International Symposium The Hague, 19 May 2014 Introduction On the 19th of May 2014 IOM the Netherlands organized an international symposium in the Hague on the assisted voluntary return and reintegration of migrants with health concerns. The event was part of the project Measures to Enhance the Assisted Voluntary Return and Reintegration of Migrants with a Chronic Medical Condition Residing in the European Union (AVRR-MC), funded by the European Return Fund Community Actions 2011 and the Dutch Ministry of Security and Justice. The project addressed the needs of this particular group of vulnerable migrants demanding special advice, guidance and resources to cope with the challenges of return and reintegration. Although this category of vulnerable migrants represents a relatively small fraction of the national return caseloads, their return and reintegration poses specific questions to stakeholders in both host countries and countries of origin. Return related stress factors weigh heavily on returnees with a medical condition. IOM the Hague has consistently received additional ear-marked funding to provide additional assistance to migrants returning with different and often complex medical conditions. As a result an increasing number of migrants with a medical condition have found their way to IOM which has been confronted with having to assist a great variety of cases. Not all EU member states and countries of origin have incorporated reintegration elements in their national return migration policies for vulnerable migrants such as medical cases. Policy makers of relevant government departments have sometimes limited information at their disposal with regard to the specific needs of medical cases. This follows from a relatively low exchange of expertise in the EU and countries of origin, and the limited number of studies on return migration and health, as it is a rather new area starting to receive attention. Indeed the attention and resources dedicated to this area of assisted voluntary return and reintegration (AVRR) could increase faster if policy makers and practitioners would be more aware and conscious of the AVRR Health issues. The symposium aimed to raise awareness by identifying key issues that should be taken into account in the return and reintegration process of migrants with health concerns, as well as to foster a better understanding of the various stakeholders roles and responsibilities regarding assistance provision. The symposium brought together over sixty key AVRR stakeholders including diplomats, public officials, policy makers, NGO s, health practitioners and return and reintegration workers from the nine countries participating in the project: Afghanistan, Armenia, Azerbaijan, Ghana, Hungary, Kosovo, Mongolia, Morocco and the Netherlands. The IOM Regional Office in Brussels and Headquarters in Geneva, as well as IOM Belgium and IOM Norway were also represented. This document reports on the event by summarizing presentations and discussions and closes with conclusions and recommendations.
Morning Session Martin Wyss, Chief of Mission of IOM the Netherlands, opened the event with introductory remarks. He stated that one should remember that people with medical concerns can be vulnerable even when they are not migrants. One should distinguish between those who come to the country of destination with a medical condition to be cured; those who become ill during the journey; and those who become ill in the country of destination. The reasons to leave the country of origin and the reasons to return have implications on the returnee s expectations. Finally Martin Wyss suggested 3 Cs: Continuity, Coherence and Change. Case studies: Egzon, Return migrant from Hungary to Kosovo, Male, 23. Health issue: diabetes mellitus and dyspepsia Egzon wanted to go to Belgium to find a proper medication for his diabetes. Getting stranded in Hungary was a difficult time for him. The family had spent their entire savings, even sold whatever they had in their possession to help Egzon, resulting in a very difficult economic situation. They live on governmental assistance of 70 per month. Together with IOM, Egzon had to search opportunities available and identify the best reintegration option. As a first step, assistance was given to renovate the family house s bathroom to ensure decent living conditions. Counseling sessions with Egzon revealed the option of buying two cows to produce milk and sell it to a local dairy plant. Pharmacy staff and doctors were not familiar with the procedures and procurement methods of IOM and initially hesitated to provide services and medicaments. Together with Egzon, IOM visited local doctors and pharmacies and opened the way for easier access to the services. IOM s assistance and the small cattle farming the Ergzon s family runs ensure that the medication he needs can be purchased in case of shortage of governmental stocks. The business established through the reintegration assistance now provides a modest but regular income and involves other family members. The family plans to increase the number of cows with the rearing of procreation of calves. The morning programme began with a presentation on migration policies in the Netherlands as a case study. Ira van der Zaal, Coordinating Policy Advisor Migration Policy Department, Dutch Ministry of Security and Justice, clarified the context of return in the Netherlands by giving information about the Dutch migration policy related to the issuance of residence permits on medical grounds and medical aspects of the asylum and return procedures. Residence permits on medical grounds may be granted if three conditions are complied with: 1) the Netherlands is the most suitable country for the specific treatment; 2) the treatment is medically necessary; and 3) the payment for the treatment is secured. Ira van der Zaal stressed that the threshold for a residence permit to be granted on medical grounds is rather high and few are indeed granted each year. Ira van der Zaal explained that the asylum seekers have access to medical care during the asylum and return procedures, in particular in reception centres. When a person expresses the intention to apply for asylum, he/she is checked for tuberculosis. Then, during the rest and preparation period, a nurse (and if necessary a doctor) examines the asylum seeker s mental condition to check if it is possible to interview the asylum seeker. If the interview has taken place and the result is a negative decision on the asylum application, the asylum seeker has 28 days to leave the Netherlands. Emphasis is put on voluntary return and only in case all voluntary options fail, forced return is organised. Various medical considerations may be taken into account. For instance, if there is any doubt, a fitto-fly check may be carried out. Departure may be suspended for one year on medical grounds (article 64 of the Aliens Act). Sacha Chan Kam, IOM AVRR Regional Thematic Specialist from the IOM Regional Office in Brussels, gave a general overview of IOM AVRR programmes and activities regarding migrants with health needs; followed by a presentation on migration and health in the context of AVRR by Dr Goran Grujovic from the Migration Health Division (MHD), IOM Headquarters in Geneva. Both experts highlighted that AVRR, in the EU context in particular, is increasing in magnitude and importance and more attention is given to health challenges linked to return migration. IOM s principle is based on humane, safe and dignified return and reintegration options and on voluntariness. The key factors in AVRR are the freedom of choice, the absence of coercion and the provision of up-to-date country of origin information. AVRR programmes are continuously adapting to the changing trends. Nowadays, IOM AVRR programmes offer a variety of assistance. They all include some type of reintegration assistance and greater emphasis is put on vulnerable groups of migrants. MHD is responsible for supporting and sustaining the health of all migrants moved under the Organization s auspices. Travel and health are closely connected. In the past, health determination was perceived as a hurdle, delaying the return process. This perception has gradually changed over the years. It is now accepted as an essential part in the IOM return procedure.
Among the AVRR actors mainly the returnee, the counsellor, the IOM office in the country of origin and the health care provider there is a current gap as regards a medical focal point who translates the needs of the migrant into specific assistance actions. In general, the counsellor is at the core of the AVRR process. Health assistance is usually triggered by a migrant s self-declaration about a medical condition or a third-party declaration. However, some migrants may have an unknown condition or a condition that they are reluctant to disclose. This gap represents one of the challenges IOM is facing during return procedures. The AVRR counsellor should be able to connect all players. A medical check-up of every migrant is not feasible; therefore when a health condition is reported or selfreported, the counsellor should request that the migrant sees a medical professional, if this has not already occurred. The counsellor should coordinate with MHD, which can advise on fitness for return and fitness for travel, based on the available heath information. If no health condition is reported but the counsellor suspects the presence of a medical condition, he/she may decide to refer to the MHD focal point. In this, the counsellor may take into account certain perceived aspects, such as breathlessness, pregnancy, jaundice and confusion. Medical documentation is crucial in this process. Sending missions with many medical cases may wish to have appointed health assessment providers who are familiar with the work of IOM AVRR programmes and to whom they can refer potential returnees. Dr Goran Grujovic referred to five important factors relevant for determination of further IOM assistance: 1) Capacity to Decide: to ascertain the voluntariness, the migrant should be mentally competent to make a decision on return and understand the consequences and implications of that decision; 2) Medical Eligibility to Return: various factors play a role in return, such as the nature of the migrant s health condition, ability to travel, migrant s will, capacity to decide Case studies: Philip, Return migrant from the Netherlands to Ghana, Male, 42. Health issue: epilepsy After 14 years in the Netherlands, Philip returned when his residence permit expired and could not be renewed. This meant that he was not allowed to work, nor was he entitled to any social security allowances. He had a strong need to build a future for himself and felt this was no longer possible in the Netherlands. He developed a return plan: back in Ghana he was going to start a business in refrigeration and air-conditioning. A container full of specific tools and equipment to be used in his business was shipped under his name by a Dutch NGO and arrived safely in the harbor of Accra. Once the housing arrangements in place and the medical issues attended, came the time to work on the business plan. Philip then realized that he would not have enough money to pay the customs duties for his container. This was a key stressor that triggered depression. Eventually, he borrowed money from several people to clear his container, but this in turn led to pressures from his creditors to repay the loans. Philip has little or no social network to resort to for support. As a chronic condition like epilepsy is taboo and stigma-breeding in Ghana, he could not talk or share his concerns about his condition with anyone around him, for fear of alienating them. He was signed up for additional mental health and psychosocial support counselling. Philip is currently busy with unloading his container and the start up of his business. and continuity of care in the country of return (availability and accessibility of prescribed health care); 3) Fitness for Travel; 4) Travel Requirements; and 5) Medical Assistance related to Reintegration, such as the review of availability and costs of prescribed health care, identification of relevant local partners and medical institutions for referral, and follow-up after arrival. The morning session ended with the presentation of two cases which showed the stress factors that are common for return migrants with health concerns. These factors relate to the challenges they have to face when they return. Afternoon Session In the afternoon a Country Assessments Report and a practical Toolkit for return counsellors were launched. The key issues that were identified during the symposium will be reflected in the final version of those two documents. The Country Assessments Report researched the challenges of migrants with chronic medical conditions reintegrating in their country of origin. 28 migrants who returned from various EU countries were interviewed about their reintegration experiences. Interviews were also held with family members, health providers and reintegration organizations. The results were presented by Merlijn van Schayk, the author of the research report. 3
Through the stories of two interviewed returnees, Merlijn van Schayk pointed out that the high cost of medication was one of the biggest stress factors. There are different reasons. Firstly, medications are not always available through free public health care but only in private health care. Secondly, generics may be available through free public care but are not trusted, resulting in returnees buying brand medication through private pharmacies. And thirdly, diagnostic tools that are only available in private hospitals. In most cases the returnee is not the only one in the family requiring medical attention. As a result of the inability to provide for him/herself and the stress of not being able to buy medication, they feel they are a burden for their family and do no have a positive outlook on the future. Merlijn van Schayk emphasized the importance of the social network in the reintegration and the fear of stigmatization and sense of failure felt by the returnees. The biggest problem resulting from stigmatization is isolation. The inability to share the reason of return with the social network is very stressful. The family usually provides for the returnee who depends on them for his/her daily needs. It shows that sustainable reintegration is also connected to the ability to provide for oneself. The Report recommends that psychological support and counselling for returnees is implemented, starting in the host country. It also stresses the importance to take the household Panel discussion 1 Country Assessments Report Findings Out of the 28 interviewed returnees, 13 felt their physical state of health had declined after return. 5 returnees stated they felt the same and 10 felt better. 22 returnees stated that they felt psychologically worse. And 4 of these returnees talked about wanting to end their life. Only 2 returnees reported that they felt mentally better after return. The psychological state of mind is related to the stress factors that returnees experience after their return, namely: return reason, length of stay in host country, length of stay in country of origin, everyday life hardship, status of health care system in country of origin, social and family network, outlook on future and IOM procedures. Out of 28 only 3 returnees were working. The main reason for not working was health related (14), retirement age and receiving pension (8), economic situation is not favorable for them to find a job (3). as the basic unit of support for an organization like IOM and advises IOM to strengthen its local network in countries of origin as local organizations have the potential to add much to the support system of returnees. Merlijn van Schayk Independent Researcher Hans Faber Director International Affairs, Repatriation and Departure Service (DT&V) Sacha Chan Kam AVRR Thematic Specialist IOM Regional Office Brussels H.E. Dziunik Aghajanian Ambassador of Armenia Cristina Gheorghe Head of AVRR Cluster IOM the Netherlands The panel discussed the findings of the report, particularly the lack of opportunities faced by medical cases, the need to support the household and to cooperate with already existing organizations and networks. Returnees have vulnerabilities that normal persons do not have, due to the stress of returning and the social stigma attached to it. Some of them sell everything before they leave for the country of destination and don t have much to fall back on when they return. This vulnerability applies even more so to returnees with a medical condition. The importance of strengthening health care systems in countries of origin and of enhancing the compatibility of health care systems in host countries and countries of origin was underlined. The returnees expectations can be high because they demand the same level of services as they experienced in the host country. Managing expectations and providing clear and reliable information before departure are therefore crucial. Trust is the key word. More cooperation is needed, between stakeholders and between host countries and countries of origin. The issues of when reintegration assistance stops and when development assistance starts, and the respect of human rights were also raised. The longer migrants stay outside of the country of origin, the more difficult it is to come back.
The Toolkit for return counsellors was presented by Janet Rodenburg and Evert Bloemen from the Dutch organization Pharos. Using role plays, they showed that facilitating the return of migrants with a chronic medical condition to their country of origin requires extra knowledge and skills from the return counsellor, in particular to gain trust and to ask the right questions. They recommend that the counsellor acquires some basic knowledge about the characteristics of certain diseases and treatments, impairments in daily activities and the impact it has on travelling and the return and reintegration process. The counsellor should discuss those issues with the migrant and health practitioner for which communication skills are paramount. The Toolkit contains practical instruments to overcome barriers that may play a role in the return decision making process of the migrant, through the formulation of a personal action plan that focuses on capacity instead of impairment. The counsellor s self care should also be taken into account and the organization he/she is part of should provide the counsellor with good working conditions, i.a. intervision and training. Panel discussion 2 Evert Bloemen Pharos Goran Grujovic Migration Health Division IOM Headquarters Geneva Eszter Sauermann Office of Immigration and Nationality Hungary Olivier Sprée AVRR Health IOM the Netherlands Paul Sterk Mind-Spring Jenna Iodice, Migration Health Division IOM Headquarters Geneva The question was raised if the counsellor can or should refuse assistance when the conditions of a return in dignity are not fully met. This question is difficult to answer in particular in case of migrants with health concerns of which the availability, accessibility and affordability of health care in the country of origin are not guaranteed or when the medical condition impacts the migrant s ability to work. The counsellor needs to have clarity about what he/she can and cannot do and make use of referrals and/or supervision. The counsellor should not focus on the outcome, but be open and work on developing trust with the migrant. To be noted is the fact that IOM reserves the right to refuse return assistance in rare cases. Four elements should be taken into account: 1) severity of the medical condition and its anticipated advancement upon return; 2) can the migrant comprehend all circumstances and implications; 3) does the migrant have support in his/her country from the family or a social network; and 4) what is the situation of health care in the country of origin. The decision to provide return assistance should be based on the health assessment of a doctor vis-à-vis return and reintegration. As migrants with medical conditions are more vulnerable and their capacity to work might be hampered by the medical condition, the socioeconomic situation should be addressed by the counsellor. The migrant s reintegration plan should include a part on how they plan to finance their medical treatment. The preparation, ensuring that migrants understand their disease and are capable of taking care of themselves once they are back, should start in the host country and continue in the country of origin. In addition, an understanding of health conditions in the country of origin including of traditional medicine is essential. The counsellor should help bridge the knowledge gap. Furthermore, close coordination between service providers in the host country and the country of origin and between the counsellor and the government, civil society and health care providers is fundamental. Through the issues raised and contributions made, the importance of having a toolkit to give practical answers was demonstrated. 5
Conclusions / recommendations The symposium gave a better understanding of the migration health issues afflicting migrants returning under AVRR programs. The lively debates and the numerous challenging questions raised by different stakeholders during the event is a clear sign that more work needs to be done on this topic in the future. Below follows a summary of the challenges and recommendations: A growing attention has been given to AVRR Health. Addressing health vulnerability in AVRR programs is a necessity. Best practices are there, but need to be consolidated. A more comprehensive approach on return for migrants with health needs, providing enhanced counselling, guidance and resources to returnees is required in order for them to be able to cope with the specific challenges of their reintegration in the country of origin; IOM and other organizations providing AVRR services have limited capacity; therefore complementary government support in the country of origin related to e.g. identification and certification issues, resulting in improved access to health care, social welfare benefits and labour market is necessary. Sharing responsibilities and cooperative measures and partnerships are essential as well as strengthening the health care systems in countries of origin and the compatibility of health care systems; Keeping close cooperation between AVRR specialists in host countries and countries of origin is essential. Information sharing needs to go both ways and interaction must continue throughout all the phases of the return and reintegration process: pre-departure, travel and post-arrival; Local expertise should be identified to complement IOM assistance: connect migrants to local possibilities and make use of local services; Social networks are important in the reintegration process. Stigma is often attached to returnees and certain health conditions; Stress factors that returnees experience after their return are linked with: return reason, length of stay in host country, length of stay in country of origin, everyday life hardship, health care situation in the country of origin, social and family network, outlook on future and IOM procedures. Lack of opportunities and costs of medical care are the most important factors; The counsellor should pay attention to physical and mental health concerns, check the availability, affordability and accessibility of the necessary medical services in the country of origin, investigate needs of the migrant and tailor assistance on a case-bycase basis; The medical condition may affect the ability of the migrant to make a decision on return. In case of doubt, it has to be assessed; Managing return migrant s expectations is important and should be done by professional counselling, including up-to-date and reliable information provision on the country of origin; AVRR programmes should include psychosocial counselling starting in the host country and take into account the household as key factor in reintegration; The AVRR counsellor has a central role. He/she needs special skills and knowledge and should be able to refer to medical focal points when needed. He/she should receive professional counselling support and training from the employer. 6