Few groups of people face less welcome in the world today than migrants forced from their homes, whether by conflict, persecution, violence, poverty, climate change or other environmental degradation, or hopelessness — or often, a mix of these factors. They seek basic safety, freedom, and opportunity — what all of us have a right to, yet is often denied migrants. These denials include health services. Migrants and refugees (that is, individuals outside their county who are fleeing persecution) are routinely denied health benefits that countries provide citizens. Only a relative handful of countries provide health benefits to undocumented immigrants (often referred to as irregular migrants) on an equal basis as citizens.
This must end. The responsibility primarily falls on governments to extend health coverage to all, including migrants — whatever their legal status — and refugees. Yet part of the solution to this routine human rights violation is creating an international solidarity fund for migrant and refugee health rights to incentivize lower-income countries to, and facilitate their ability to, extend equal health coverage to their non-citizen populations.
Make no mistake. Under international law, discrimination against migrants with respect to their right to health (and other rights) is prohibited. The International Covenant on Economic, Social and Cultural Rights (ICESCR), the core international treaty guaranteeing the right to health, prohibits discrimination on grounds including “national or social origin” and “other status” (article 2(2)). The Committee on Economic, Social and Cultural Rights (CESCR), charged with monitoring the ICESCR, explains that “[t]he Covenant rights apply to everyone including non-nationals, such as refugees, asylum-seekers, stateless persons, migrant workers and victims of international trafficking, regardless of legal status and documentation” (CESCR, General Comment 20, at para. 30). A specific example the Committee offers is that undocumented children “have a right to receive education and access to adequate food and affordable health care.”
Fulfilling countries’ right to health obligations — much less their commitments to universal health coverage and that “no one will be left behind” under the Sustainable Development Goals — therefore requires that they extend health coverage to citizens and non-citizens, including undocumented immigrants, on an equal basis. Overall, there are about 258 million international migrants, about 3% of the world’s population, some of whom will already be covered through national health programs (or satisfied with their coverage through affordable private insurance). The International Organization of Migration estimates that in 2017, there were about 58 million irregular migrants (p. 46), less than 1% of the world’s population.
Many countries will be able to afford to extend coverage to all migrants. Yes, those who have the economic wherewithal may need to pay slightly higher taxes. Count me in. That is the nature of a society where we care about human rights — where we care about each other. And where, like in the United States, even undocumented migrants do receive emergency care, new costs will be accompanied by significant cost savings, as emergency care — much of which will be avoided if migrants receive preventative and other regular care — is especially expensive.
Some lower-income countries, though, with a far smaller tax base, already face considerable challenges and require international support to extend comprehensive, quality coverage to achieve “universal” health coverage even under the discriminatory norm of citizens only, or citizens and only a subset of immigrants. This is not an excuse for permitting discrimination — one person deserves coverage no less than another, citizen or not, because rights are about our being people, not citizens.
However, politically, governments may have trouble justifying to their voting (citizen) populations that they are including all immigrants, including those without documentation, in health coverage schemes — though I hope we arrive at the day when the norm of non-discrimination is strong enough that such inclusiveness becomes people’s expectations, even demand. Will this mean, they may ask, that it will take longer for us (citizens) to receive coverage? Will this mean fewer benefits, lower quality care for us (citizens)?
To facilitate governments in extending coverage to their entire populations, including immigrants regardless of their legal status in the country, higher-income countries should provide financial support (along with the additional financial support required as it is for lower-income countries to achieve universal health coverage under current approaches). Politically, with few high-income countries themselves achieving non-discriminatory health coverage, we might look to a fund spearheaded by the few wealthier countries that do extend health coverage to all their residents. Belgium, France, Switzerland, Portugal, the Netherlands, and Spain all do so (or at least come close, such as having short continuous residency requirements before irregular migrants are covered).
This fund might, in a sense, follow in the footsteps of a global health initiative that the Netherlands launched in 2017, what the Dutch Foreign Minister dubbed the She Decides global fundraising campaign, a response to the U.S. administration’s decision to broaden the scope of the global gag rule. Under that rule, the United States refuses to provide foreign assistance to international organizations that perform — or even discuss — abortion. At least nine other countries joined the Dutch-initiated effort, funding organizations that lost funding due to the U.S. administration’s policy.
Of course, the political climate regarding undocumented immigrants — and indeed serious human rights abuses against irregular migrants, as in Switzerland and the Netherlands — even in the countries that provide health care to undocumented immigrants without (or at least nearly without) discrimination will make it less likely that they will lead in helping bring the right to health to irregular migrants outside of their borders. If even one or two of these countries launched the fund, though, others might follow. Entities other than states could join in the effort as well, foundations and maybe even immigrant-friendly companies.
The fund might have another important benefit, besides facilitating lower-income countries that are inclined towards non-discriminatory treatment of immigrants. By participating countries demonstrating this heightened level of solidarity with undocumented immigrants, the participants in this fund would not only help bring greater public and political focus to the issue of health coverage for undocumented immigrants, but also perhaps shame and incentivize some countries into extending coverage to their own undocumented populations.
The question now is, will any of the countries that assert their commitment to human rights and non-discrimination — and even in this time when many countries are headed in the opposite direction, such countries do exist — put their policies and resources behind this commitment, and support the right to health for migrants and refugees everywhere — without any discrimination, whatsoever?