1. Manuel da Quinta 23 July 2014 AIDS 2014, Melbourne , Australia
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
This Study was commissioned by JUNIMA, the Joint UN Initiative Migration, Health, HIV in Asia with the support from ILO and UNAIDS Regional Offices in Bangkok
Manuel da Quinta
23 July 2014
AIDS 2014, Melbourne , Australia

2. Presentation outline Assessment scope and methodology Limitations
Background and rationale
Findings and analysis
Discussion
Recommendations

3. Assessment Scope and Methodology
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.
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.
FGD with prospective, returnee and deportee migrants.
Triangulation included:
Literature review
FGDs with migrant workers: conducted in local language
Key informant interviews: recruiting agencies, health testing centers, Ministries dealing with labor and migration as well as health issues
Key partners for country consultations
Achieve in the Philippines
CARAM Cambodia and
Solidaritas Perempuan (SP) in Indonesia

4. 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
On the third point, mention that there may be many small scale pilot programs, which were not necessarily reviewed due to time constraint. During the course of study, it was also revealed that ministry of interior have a significant role in dispute settlement, deportation, etc. but due to time-constraints, they were not contacted.
Mention that the findings can not be used to make broad generalization but do paint a overall picture of the situation and response

5. 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
Since the main aim of the mandatory testing is often to deny employment, it violates the right to work, especially of those whose medical care is perceived to be to costly or to keep “disease” away from the host country through misguided perceptions and practices on moral grounds of certain communities”
Also some health concerns such as HIV, STI is spread by specific behaviors rather than the mere presence of carriers and since the virus already is present in virtually every country, so an ineffective public health measure
UNAIDS, ILO recommend voluntary HIV testing – in the context of confidentiality, informed consent and pre- and post-test counseling – as opposed to mandatory HIV testing of workers, whether individuals are seeking work within
their countries of origin or abroad, to preserve their human rights and promote public health

6. International Labor Standard on HIV and AIDS ILO Recommendation 200, 2010
Emphasis on Migrants
Prohibits mandatory testing, screening or disclosure, prohibits discrimination in or 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
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
ILO Recommendation 200, is the only International legal instrument aiming to strengthen universal access to HIV prevention, treatment, care and support services for all workers including migrants regardless of legal status or their occupation

7. 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”
medical screening/health screening/health testing is interchangeably used – called differently in different countries/context
HIV positive in the “UNFIT” category
Medical tests examples:
Drug test Blood- VDRL (viral syphilis) , HIV, Hep. B and C, STI, TB, Jaundice, diabetes, Urine- sugar, pregnancy, hypertension
Cholesterol, Blood pressure, Chest X-ray, Asthma, Epilepsy, Skin diseases
Mental illness – depression, psychiatric disorder, amnesia, pregnancy, etc.

8. This table shows all the mandatory health screening tests demanded from receiving countries from sending countries.
Thailand does not require mandatory testing on HIV but has a poor implementation of the law.

9. 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 head-lice. 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
…although NONE of the migrants could name a complete list of medical tests they undergo
Post counseling – migrants had varying perspective on receiving post counseling services. In the Philippines, only few said post counseling was provided for those with positive sero-prevalence result and were referred for confirmatory test

10. Finding 2: Minimal referral for “unfit to work” migrants
Referral from the recruiting agency
Cambodia & Indonesia
Philippines
Medical certification by the testing facilities
Test results at designated medical screening facilities
Migrants receive results
Recruiting agencies
Authentication of results and certification at DoH
Unfit
Fit
Unfit
Fit
Permanent
Temporary
Temporary
Permanent
Training and deployment
Referred for confirmatory tests and other medical treatment
This slide shows the Health Screening and referral flow chart for migrants.
DoH Bureau of Health Facilities and Services in Philippines authenticate medical exam report and medical certification of OFWs while in Cam and Indo, medical certification done by the health screening facilities, no need for authentication.
In Cambodia and Indonesia, migrants do not have a direct contact with the health screening facilities. This hampers their access to services, and first hand information they need. Although two health screening facility, one run by the government and the other GAMKA clinic in Indonesia reported providing referral services for the Unfit workers, but this depended on migrant workers coming back to the clinic. There was no formal mechanism to call the migrant workers as the results were first provided to the recruiting agencies, who then informed the migrants that they are unfit.
Philippines
A clear guidelines and an established mechanism for referral
“unfit to work” referred to health services for confirmatory tests and treatment
Especially true for temporary “unfit to work” (i.e. TB)
Referral made by medical screening facilities
Referral generally happens in the form of information sharing about where to go
No accompanied referral or follow-up mechanism, a challenge
Cambodia and Indonesia
No guidelines or established mechanisms for referral services
No referral services” for unfit migrants
Migrants DO NOT receive their test results so don’t know if they are fit or unfit until informed by recruiting agencies
This limits referral from the medical screening centers
If temporarily “unfit’, migrants referred for treatment by recruiting agency
If permanently “unfit”, no referral, no information sharing from the recruiting agency “…we don’t have the money to make referral…we simply tell them that they are “unfit” and tell them to go to NGO for treatment...” a recruiting agency in Cambodia.
HOWEVER
Cambodia -- dept. of occupational health and safety health screening center include referral and treatment for “unfit migrants” but loss to follow-up a concern
Indonesia – one of the certified health testing center reported providing accompanied referral in case of HIV confirmatory tests
Health service referral
Revealed without details and told to get help
Treatment , certification and deployment

11. 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 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
Of est migrant workers tested every month for GCC countries, approx. 5-10% test “unfit for work” (ASSAADAH, 2013) -- anecdotal
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)
First of all, there are a relatively big size of permanently “unfit to work” migrants on health grounds although data/information is patchy
Permanent are like ghost population with limited and inadequate access to services. They reported hopelessness, anxiety about employment opportunities, and face isolation, stigma and discrimination.
Employment, access to ARV and regular HIV treatment related follow-up services are some of the key issues facing this group of migrants.

12. Unfit Cases by Disease Category by a GAMCA certified clinic in Jakarta
GAMCA ( Gulf Approved Medical Centers’ Association) certified and government accredited clinic in Jakarta shows that out of migrant workers tested at this clinic between the period of January to August 2013, a total of 1446 were certified “unfit to work”.

13. 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
UNFIT for Work = DEPORTATION (except from Thailand)
Fit to work certification required for issuance and renewal of work visa and residence permit in all three countries
If unfit, deported from GCC and Malaysia…
Experience of deportation from Thailand slightly different
Deportation on a case by case basis, depending on the employer
Sometimes, possible to look for other jobs even when visa/work permit cancelled
Deportation not as inhumane- employer brings the migrant to the border and are “handed-over” to recruiting agencies and/or NGO transitional facilities
Discriminatory practice against pregnant women
But migrants NOT informed about the reason for their deportation
Work permit/visa usually the first thing to be cancelled

14. 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
First of all, in all three countries, there are well-established departments within Ministries of Health, Labor and Migration as well as Ministry of Interior with responsible for migrant welfare including for health and social protection. And there seem to be many relevant and important initiatives in the pipeline.
But the existing policies and programs are different and similar in many aspects.
In the Philippines, there seem to be established mechanism and thus, a better coordination among partners such as health care providers, recruiting agencies and government agencies to monitor and report on migrants health screening.
In Indonesia and the Philippines, there is a SOP for health screening among migrants but in Cambodia, there is no such guidance.
In the Philippines, an administrative order No. 1 series of states that medical screening, especially for HIV, VDRL and Hep. B of all OFWs based on the requirement of the destination country. This is despite a national law that states HIV test should be voluntary and confidential. The caveat is that overseas are not protected under the national law.
In Indonesia, 2007 HIV testing guidelines for migrants clearly laid out that HIV testing should be voluntary and confidential. However, in 2011, a presidential decree#64, article 3 has been passed obliging health screening (mental and physical and additional tests required by the third party) of migrant workers. Although the same decree, article 22 regulates health screening to be conducted using VCT or PICT (provider initiated counseling and testing) unless in medical emergencies, for police and armed forces and request from authority based on national laws and regulations.
Cambodia follows ILO Recommendation 200, and there is a law that prohibits mandatory testing but in reality HIV test for migrants is mandatory

15. Changes must begin at home!
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
A great deal of negative impact of mandatory testing: loss of overseas employment opportunity, fear and isolation driving migrants away from required health services, and violation of their fundamental rights to integrity, dignity, privacy and information

16. 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
Under the hiring policies of GCC states – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, foreign workers from the India, Srilanka, Pakistan, Bangladesh, Philippines, Nepal, Indonesia other Asian countries are required to pass the medical tests conducted only by GAMCA ( GCC Approved Medical Centers’ Association ) clinics. GAMCA - G.C.C Approved Medical Centers' Association
Foreign workers medical screening experts (FOMEMA)

17. 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
Yes, in many parts of Asia, we have heard that the recruiting agencies are problematic for migrants. They need to be sensitized on human rights issues of migrant workers.
In a way, they are like the police and law-enforcement for key population interventions, traditionally seen as “enemies’ rather than allies…
They have the potential to be the “critical enablers” of safe migration program!
This study revealed there is an urgent need to develop a strategic partners with at least “interested” “open” “champion” recruiting agencies to address some of the abuses, exploitation and health concerns facing migrants.

18. 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
Ensure safety & reliability of test
Focus on “unfit to work” and deportee migrants

19. 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.

20. 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

21. 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.

22. 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.

23. 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!

24. THANK YOU