (EU) mission. Yet, even a patchy survey shows that the healthcare system built to assist illegal immigrants does not couple with these concepts since each country gets its own system. Owing to the lack of a shared agenda, across the board improvement perspectives still lie beyond the EU grasp


by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

Illegal Migrant Status and the Littleness of the European Health System


Illegal immigration is hot topic today. Indeed, the future of  Shengen Agreement is in the politicians’ hands now that a flow of exhausted immigrants requiring health assistance crosses the EU borders every day. Is the European healthcare system able to cope with such an unprecedented emergency?

Illegal migrants are at most risk of health problems since, as a result of their financial fragility and illegal status, their rights and privileges are far below those enjoyed by the regular citizens. Under these circumstances, they are denied access to countries’ health assistance system because they are not entitled to the rights granted by national laws. Social benefits for them are usually limited to basic medical assistance in emergency situations, whereas poverty and hardship prevent them from accessing private healthcare.

The current dynamics of external migration to EU incorporate many health risks including epidemic diseases, difficulties related to pregnancy, vulnerability to HIV and AIDS, as well as children’s illnesses and psychological problems.

Some countries in the EU including France, Belgium, Italy and Spain have put systems in place to cope with these issues.

For instance, the Italian government has set up a scheme whereby foreign citizens who are illegally present in Italy are given an “STP” (Temporarily Present Foreigner) six month-valid, though renewable, identification code entailing some benefits. Illegal migrants who cannot afford to fork full ticket expenses out of pocket will only pay a fraction. Otherwise, by signing a “declaration of indigence”, which is valid for six months, they can be exempted from the entire amount duty. The “declaration” entitles them to services such as first level health, emergency and pregnancy services, as well as services for exempted diseases and aging or disabling conditions.

“Aide Médicale de l’État” is the scheme provided by France: one year validity and renewable, it allows undocumented migrants to access health care free of charge.

In the face of this, other countries that do not provide the same health care protection, such as Sweden or Denmark, presently are among the main final destinations of immigrants.

In Sweden, the entitlement of undocumented migrants to health care is highly restricted. However, since July 2013, undocumented adults have the right to subsidized care for conditions requiring urgent medical attention, whereas undocumented children are given the same rights as Swedish residents: a step forward since illegal migrants were previously entitled to unsubsidized emergency care only, except for former asylum seeking children, who had the same rights as Swedish residents.

In Denmark the situation is even worse. In fact, asylum seekers and foreign nationals without legal residence are not covered by the national health insurance system. Only children benefit from the health care service on equal footing with regular residents. Actually, while the “Danish Immigration Service” is tasked with caring for illegal migrants, it only covers pain relief treatments or interventions that cannot be postponed.

The reported country cases above shed some light on the main EU problem, namely the lack of any relevant shared agenda and common operational strategy. Article 35 of the Charter of Fundamental Rights of the European Union leaves the establishment of rules for access to health care to national legislators by stating that “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all the Union’s policies and activities”.

What’s more, at country level marked  differences exist in the way regions and municipalities implement existing national legislation with the effect that irregular migrants are not granted equal enjoyment from health care services throughout the country.

In this regard, the local authorities of Stockholm city in Sweden and of Bremen, Cologne, and Frankfurt cities in Germany have chosen a more friendly health policy towards irregular migrants as compared to the rest of either countries. For example, the municipal administrations of Bremen, Cologne and Frankfurt have set up dispensaries for medical consultations to illegal immigrants and basic services as outpatient centers providing free medical examinations without restrictions. The patients are only charged the service cost in proportion to their income if they have one. In case of serious illness, the medical officers may opt for the patient admission to specialist hospitals involved in the project, and/or check whether it would be the case for an asylum grant on health reasons. The structures in question are also collaborating with local NGOs that seek to offer complementary services to health care assistance.

Overall, the fragmented system highlighted here is inconsistent with the main values flaunted by the EU institutions. Expressions such as respect for human dignity and human rights, including the rights of persons belonging to minorities, or equality and human dignity, represent the core values supporting the EU legitimacy. Unfortunately, these concepts risk to lose their integrity when they collide with political and financial interests and a narrow-minded mindset.

All the European member states must find a common solution to the illegal migration issue. Meanwhile, the EU leadership should firmly bear in mind that if Europe lacks the structural strength to host overflowing masses of people, the respect for human rights and equality should never be forgotten.


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Race is on to develop Zika vaccine but tests on pregnant women raise concern 

How and when will we get to a Zika vaccine? 

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The Launch of an International Institute for Primary Health Care in Ethiopia: Revitalizing ‘Health for All’ through the Primary Health Care Approach 

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‘Neoliberal Epidemics’ in Global Context

Conditionalities attached to loans from the World Bank and IMF were among the key negative influences  on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied. Best available evidence suggests that this 'neoliberal epidemics' era is not over. In the future, neoliberalism is likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy


by Ted Schrecker, professor of Global Health PolicyClare Bambra

and Clare Bambra, professor of Public Health Geography

Durham University, England

‘Neoliberal Epidemics’ in Global Context


An aid-funded Canadian team that sought to rebuild Tanzania’s health system on a pittance wrote in 2004 that: ‘The era of structural adjustment may be over, but the effects of earlier damage continue to cast a long shadow’.   The length of that shadow became apparent a decade later, when the Ebola outbreak in Africa in 2014 dramatised the fragile state of national health systems – attributed by commentators writing in The Lancet and Foreign Policy to the damage done by long periods of expenditure restraint mandated by the International Monetary Fund.  (The IMF, predictably, contested these claims.)  The specifics of the Ebola response aside, conditionalities attached to loans from the World Bank and IMF were among the key influences on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied, and the best available evidence is that the era was not over at least circa 2007.

Structural adjustment programmes involved a relatively standard neoliberal package of privatisation, deregulation, reduced subsidies for consumer goods including food, economic restructuring that prioritised export sectors, and what would now be called austerity – demanded in exchange for loans that enabled countries to reschedule their external debts.  At least as early as 1987, a major UNICEF study warned of the destructive human consequences.  Similar consequences are now being experienced in Greece in the context of analogous demands by the ‘troika’ of the IMF, the European Commission and the European Central Bank.  As in the 1980s and the 1990s, primary beneficiaries are commercial banks that hold the country’s debts.  (The ‘debt crisis’ that ushered in the era of structural adjustment became part of the US foreign policy agenda in the early 1980s mainly because of threats to several of the country’s major banks.)

In a book published last year, we used the term ‘neoliberal epidemics’ to describe the spread of overweight and obesity, austerity (expenditure cutbacks), inequality and insecurity in the United States and the United Kingdom – the large, high-income countries that have travelled farthest down the road of neoliberal or ‘market fundamentalist’ policies.  These are epidemics in the sense that they exist on such a scale and have spread so quickly across time and space that if they involved pathogens they would be seen as of epidemic proportions; indeed, references to the epidemic of overweight and obesity are now commonplace.  They are neoliberal in that they are direct consequences of neoliberal economic and social policies.

The example of structural adjustment programmes and their contemporary European analogues shows that in global context, the concept of neoliberal epidemics is even more relevant.  In another example, references to the epidemic of overweight and obesity, now convincingly linked to the neoliberal transformation of food systems and the increasing unaffordability of healthy diets, have become commonplace in the high-income world.  The connection is evident, as well, in many low- and middle-income countries where rapid transitions to a diet that is conducive to obesity have been connected with trade liberalisation and the growth of foreign investors, to the point where one article described a pattern of ‘exporting obesity’ from the United States to Mexico, notably in the form of (subsidised) high-fructose corn syrup for use in fizzy drinks.  Predictably, the prevalence of obesity in the two countries is now comparable.  Neoliberalism is also implicated in the spread of precarious and insecure work, which is increasingly recognised as a social determinant of (ill) health.  One author, Guy Standing, has argued that it has generated a new global class – the precariat – as ‘flexible’ labour market regimes become the price of attracting and retaining foreign investment.  In an especially striking illustration of the consequences, in 2012 The New York Times revealed that not long before a disastrous fire at a Bangladeshi garment factory, Walmart had resisted an initiative to improve fire safety in such factories.

In the future, neoliberal epidemics are likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy.  William Robinson, a leader in the emerging field of critical globalisation studies, pointed this out more than a decade ago when he argued the need to move from a ‘territorial’ to a ‘social cartography’  in understanding development.  More recently, social theorist Nancy Fraser has made a similar point, noting not only the spread of austerity programmes to Europe but also phenomena like ‘the terrible impoverishment of the old industrial cities, of the global north, which are starting to look more and more like the periphery’, and the fact that ‘the conditions of working class people in the global north are converging with the conditions of the global south’.  On one estimate, 1.4 million UK workers are on zero-hours contracts, which do not guarantee them even a single hour of work in a given week.  Trends like this help to explain the widening of health inequalities in the UK, such that in the small municipality of Stockton-on-Tees where one of us (TS) lives and works, the 17-year gap in male life expectancy between the most and least deprived neighbourhoods is comparable to the difference in national average male life expectancy between the UK and Senegal.

This analysis is not a counsel of despair, but it does suggest that the success of efforts to fight neoliberal epidemics and reduce health inequalities will depend on blurring boundaries: between the global and local frames of reference, and between public health practice and the politics of health.  This last blurring means a return to the wisdom of Rudolf Virchow, to the effect that ‘medicine is a social science, and politics is nothing else but medicine on a large scale’.  As Martin McKee and colleagues wrote in a 2012 commentary on the failure of austerity policies, ‘Virchow’s words are as relevant today as they ever were’.  Understanding how to translate that insight into political action will require the development of a comparative political science of health inequalities – a critically important project that remains in its infancy.

Ensuring Health Care Equity in Ethiopia

Although Ethiopia’s health care is grounded in equity principles and health outcomes have shown considerable improvements during the past 20 years, substantial challenges persist. Indeed, though equal access to essential health services for those in equal need has been largely ensured, equal utilization of health care for them and equal health outcomes have not been attained yet. Systematic disparities in the burden of diseases, service uptake and health outcomes prevail between communities, particularly arising from differences in places of residence. In the face of this, a range of diverse initiatives have been taken by the Ministry of Health to mend the chasm in health service uptake and health outcomes between the regions

Taye Balcha

by Taye Tolera Balcha

Head, Office of the State Minister

Ministry of Health, Ethiopia

Ensuring Health Care Equity in Ethiopia


With a little less than 100 million people, Ethiopia is the second most populous country in Africa. About 80% of Ethiopia’s population live in the rural part of the country. While an overwhelming majority of rural residents live on agriculture, 10% of the population living in the Eastern and South Eastern parts of the country are pastoralists. Generally, pastoralist parts of the country are sparsely populated. Ethiopia is one of the fastest growing economies in the world. The World Bank predicts that Ethiopia will be a middle-income country by 2025.

Health outcomes in Ethiopia have shown considerable improvements during the past 20 years. A sharp rise in the life expectancy at birth from 46.7 in 1990 to 65 years to date shows a significant leap in the aggregate picture. The child mortality rate, which had been 204 per 1,000 live births in 1990 dropped to 62 per 1,000 live births in 2014. Between 1990 and 2014, maternal mortality declined by 72%. Both international and national targets set for health have been met. In particular, Ethiopia achieved all health Millennium Development Goals (MDGs).

Ethiopia chalks up its success to an equity-based primary health care. In 2003, the country introduced a signature primary health care- Health Extension Programme (HEP). By design, the HEP combines the overall capacity of the country with community contexts and needs. With low cost for the nation and prominent community participation, a health post has been constructed in each village across the country. To address social and basic health intervention demands of the community, an army of female community health workers – Health Extension Workers (HEWs) – have been recruited, trained and assigned to the health posts. Paid by the government, the chief responsibility of the HEWs (usually 2 or more at each health post) is to provide culture-sensitive package of health promotion, disease prevention and essential curative health services. Interventions targeting maternal and child conditions and infectious diseases stand out in the set of services provided at primary health care level. The recruitment of HEWs from the community they eventually serve is instrumental in providing sustained, community-desired and individually-preferred services at each health post. For instance, HEWs can provide oral contraceptive pills, injectables or implants for family planning depending on the women’s choice.

The HEP is particularly an enormous success in the agrarian parts of the country. Over the past decade, the HEWs have graduated millions of model households (those who utilize all community level health interventions they are eligible for). As a consequence, improvement in health literacy and an upsurge in community-based service uptake have been reported. Recently, the HEWs trained women development groups in each village to advance the community engagement in and ownership of their health. This resulted in organized communities that demand and enthusiastically contribute to improved essential health services. This further catalysed the rising service uptake including utilization of family planning, skilled birth attendance, immunization, nutrition services and construction and use of improved latrines. The effectiveness of initiatives of health promotion and disease prevention targeting major communicable diseases including tuberculosis, HIV and malaria has shown considerable improvement. Bolstered by the growing impacts of the community in improving health, Ethiopia has planned to transition the concept of model households to model villages. Similar to model households, to be categorized as model villages, entire member residents of the village should utilize all key community level health interventions. Additionally, model villages should be represented in health facility governance at each level of care to foster accountability and continuous quality improvement. The metrics used in model village evaluation and categorization largely focus on an individual member of the village rather than aggregate village or district picture to eliminate disparities in service utilization within a specific community.

Higher levels of health care have received adequate emphasis. Thousands of health centres have been constructed across the country, one for 25,000 people or less. Owing to the rising public expectations, massive construction of primary hospitals is underway for some time to achieve the target of 1 primary hospital for 100,000 population. Equity-centred distributions of zonal and specialized referral hospitals complete the spectrum of health care in the country. Concurrent investment has been made into the development of human resources for health. The number of public medical schools has jumped from a paltry 3 in 2004 to 34 in 2015. Currently, more than 3,000 medical doctors graduate annually compared with about one hundred, eventually overworked doctors a decade ago. Likewise, training of other cadres including specialized nurses, mid-wives, integrated emergency surgical officers and public health officers has been fast-tracked to fully staff the growing number of health facilities. The construction of health facilities and assignment of health staff to each region in the country is guided by an equity-sensitive ratio, nationally endorsed by Ethiopia’s House of Federation for allocation of all types of resources.

Although Ethiopia’s health care is grounded in equity principles, substantial challenges persist. Most notably, equal access to essential health services for those in equal need has been largely ensured. Yet, equal utilization of health care for those in equal need and equal health outcomes have not been attained. Systematic disparities in the burden of diseases, service uptake and health outcomes prevail between communities, particularly arising from differences in places of residence. For instance, in 2012, the HIV prevalence ranges from 0.9% in the Southern Nations, Nationalities and Peoples region (SNNPR) to 6.5% in Gambella region. The proportion of children younger than one year who received their full immunizations in 2015 is 34% and 98% in Ethiopia Somali region and SNNPR, respectively. In 2011, child mortality rate substantially varied between 53 per 1,000 live births in Addis Ababa and 169 per 1,000 live births in Benishangul Gumuz region. In general, the two pastoralist regions in the Eastern part of the country (Afar and Ethiopia Somali) and the two regions in the western part of the country (Gambella and Benishangul Gumuz) are worse-off in service uptake and health outcomes than every other region in the country.

The current geographical inequities in health care in Ethiopia is mainly attributed to inadequate implementation capacity and deficiencies in the health systems in the pastoralist and in the regions located in the extreme west of the country. The Ministry of Health has taken a range of diverse initiatives to mend the avoidable chasm in health service uptake and health outcomes between the regions.  The ratios of HEWs, health posts and health centres to the population have been adjusted upward to address the remaining barriers in regards to access to essential health services. Mobile clinics are providing essential clinical services in selected districts of the pastoralist regions along pasture and water points for their cattle to tailor the health service to the lifestyle of the community, and thus boost the service uptake. To strengthen the health systems in these 4 regions, a Health Systems Special Support Directorate is designated at the Ministry. The directorate provides an intensive systems support to these regions. Furthermore, the Ministry is currently hiring dozens of senior public health specialists to be based at each region and galvanize the health systems, and thus the performance of each health facility. Salaried by the Ministry, a mix of public health and clinical officers are also placed at selected districts to beef up the implementation capacities of the districts. Differential support in regards to ambulance services, an array of public health and clinical interventions including maternal and child health and major communicable diseases (malaria, tuberculosis and HIV) prevention and control, and heightened overall support has been provided to these regions.

Ethiopia’s Health Sector Transformation Plan (2015-2020) boldly states that all health indicators in these regions should rise to the level of the national average within the next 5 years. These targets are overly ambitious. Equally notable, the commitment of the government to holding down health inequities arising from differences from personal or community characteristics is unprecedented. More specifically, the health sector has embarked on multi-layer equity insuring interventions: authentic community engagement in health in all regions, provision of tailored health services and health systems overhaul in the societies and geographies left behind. The 5 year health sector transformation plan also highlights the need for progressive evaluations of barriers to healthy behaviours and subsequent implementation of equity-targeted social, public health and clinical interventions. Socio-economic factors fostering service uptake will be assessed and encouraged regularly; a detailed, right-based scrutiny will be performed on unreached individuals and populations; and bi-annual status of inequality report will be produced and disseminated. Innovations that could improve the health status in the four regions will be stimulated; and innovations with promise for population level impact will be transitioned to investment at regional scale. Most importantly, the government just transitioned community-based health insurance (targeting citizens engaged in informal sector) from a learning phase to a national scheme. Employees of formal sector are planned to be fully covered in 2016 through social health insurance.  The two insurance schemes are expected to completely remove financial barriers to health care and enhance care seeking behaviour.

In conclusion, Ethiopia is determined to ensure equitable access to essential health services. This can be done through intensifying differential systems support to the group left behind. The local health leadership in the regions and the general health workers should fully comprehend the prevailing equity challenges and work towards rooting them out. Initiatives explicitly targeting the unreached populations will be implemented. The sheer power of partnership with community to ensure equitable access to good health should be recognized. The new initiatives including health insurance schemes will contribute to attaining better health for all citizens living in all geographies of Ethiopia.