Narrative change for inclusionary health and migration policies
Authors: Nora Gottlieb, Andreas W. Gold, Irene Palla, Ifunanya Concilia Dimaku, Berta Güell, Imanol Legarda Díaz-Aguado, Kayvan Bozorgmehr
Journal: The Lancet Regional Health - Europe (2024)

Several papers in this Series on "Addressing migration and health inequity in Europe" reflect discrepancies between Universal Health Coverage (UHC) ambitions and the actual exclusion of many migrants from national health systems. Amidst increasingly hostile discourses towards migrants, we argue that endeavours for UHC should not only address "implementation gaps", but challenge the narratives fuelling these discourses. Evidence shows that the costs of restricting migrants' access to healthcare outweigh the benefits. In Germany, restrictions on asylum-seekers' healthcare were shown to compromise health equity, efficiency, and other health system outcomes, including up to 40% higher expenditures.1Bozorgmehr K. Razum O. Effect of restricting access to health care on health expenditures among asylum-seekers and refugees: a quasi-experimental study in Germany, 1994–2013.PLoS One. 2015; 10e0131483https://doi.org/10.1371/journal.pone.0131483Crossref PubMed Scopus (198) Google Scholar,2Gottlieb N. Ohm V. Knörnschild M. The electronic health insurance card for asylum-seekers in Berlin: effects on the local health system.Int J Health Policy Manag. 2022; 11: 1325-1333https://doi.org/10.34172/ijhpm.2021.34Crossref PubMed Scopus (4) Google Scholar The 2015 NHS charging regulations in the UK have aggravated health inequities and adverse public health outcomes, thus potentially increasing costs.3Rassa N. McCarthy M. Casalotti S. et al.The impact of NHS charging regulations on healthcare access and utilisation among migrants in England: a systematic review.BMC Public Health. 2023; 23: 1-12https://doi.org/10.1186/s12889-023-15230-9Crossref PubMed Scopus (3) Google Scholar In Spain, the 2012 Royal Decree-Law restricted undocumented migrants' access to healthcare, with adverse public health and economic effects.4Peralta-Gallego L. Gené-Badia J. Gallo P. Effects of undocumented immigrants exclusion from health care coverage in Spain.Health Policy. 2018; 122: 1155-1160https://doi.org/10.1016/j.healthpol.2018.08.011Crossref PubMed Scopus (18) Google Scholar Still, exclusionary narratives advocate for restricting migrants' health entitlements as a means to safeguard resources, invoking welfare nationalism and portraying migrants as 'free-riders' and presumed burdens on health systems. Given the existing evidence to the contrary, one may wonder why exclusionary narratives persist and thrive in health policy-debates. What makes them so compelling? And what lessons can we draw? The success of exclusionary narratives has been explained with Othering as a simple, powerful, and emotional narrative that demarcates and depreciates out-groups, thereby enhancing the perceived value of the in-group. In migration contexts, Othering sums up to "they come to get what is ours".5Namer Y. Coskan C. Razum O. Discrimination as a health systems response to forced migration.in: Bozorgmehr K. Roberts B. Razum O. Health policy and systems responses to forced migration. Springer International Publishing, Heidelberg/Berlin2020: 195-211Crossref Scopus (2) Google Scholar This narrative resonates with fears of competition for housing, labour and welfare resources, and with a neoliberal performance ideology devaluing those (genuinely or supposedly) reliant on the welfare state.6Küpper B. Wolf C. Zick A. Social status and anti-immigrant attitudes in Europe: an examination from the perspective of Social Dominance Theory.Int J Conf Violence. 2010; 4: 205-219https://doi.org/10.4119/ijcv-2826Crossref Google Scholar Essentially, exclusionary narratives provide simple, albeit delusional answers to complex questions—such as healthcare inequalities—while leveraging negative emotions like uncertainty and resentment and engrained beliefs about identity, belonging, and deservingness. Against this backdrop, they help mobilise support for broader authoritarian agendas, including policies "that worsen the conditions for those who support them, yet manage to retain their support by blaming others".7Falkenbach M. Greer S.L. The populist radical right and health: national policies and global trends. Springer Nature, Cham2021Crossref Scopus (11) Google Scholar In obscuring the real causes of social inequities and those who benefit from them, exclusionary narratives legitimise political and economic elites in times of crises and deflect their responsibilities.8Sayad A. La double absence. Des illusions de l'émigré aux souffrances de l'immigré. Seuil, Paris1999Google Scholar Indeed, governments were shown to decouple evidence-based practice from rhetorical commitment to illiberal, radical-nationalist narratives when they are under pressure to deliver outcomes; while they tend toward technocratic narratives when under less pressure.9Boswell C. Smellie S. Migration narratives in political debate and policy-making. Conceptualising and operationalising work packages 7 and 8. BRIDGES Working Papers No.: 19. 2023.https://doi.org/10.5281/zenodo.10066255Google Scholar What if we used these insights to promote healthy societies and inclusive health policies? This would mean acknowledging the role of narratives in policymaking and, consequently, that mitigating the gap between the status quo and UHC will require more than technical solutions alone. It would mean developing a better understanding of when, how, and why decision-makers embrace, reject, or ignore narratives. Primarily, it would require the health community to develop narratives that are captivating and powerful enough to garner broad public support for equity, diversity, and inclusion, and thus side-line exclusionary frames. What would such narratives look like? Narrative change comprises a more comprehensive and complex approach than trying to counter exclusionary frames (which may achieve the opposite10Lakoff G. Don't think of an elephant!: Know your values and frame the debate: the essential guide for progressives. Chelsea Green Publishing Company, Chelsea2004: 124Google Scholar). It advises prioritising shared values over problems; creating solutions rather than reducing something bad; and bringing real people, their decisions and actions, into the frame rather than vague concepts like "widening gaps".11Shenker-Osorio A. Messaging this moment: a handbook for progressive communicators.https://communitychange.org/wp-content/uploads/2017/08/C3-Messaging-This-Moment-Handbook.pdfGoogle Scholar Narratives should anchor in people's lived experiences to engage them in jointly realising a positive vision. Too often, public health addresses migrant health by talking about problems and needs, invoking subordinating metaphors of vulnerability and charity, and unwittingly singling migrants out from "the general public". Instead, we need narratives that unite and empower us, whether settled or on the move, to jointly build a desirable future for ourselves, our families, and societies. Finally, good narratives are an asset, but not enough for change. Credible politics, institutions, and leaders are essential, not only in rhetoric but in action. Public health and medicine should lead such narratives to maintain the moral groundwork and public credibility, but they often lack the tools. Communication science has the tools but is poorly represented in the migrant health community. Civil society and migrant organizations are ahead of academia in understanding and leveraging narrative change; however, the academic community often operates separately, foregoing their expertise. Building alliances between migrant health and communication science, as well as between academia and civil society and migrant organizations, will be instrumental in jointly changing narratives and policies toward greater inclusion, equity, and social justice. NG conceptualised and wrote this Commentary, with substantial input from KB. AG, IP, ICD, BG, ILDA, and KB each contributed as co-authors by providing input to several iterations of the manuscript. All authors have reviewed and confirmed its final version. We declare no competing interests that are relevant to the content of this Commentary. Some of the ideas presented here were developed as part of the joint work of NG, IP, BG, ILDA and further partners within the framework of the EU funded project DignityFIRM (HORIZON-CL2-2022-TRANSFORMATIONS-01, project no. 101094652). How to address migrant health inequity in EuropeIn one of the world's wealthiest and most progressive regions, migrant health remains desperately neglected. Despite 36% of all global migrant populations residing in Europe, less than half of the member states of the WHO European Region report health data for migrants, exposing a systemic failure to prioritise their wellbeing. Migrant populations face legal, structural, linguistic, and cultural barriers that systematically exclude the majority of individuals from national health-care systems with undocumented migrants bearing the brunt of discrimination. Full-Text PDF Open AccessUniversal health coverage for undocumented migrants in the WHO European region: a long way to goThe number of people on the move internationally is increasing, and a sizable number of these individuals are migrating through and to the WHO European Region. The UN Sustainable Development Goals demand that we leave no one behind and ensure equitable implementation of Universal Health Coverage (UHC), regardless of immigration status. In the WHO European region, some of the migrants in the most precarious situations are undocumented; defined as those who may have been unsuccessful in asylum applications, born to undocumented parents, continued their residence in a country after their permit or other means of stay expired, as well as those who have entered the country irregularly. Full-Text PDF Open AccessPriority setting and migration health policies for European countriesThe 2030 Sustainable Development Goals (SDG) agenda has committed to 'ensuring that no one is left behind'. Applying the right to health of non-citizens and international migrants is challenging in today's highly polarized political discourse on migration governance and integration. We explore the role of a priority setting approach to help support better, fairer and more transparent policy making in migration health. A priority setting approach must also incorporate migration health for more efficient and fair allocation of scarce resources. Full-Text PDF Open AccessCapacity building in migration and health in higher education: lessons from five European countriesCapacity building in migration and health in higher education is key to better, sustainable, and equitable health care provision. However, developments so far have been patchy, non-structural, and often unsustainable. While training programs have been evaluated and competency standards developed, perspectives from individual teachers are hardly accessible. We present expert perspectives from five European countries to illustrate good examples in higher education and identify gaps to further the advancement of capacity building in migration and health. Full-Text PDF Open AccessMigrant-sensitive healthcare in Europe: advancing health equity through accessibility, acceptability, quality, and trustThe advancement of migrant-sensitive health care in Europe has been a topic of many initiatives and academics debates for over 20 years in Europe, yet with rather limited progress in terms of comprehensive and sustainable implementation. We argue that a human rights-based approach with clearly defined duties and responsibilities of governments, relevant public and private institutions as well as professionals is needed, in line with a sound understanding and thoughtful implementation and further development of concepts and standards for providing migrant sensitive care as an essential component of Universal Health Coverage. Full-Text PDF Open AccessDiscriminatory, racist and xenophobic policies and practice against child refugees, asylum seekers and undocumented migrants in European health systemsChild refugees, asylum seekers and undocumented migrants who have been forcibly displaced from their countries of origin have heightened health needs as a consequence of their migration experiences. Host countries have a duty to respond to these needs, yet across Europe we are seeing a rise in potentially harmful discriminative, hostile and restrictive migration policies and practices. Research exploring the role racism, xenophobia and discrimination in European health systems may play in child migrant health inequities is lacking. Full-Text PDF Open AccessStrengthening life-course immunisation in migrant populations: access, equity, and inclusionAdult and adolescent migrants worldwide, and those arriving in Europe, are an under-immunised group for routine vaccinations due to missed childhood vaccines and doses in their countries of origin, and their subsequent marginalisation from health and vaccination systems. Declining population-level coverage for routine vaccines across Europe, which has accelerated post-pandemic, places these and other under-immunised populations at even greater risk of vaccine-preventable diseases. However, despite clear guidelines around the importance of delivering 'catch-up' vaccination throughout the life-course, migrants are rarely effectively incorporated into routine vaccination programmes on arrival to Europe. Full-Text PDF Open AccessNormalising participatory health research approaches in the WHO European region for refugee and migrant health: a paradigm shiftWhile people's involvement in health research is increasingly the encouraged norm in many countries, the involvement of refugees and migrants in research about their health is rare. Here, we call for a paradigm shift in the field of refugee and migrant health to make participatory health research routine, i.e. normalised. To disrupt 'business as usual', we synthesise evidence about meaningful research partnerships and features of inclusive participatory spaces. We present examples of decolonial, culturally attuned methods that can be used to reimagine and reinvigorate research practice because they encourage critical reflexivity and power-sharing: arts-based research using music and singing, participatory learning and action research, Photovoice and co-design (ideas generation) workshops. Full-Text PDF Open Access