Journal Club - Faculty of Public Health, KKU
Journal club – Faculty of Public Health, Khon Kaen University
March 2020 (2563)
Universal Health Coverage – beyond globalization the individual counts
To improve the access to health care providers through the Universal Health Care Coverage should help to meet one aspect of the 3rd Sustainable Development Goal. Despite enabling those requiring health care to approach the health care system, additional constrains should not be overlooked. The problem is that the expectations and need of health care seekers are difficult to meet, as a study about African migrants in the USA illustrates.
The Sustainable Development Goals (SDGs) is the backbone of the United Nations (UN) global policy to improve the lives of people all over the world in all important aspects. Major health issues are listed under Goal 3 of the SDGs which includes among other health systems and funding. The ‘Universal Health Coverage’ might be considered as one measure to achieve that goal globally. There is nothing wrong with attempting to increase substantially access to the health delivery system on a global basis. Yet the ultimate goal should be that the system as such is fit enough to care for the individual needs of those approaching the health care providers. But there is no automatism to assure that, and especially one particular group of health care seekers, that are the migrants, might face very specific constraints, since they are forced to adjust themselves into a social environment, they are very often not familiar with.
Migration and health care coverage
Migration is a pressing global problem. It is a conversely discussed political issue and it involves human beings with real needs to assure their existence. As far as health care is concerned the World Health Organization suggested a Global Action Plan for ‘safe, orderly and regular migration’. Thailand responded, as far as health care is concerned, to such a plan for quite some time already, since the country had to deal with migration for long. Presently the country’s migrant policy is linked to the ‘Universal Health Coverage’ (1). The main concern is the health of the labor force from neighboring countries such as Lao PDR, Cambodia and Myanmar. From the more than 3 million people involved, 90% of them are from the above-mentioned countries. The scheme still is facing some constraints especially when it comes to ‘undocumented migrants’, but more or less the access to the health delivery seems to be generally secured. But what about the health care experiences and need of the migrants? It might well be that in issuing health insurance cards to migrant workers and their children and to ‘all non-Thai populations (except for tourists and Caucasian foreigners)’ will provide a sufficient access to health care for all the migrant groups as mentioned above, however, those migrants from different South East Asian countries might have different expectation and needs, in comparison to the Thai population, as far as health care for the individual patient is concerned. A very telling example about the significance of this question has been published recently in exploring health care difficulties of modern-day African immigrants into the United States of America (USA), which turned out to be quite different from ‘US borne black citizen’ in the states (2).
Health differences of migrants from Africa compared to African Americans
Africans not born and migrated to the USA more recently increased from the year 2000 up to now for 41% and is estimated to be 5% of the total US population. The majority with 36% are from West Africa, 29% from Eastern- and 17% from Northern Africa. A quite relatively high proportion of those migrants are from Nigeria and Ethiopia. The migrants, who were allowed to enter the country by either joining family members already in the country, claiming to be refugees because of the political situation in their home country or because of enrolling into educational institutions. Other opportunities to enter the USA were to follow the ‘diversity lottery program’ or be accepted into the labor force for instance as medical doctors or nurses. Many African migrants are in need of health care because of war and poverty in their countries of origin (3, 4). Despite of the necessity to know more about the health care experiences of this group of migrants, there is a substantial lack of information. Relevant research is lacking and as far as some investigations had been undertaken, all the black people within the US had been considered as the same group. In other countries, African migrants are even more inadequately considered together with people originated from Latin America and Asia. However, there are distinct differences between the groups and this also is true when comparing migrants from Africa with African Americans, i.e. those borne in the USA and being citizen of the country. So, for instance, the birth weight of babies born to African-born mothers are higher in comparison to the babies from African American mothers (5), and risk factors for cardiovascular diseases, diabetes mellitus and hypertension are lower in Africa borne migrants compared to their American borne counterparts (6).
To summarize experiences about health care and needs of this the particular group of migrants, a review of the relevant literature was published as ‘qualitative’ information based on questionnaires answered by the migrants. The papers selected, written in English, covered the time of publishing between 1980 to 2016, and contained the responses of ‘non-refugee’ African immigrants in the USA. From 1,392 papers identified in a first attempt, only 14 were finally found meeting the selection criteria. The main topics of interest voiced were cultural influences, standing against a basic understanding of what health care is all about in the USA and the subsequent negative experiences the migrants reported.
Culture and spirituality
The indifference of modern western medicine towards traditional beliefs of the migrants, their religiosity and spirituality erode the trust in the health care system in the USA in addition to the high cost it involves to use it. Serious diseases such as HIV and cancer are accounted for as ‘the result of spiritual forces’. For Muslims and Christian alike health and diseases are determined by God. In case of treatment helps than this is not because of the ability of the system in particular of the physicians but through ‘divine’ assistance. The underlying attitude is certain submissiveness in one’s fate. One even might shy away from unnecessary consultations to the medical doctor in that this might ‘lead to unwanted diagnosis’. Routine health checks, i.e. cancer screening, might consider a waste of time and an unnecessary cost item. In fact, even hypothetical questions are refused to answer in the belief that ‘words and thoughts’ could influence one’s life. As far as routine measures for treatment are concerned, traditional medicine and herbs are common remedies in the countries of origin and the migrants miss the use of these options by the physicians.
Once the disease had stricken, such as HIV the patient tries not to recognize it, mainly because of fear of stigmatization within their social environment. This attitude might also apply, not only in the case of sexually transmitted diseases but also for cancer, which might perceive as a curse. HIV and cancer are ‘death sentences and shameful’ so that family and friends start to keep a distance to the diseased. Mental problems, such as depression also is subjected to stigma. The belief is that such a disorder befalls only white people in their surroundings. Likewise, other psychiatric diseases such as bipolar disorders are classified as ‘madness’. Stigmatization only affects the individual but also might be extended to the family of the diseased person.
Communication problems, in the paper termed as ‘linguistic discordance’, are additional barriers the migrants face in their approach to the health care system as well. This includes the inability of migrants to express their health needs. This is not only due to problems with the English language but also the difficulty to name certain cultural perceptions in English. The respondents also remarked that health care staff reacted negatively to them as Africans and others complained that caregivers didn’t care to ask them ‘about their cultural or religious beliefs’. Others mentioned that advice given was not useful, i.e. recommending changes in the diet without giving hints how that could be done in view of the African staple food.
 or manic depression as it was named formerly
Conclusion and comment
The publication reviewed here concentrates on migrants and the cultural differences as one of the major barriers to fully benefit from the health care system of their new home country. The example here demonstrates that providing the right to participate in using the health care system does not necessarily mean that the service of the system, despite all good intentions, will be really beneficial for the individual. This includes, in this particular case the observation, that despite ethnic similarities, here considering African American and African migrants, not only differ in their health risk factors but also to a great extend in their cultural attitudes. That also might be true when considering different southeast Asian populations, or even when comparing population groups of different regions within one and the same country. There are distinct regional cultural differences even within Thailand, determining a variation in expectations and needs. One just only have to think about the patient from the rural areas of the Northeast and the medical doctor brought up and trained in Bangkok, and the difficulties they might have in making themselves understood. That might not only be due to the language barrier caused by the inability of the medical doctor to follow the northeastern dialect. Similar problems might evolve when dealing with patients from neighboring countries. Patients from Lao PDR might have fewer problems to make themselves understood in using the Thai language in comparison with patients from Myanmar, but certain cultural differences might be of importance as well. More investigation as the once reported here should be worthwhile and helpful to further enhance the medical system of Thailand as well.
1. Suphanchaimat R, Kosiyaporn, H., Limwattanayingyong, A. Migrant policies in Thailand in the light of the Universal Health Coverage: Evolution and remaining challenges. Outbreak, Surveillance, Investigation & Response (OSIR) Journal. 2019;12(2):7.
2. Omenka OI, Watson DP, Hendrie HC. Understanding the healthcare experiences and needs of African immigrants in the United States: a scoping review. BMC Public Health. 2020;20(1):27.
3. Chaumba J. Health status, use of health care resources, and treatment strategies of Ethiopian and Nigerian immigrants in the United States. Soc Work Health Care. 2011;50(6):466-81.
4. Venters H, Gany F. African immigrant health. J Immigr Minor Health. 2011;13(2):333-44.
5. David RJ, Collins JW, Jr. Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997;337(17):1209-14.
6. Sewali B, Harcourt N, Everson-Rose SA, Leduc RE, Osman S, Allen ML, et al. Prevalence of cardiovascular risk factors across six African Immigrant Groups in Minnesota. BMC Public Health. 2015;15:411.