The Health of Migrant Children. Migrant Children. Personal Background Interest in health: Meningococcal Meningitis (1997) MBBS (Hons(

Transcription

1 The Health of Migrant Children Phoebe Williams MSc Global Health Science candidate CUHK & The University of Oxford Personal Background Interest in health: Meningococcal Meningitis (1997) MBBS (Hons( Hons) - The University of Sydney Interest in children: Therapist for children with autism ( ) 2004) Interest in migration: Link to development (B Com) Link to psychology (B Psyc) Travel through Africa, Europe, India, and work in the refugee clinic at The Children s s Hospital at Westmead (Sydney University) Migration - The Facts Migration is one of the defining global issues of the 21st century - more people on the move today than ever before in history Currently 192m people live outside their place of birth (3% of world population) Current annual growth rate of migrants: 2.9% Migration is an essential and inevitable component of the economic and social life of every State. Orderly and properly managed migration can be beneficial for both individuals and societies yet few countries manage migration effectively International Organisation for Migration, Overall Research 1. A Systematic Review on the Health of Migrant Children 2. A research document addressing the unique issue of the health of internal migrant children in China Systematic Review Study Protocol Population: : Children aged 0-18yrs0 Intervention: : Migration Outcome: : Child Health Study Types: : Observational analytical 1

2 Systematic Review Methods Search Strategy: Searches conducted in Pubmed, Embase, Global Health, Psycinfo & The Cochrane library database Studies published English only Search Strategy Key words & MeSH headings (italics) used in literature search: Population Child Child* Infant Student Adolescent Intervention Migrant* Migration Migrants Immigr* Emmigr* Outcome Child health Mental Health Psychosocial Factors Socioeconomic Factors Malnutrition Health service utilisation Drug use Teenage Pregnancy Vacc* Immunis* Immuniz* Infectious Diseas* Obes* Stunt* Supplementary Search Strategy: China Report Grey literature: Conference proceedings, briefing papers, and reports Newspaper articles Discussions with key informants in major migrant cities in China Google search engine Conference proceedings Systematic Review Inclusion Criteria: Observational studies which examine a health impact of migration on children (0-18yrs) in contrast to a comparison population Exclusion Criteria: Languages other than English Research lacking a clear comparison group 2

3 Anticipated Results Synthesis: Systematic Review Review of study quality Report findings in a tabulated form, with a narrative synthesis Numerous heterogeneous health outcomes anticipated; which will be discussed separately Where possible, a meta-analysis analysis will be performed for sub-groups (with accompanying chi-squared test for heterogeneity) Generalised Findings to Date Almost all literature worldwide examines the effect of international migration, comparing health outcomes to resident children (not( native children) Migrant children face significant barriers in accessing health care systems Compared to resident children, migrant children have: Lower immunisation rates - higher rates of infectious disease Lower rates of breast-feeding Increased prevalence of atopy Increased prevalence of dental caries Increased prevalence of accidents and injuries Increased prevalence of lead poisoning Poorer maternal and neonatal health outcomes & indices Higher rates of obesity; micronutrient deficiencies Higher rates of teenage pregnancy & abortion Higher rates of psychological ill-health: anxiety, depression, substance abuse, criminal behaviour These effects diminish with time (degree of acculturation) Internal Migration Part Two Internal Migration in China Can rural mothers or parents improve their child s s survival by leaving their villages and settling in towns and cities Where modern health and social services, employment opportunities, housing, stable food supplies, and increased information on child health care are more generally available? Internal Migration Or, does it increase the risk of health issues to both migrant and urban children? Do migrant families settle in crowded slums where basic household facilities essential for good health are unavailable? Are they vulnerable to new diseases; separated from their support network; unable to breast feed due to employment? Types of Child Migrants 1. Those who accompany their families to towns and cities 2. Those who are born after their parents migrate (in the city) 3. Left behind children Does they bring new infectious diseases to the city which spread, and place increased demand on already-stretched urban resources? 3

4 The impact of rural-urban urban migration on child survival Brockerhoff (1994) - Research on 17 nations between 1986 and 1990 found: Risk of child mortality is increased if: Single moves occur over great distances or long durations Migration is involuntary (eg( IDPs) Children are exposed to new epidemiological environments Child survival depends on: The conditions underlying migration; The reasons for the move; Intended duration of stay The receptivity of existing urban populations and authorities Migrants need to be able to achieve sufficient economic success to attain the modern housing facilities and access to effective health services that influence a child s s survival changes Overall, increased risk of mortality in short-term term; decreased risk of child mortality over long-term Main Determinants of Child Survival during Rural-urban urban Migration Stage of Migration Pre-Migration (Selection factors of migrants in rural areas) During Migration -Exposure to new disease -Abrupt termination of breast-feeding or change in intensity -Temporary unavailability of health services, support network, adequate shelter and nutrition -Physical hardship of move -Temporary loss of income Post-Migration Negative impacts -Loss of entitlement to basic needs (food, income, shelter) (eg IDPs) -Exposure to new diseases -Language and cultural barriers -Barriers to accessing housing, employment, health services -Psychological stress of adjustment -Crowded living conditions -Discrimination by local authorities in service provision -Depleted savings (due to need to send remittances) Positive impacts -Maternal Schooling -Occupational skills -Wealth / income -Postponement of marriage or childbearing in women -Improved housing facilities and structure -Increased access to / use of modern health services -Increased disposable income -Gradual adoption of modern reproductive and child-rearing practices -Access to social support networks The Unique Situation of China Population: 1.3bn Population <18yrs: 342m Rapidly urbanising: 42% (projected 70% by 2050) Migrant Population of 225m (2008): The World s largest ever peacetime migration Increased from 26m (1988) Estimated to reach 300m by 2015 Viewed as a life stage (chuqu - to go out ) between school and marriage Almost all are of child-bearing age Responsible for 16% of China s total GDP growth Migrant Children: 20m Invisible children: lack of registration and access to social services Left Behind Children: 20m Where do internal migrants in China come from? >10m people: Sichuan, Henan >5m: Anhui, Jiangsu, Shandong, Hubei, Hunan, Guangdong, Guangxi Where do they go to? 70% to the East 16% to the West 14% to the Centre Drivers of Internal Migration in China Marked spatial inequality: Urban-rural income disparity Surplus agricultural labour Economic Reform: The disintegration of state-owned enterprises (SOEs) & emergence of private enterprise with the marketisation of the economy Diversification from a previously largely agrarian economy Poverty Reduction: Even more beneficial than international migration Average US$545 per migrant sent to local communities through remittances per year An economy characterised as capital scarce but labour abundant Huang Ping & Frank N. Pieke,, 2003: China Migration Country Report. DFID Research Report, May

5 Rural-urban urban income inequality The 1978 Economic Reforms (Gaige Kaifang - reform and opening up to the outside world) Transition from central planning to a market economy Including the marketisation of health care: Halt to state provision of medical insurance Introduction of user fees Privisation of health care Followed the Soviet Model of development: high priority on heavy industry to speed industrialisation Has resulted in remarkable economic growth (average 9%pa) which has diminished poverty; yet gains have been highly inequitable Liu et al. (1999). Equity in Health & Health Care: The Chinese Experience. Soc Sci Med 49, (1999). Increased demand for industry & construction sectors in the cities As strict migration control was relaxed, there was incentive for surplus rural population to migrate to cities to find work Rural China Prior to the Economic Reforms Rural population had guaranteed access to land (organised into communes) - no landless poor Strong cooperative Medical System The Economic Reforms resulted in: The decollectivisation of Agriculture: Emergence of the Household Responsibility System: : rural households given individual responsibility for agricultural production (shift from communal production) Resulted in a vast surplus of rural labour Collapse of the Cooperative Medical Insurance The Unique Situation of China The Hukou (Household Registration System) Established 1950s: To control rural to urban migration? Or as part of a larger system established to provide the state with w means and information that can be used for securing social and political order? Linked entitlements to food and services to place of residence Characterises citizens by two classifications: 1. Residential location 2. Socioeconomic eligibility: Agricultural / Non-Agricultural The Hukou Polarised rural and urban China: Urban residents: Provided with state-provided employment, benefits Since 1984, the hukou has become more lenient to encourage restricted, regulated, orderly rural labour migration However, it still plays an important role in defining entitlements to state aid and access to key services (education and health care) Hukou transfer is (almost) impossible. Instead, a person staying outside their locality >3months must apply for temporary residence registration The Hukou The nation s s social welfare & health care systems are still based on the hukou Rural migrants and their children are unable to transfer their hukou status to cities, so therefore suffer from very limited access to social services, including health care Compounded by the known health risks associated with migration, the result is poorer health outcomes in migrants and their children China is unique in that: It has the largest worldwide population of internal migrants Its rural and urban citizens, and their access to social services, s, are divided by the hukou 5

6 The One Child Policy Introduced in 1980s Incentives, close monitoring and bureaucratic system of pregnancy approval Migrant communities, lacking household registration in cities, often have more than one child Further disincentive for registration and accessing social service schemes Recent laws mandated by Central Government will result in increasing fines Another unique issue to China Health Care Reforms : 1980: Universal access to affordable health care Insurance schemes in place: LIS, GIS, collective responsibility in rural sector As part of the economic reforms, health care financing was also revised: Increased co-payments Decline in insurance coverage Rapid increase in cost of health care The Result: Widening health gap between rural and urban residents Increased IMR inequality: between rural and urban areas rose from 1.67 (1981) to 2.93 (1993) Currently ranked 188th (/191) worldwide for health equality China s s Achievements in Health Mid 20th Century: Positive outlier on the Preston Curve Excellent public health services Focus on preventative medicine Improvements in Child Health (U5MR): 118 per 1,000 (1970) 45 per 1,000 (1990) 22 per 1,000 (2007) Demographics & Living Circumstances Male: 66%; Female: 33% Age composition: 70% are aged 16-35yrs Education level: majority have completed 9 years in school Distribution by industry: The Three D s: D Dirty, Dangerous, Degrading 30%: Manufacturing 23%: Construction 18% Street vendors 13%: Social services 8%: Food & restaurant business 82% work 7 days per week 33% work more than 11 hours per day Average wage: 780Y (58% of average wage of urban workers) Only 3% have medical insurance 45% have no bathroom or toilet in their urban home Subject to intermittent government cleaning up campaigns (demolition) Eggleston et al. (2008). From plan to market in the health sector: China s experience. Journal of Asian Economics, 19, The Hukou Restricts Access to Health Care If a little sick, they don t go to the hospital or take medicine. If very sick, they just go home. Almost all migrants lack health insurance Even though cooperative insurance eligibility has been extended to temporary residents of Shanghai, the uninsurance rate is significantly higher in temporary (66%) v s permanent (21%) child residents [ORL 5.85, ] In cities in which migrants are not included in new health reform m programs, they lack insurance all-together Must pay out-of of-pocket for health care 93% OPP; v s 26% of local residents Consequently, migrants have: Higher rates of self-treatment Less access to health information Compounded by the current technical inefficiency of China s health care system (over-diagnosis, over-treatment, escalating costs) The Health of Migrants High rates of: Benzene poisoning Pneumoconiosis Infectious disease (increased SARS prevalence; STIs) Work-related injury: 12,000 accidents / year in Shenzhen alone Chronic Disease Poor reproductive health: MMR 3-7x higher than urban resident women In Shanghai, 2/3 of all maternal deaths occur in migrant women 2x rate of stillbirth Lack of health knowledge 6

7 Impact on Migrant Children: Lack of Education There are 7-8m 7 migrant children of school age Estimated 1.8m are not in school Restricted by a number of fees: out-of-catchment fees, textbooks/miscellaneous extras Central Government policy to waive fees, but local governments are given discretionary power to decide whether to include migrant children in mandated laws If fees are waived, many barriers are still in place - eg both parents must have temporary resident cards In 2003, local children in Shenzhen were paying as much as 3x local children for their education 67% pay higher school fees than urban resident children Continues the intergenerational cycle of poverty Significant discrimination: from teachers, classmates Migrant Children: Health Consequences Lack of access to basic health care Forced into marginal activities such as rubbish collecting Higher rates of child labour Higher CMR, IMR and MMR rates compared to (urban) resident populations Shanghai: IMR (resident children): 2.9 per 1,000 IMR (migrant children): 7 per 1,000 Live in highly polluted, unhygienic, crowded conditions Poorer Health from Conception Migrant women have less prenatal care In Shanghai, 50% have prenatal examination Compared to <5% of permanent residents Higher rate of emergency C-sectionsC Less knowledge about post-natal health care practices Multiple barriers limit maternal health access: low education levels, lack of health insurance, one child policy, lower income, lack of registration Migrant Children: Infectious Disease Significantly lower vaccination rates than national averages: Guangdong province: Only 51-71% of migrant children obtained rubeola vaccination 57 80% have BCG 51-74% have polio Much higher occurrence rate of infectious diseases: in Guangdong, were migrants make up <20% of population, they make up 53% of rubeola cases Wuhan (Hubei Province): Only 30% of migrant children have been properly vaccinated; 8% had never undertaken any vaccination Only 25% had regular health examinations Shanghai (CDC data): 95% vaccination coverage in resident children 85% in migrant children Measles: 50% of cases occur in migrant children Chongqing CDC 22% of local child population are migrants Migrant children constitute 52% of measles cases For immunisation programs, an additional 20% of vaccines are now provided (despite lack of childrens registration) Children are all checked for immunisation status on entering school - catch-up programs for those missing any vaccines Challenges: Lack of funds; difficulties in maintaining records on a highly mobile population; lack of parental education and health knowledge Liang, Z. et al. Migration and the well-being of children. 7

8 Action by the Government 2006: Revision of the Law on Protection of Minors Regulations to ensure migrant children have access to education, abolition of non-residential fees for migrant workers Relaxation of the hukou: 2002: Central government designated migrant workers as members of o the working class, rather than (formerly) peasants 2003: Central government committed to: Abolish restrictions on rural labourers seeking urban employment Improve the living conditions, health care and personal safety of migrants Provide access to education for children of migrant workers 2007: Ministry of Public Security proposed to the central government to eliminate the hukou to allow freer migration, allowing citizens to change their registration Some provinces (Hebei( Hebei,, Shandong, Lianing, Guangzi,, Chongqing) and cities (Beijing, Shangai) ) have launched trial hukou reforms Shenzhen Residence Cards Launched 1st August 2008 Aimed to reach 5m non- hukou residents in the city Allows for access to: permits to HK / Macao, education access, social security, family planning Aims to establish comprehensive demographic information to better serve and monitor migrant population Health System Changes Alongside hukou relaxation, there are also reforms of the Chinese health system in place However, although authorities have mandated that enterprises should offer medical insurance to migrant employees,, in reality this does not happen: Approx. 5m workers in Shenzhen Only 1m receiving medical insurance Local officials explicitly state that it is not in their interest to devote much effort towards protecting migrant workers rights if they did so, it would increase the labour cost for the enterprises and foreign investors may just move to where labour regulations are more lax. Positive Programs in Place BEIJING: Largest population of migrants in China (~4m children) Dashila St Medical Centre: Offers free family planning, reproductive health checks; Children s s Day (1st June each year): Free health checks Health education seminars Liulichang Health Centre: Half Price treatment for migrant workers Zhejiang: Clinics established by fellow migrants Government program: to increase MCH & vaccinations Positive Programs in Place The Central Government is planning to mandate improved social services for migrants and their children - free infectious disease prevention, treatment; vaccinations; maternity care Two recent documents: Medical Reform Consultation Paper and the Draft Social Insurance Law acknowledged the needs of migrant workers However, these services rely on: Migrants having registered as temporary residents in their new cities (costly, time- consuming, one-child policy issues) Migrants having sufficient funds to pay for any extra expenses which may not be free despite government mandates Many programs are encouraged by the central government but local governments / employers are not mandated to provide services to migrants and their children 8

9 New Concerns & The Future The Financial Crisis: 30m migrants have lost their jobs Has resulted in increasing number of children left behind Sudden increase in demand for rural resources 2008: Central government policies issued to assist: Local governments should assist returning migrants Urban governments must only assist permanent residents and skilled migrants (re-training opportunities, budget housing etc) Therefore, those families most at risk are left with little protection In n Conclusion Internal migration is a unique phenomenon in China, affecting millions of people and their children The children of internal migrants are particularly affected by: Lack of urban hukou Restricted education Restricted health care access Discrimination by peers Being born outside the one child policy The psychological impact of being left behind Several policy reforms must be mandated by the Central Government if this marginalised,, and growing, population is to receive the equal accses to basic human rights. Thank you References 1. Hu X, Cook S, Salazar M. Internal migration and health in China. Lancet. L 2008;372: International A CSR C. Unicef tours Beijing area for migrant women and children Hong Y, al. e. Too costly to be ill: Health care access and health th-seeking behaviours among rural-to to-urban migrants in China. World Health Report. 2006;8(2): WHO Wei C, Benyon L, Maher K. Poverty among children in urban China: A survey of poverty-affected families in three cities. Childhood Poverty Research and d Policy Centre. Report No International A. Internal migrants: Discrimination and abuse. The T human cost of an economic 'miracle'. Amnesty International. 2007;March Wong F, Chang Y, He X. Correlates of psychological well-being of children of migrant workers in Shanghai, China. Soc Psychiat Epidemiol Solomon C, Yuan R, Fei X, Maher K. Urban poverty, childhood poverty and social protection in China: Critical issues. Childhood Poverty Research and Policy Centre. Report No Lu A, Wei Z. Child poverty and well-being in China in the era of economic reforms and external opening. ng Xiao X. A survey on health care conditions of migrant children. China Women's Healthcare. 1999;14: Liu X, Zhan S. Health care for internal immigrants. Strait Journal of Preventive Medicine. 2000;6(1): Agency XN. China calls to protect rights of migrant children Shaokang Z, Zhenwei S, Blas E. Economic trasition and maternal health care for internal migrants in Shanghai, China. Health Policy and Planning. 2002;17(Suppl 1): Institute OD. Internal migration, poverty and development in Asia Guo F, Iredale R. Unemployment among the migrant population in Chinese cities: Case study of Beijing. Proceedings of the 15th Annual Converence for the Association for Chinese Economics Studies Australia (ACESA). 18. Shaohua Z. Rural labour migration in China: Challenges for policies. Management of Social Transformations. 2005;Policy Papers / Nielsen I, Nyland B, Nyland C, Smyth R, Zhang M. Determinants of school attendance among migrant children: Survey evidence from China's Jiangsu Province. Determinant D of Management Working Paper Series ISSN Fitzner K, Coughlin S, Tomori C, Bennett C. Health care in Hong Kong and mainland China: one country, two systems? Health Policy 2000;53: Organisation. WH. The World Health Report 2000: Health systems - improving performance. Geneva Chan E, Griffiths E, Gao Y, Wan Chan C, Fai Fok T. Addressing disparities in children's health in China. BMJ. 2008;93(4): ;93(4): Liu Y, Hsaio W, Eggleston K. Equity in health and health care: the Chinese experience. e Social Science & Medicine. 1999;49: Biao X. Migration and health in China: Problems, obstacles, and solutions. Asian Metacentre Research Paper Series. 17: Lu M, Zhang J, Ma J, Li B, Quan H. Child health insurance coverage: A survey among temporary and d permanent residents in Shanghai. BMC Health Services Research. 2008;8: Chan K, Zhang L. The Hukou system and rural-urban urban migration in China: Processes and changes 27. Feng C. China mulls reform of household registration system Zhu L. Children of migrants to have some inoculation as urban peers. ers Government TC. Shanghai: better care for city's migrants Mingxin B. Beijing opens up free classrooms to migrant workers' children News A. Stiffer penalties for migrants who do not respect the one e child policy WHO. Maternal and Child Health in China CLB. The Children of Migrant Workers in China.??? 34. Chihua W. Migrant children beset by growing pain. UNICEF [Online]. 35. CRI. China's Migrant Workers Daily Ps. China's migrant children increase in number, visibility Brockerhoff M. The impact of rural-urban urban migration on child survival. Health Transition Review. 1994;4:127 4;4: Ping H, Pieke F. China migration country study. Regional Conference on Migration, ion, Devleopment & Pro-Poor Poor Policy Choices in Asia Li K. Protecting the rights of China's migrant children. UNICEF [Online] Hong'e M. China unveils action plan for universal access to basic health care. The Chinese Government Hongjiang W. China unveils health-care reform guidelines. The Chinese Government [Online] Hui L. Shenzhen launches residence cards. The Chinese Government [Online] Yan Y. Free schooling for migrant children. The Chinese Government nt [Online] China NBoSo Statistical Communique on Labor and Social Security Development in