Protecting migrant children's well-being in Ecuador's public schools

Abstract

Education plays a crucial role in the adaptation and broader societal inclusion of immigrant students and their families. The current study explored the inclusion of migrants in Ecuador's school system as a fundamental tenet of protecting their health and well-being. We conducted a thematic analysis of 13 policy documents, 12 national laws and international agreements, and 31 key informant interviews, applying a human rights lens. We find that, although the 2008 Ecuadorian Constitution and migration laws protect the right of migrants to health and education, key informants argue that these laws are poorly implemented. Furthermore, they agree that the health sector generally does not consider education as a relevant setting for health. In contrast, the public education sector and non-profit organizations at the national and local levels appear to recognize the importance of coordination across the health and education sectors, including school-based initiatives for migrant inclusion.

Introduction

The political, economic, and social crisis in Venezuela has resulted in the forced migration of millions of its residents to other countries in the region (Malo, 2022; Cheatham et al., 2023). By the end of 2022, there were an estimated 6.3 million refugees and migrants from Venezuela hosted across 17 countries in Latin America and the Caribbean (R4V, 2023b). While some are granted refugee or residence status, most Venezuelan migrants remain undocumented. Ecuador, located relatively near Venezuela, has been significantly affected by the influx of migrants from that country (Pugh, Jiménez and Latuff, 2020) grappling with challenges to provide public health and education services to this population (Chaves-González, Amaral and Mora, 2021). Ecuador has the highest number of recognized refugees from all backgrounds in Latin America (74,872) and 248,000 Venezuelan migrants who are registered in the government system (Reliefweb, 2023; UNHCR, 2023). It is estimated that approximately 500,000 refugees and migrants from Venezuela currently reside in Ecuador, with 73 % of them with an irregular (undocumented) status in the country (R4V, 2023a). In general, migrants in Ecuador do not live in formal or informal encampments, but rather integrate into the host population (although largely in marginalized urban areas).

Migration is a challenging process that impacts national identity, family and social relations, and socioeconomic status. Migrant children's education plays a crucial role in the adaptation process and the inclusion of both the students and their families in the host countries (Summers, Crist and Streitwieser, 2022). Moreover, education is the one of the best paths to social mobility, offering possibilities to improve overall quality of life (Duraiappah et al., 2022).

Due to the Covid-19 pandemic, Latin America and the Caribbean had the highest number of children who did not attend a classroom for the longest periods worldwide, with an average of 158 days of missed in-person education (UNICEF, 2021). In March 2021, one full year after school closures began in the region, only seven countries in Latin America and the Caribbean had fully resumed in-person schooling, 12 countries and territories continued to keep their schools completely closed, and the rest had partially reopened (UNICEF, 2021). According to UNESCO's COVID-19 Education Response dashboard (UNESCO and UIS, 2022), Ecuador closed its schools for 40 weeks between the first quarter of 2020 and the first quarter of 2022 – a longer duration than countries such as Chile, Colombia, and Argentina.

Ecuador's legal framework ensures universal access to services such as health care and education, regardless of nationality and documentation status (R4V, 2023a), so migrant children do not need a regularized (documented) status to attend school. Hence, the Ecuadorian school system has admitted progressively more Venezuelan students: 10,730 students in the 2019–2020 academic year, and 45,348 in 2020–2021 (Ministry of Education, 2023). Nevertheless, it is estimated that 30,000 Venezuelan students between 5 and 17 years old were not attending school at the time (UNESCO, 2020). After both the country's borders and schools reopened, 55,759 Venezuelan nationals were registered for the 2022–2023 school year (Ministry of Education, 2023). Still, there are many ongoing challenges associated with enrolling in school and educational offerings in addition to widespread gaps in resources and inequity in the distribution of resources across the education and health systems (Ministry of Education, 2023; UNESCO, 2021). In the health sector, limited access to public services is demonstrated in the high out-of-pocket spending (33 % of all health expenditures in the country) (INEC, 2022). In the education sector, disparities are exemplified by the direct correlation between income and lower learning outcomes and the 65 % gap in student counseling staff in public schools (Ministry of Education, 2022).

In this context, the aim of this research is to explore the inclusion of migrant children and youth in Ecuador's school system as a fundamental condition for their health and well-being, applying a human rights perspective. We analyze the role of policy and practice in fostering migrants' educational access to address the wider social determinants of health. Our study focuses on four dimensions across the education and health sectors: human rights principles, the right to health, underlying determinants of health, and public policies and laws, as levers for health equity.

Methods

In this study, we focus on the policies guiding access to schools for foreign nationals and their inclusion in the school system, as well as the relevance of schools in children and youth's physical and mental health and overall well-being. We also consider the unique economic and social conditions affecting migrant children and youth. Qualitative data were collected and analyzed from key informant interviews conducted in 2022 and relevant policies that were current in the same year.

Analytical framework

The present study assumes that policies, programs, and practices concerning the education of migrant children and youth are relevant to their health and well-being. Access to schooling and inclusion in the school system requires mitigating disruptions in education due to school closures (e.g., during the Covid-19 pandemic) or due to students moving across and within countries. We examined the policies and their application with respect to the following four human rights dimensions (Knipper, 2016):

Human rights principles: Stated principles that are concerned with diminishing and eliminating disparities rooted in nationality or migratory status and guaranteeing inclusiveness are relevant to the formulation of policy. Here, the focus is on gauging the extent to which policies and programs incorporate values such as non-discrimination, fairness, engagement, and responsibilities towards children.

The right to health: Access of migrant children to education and their inclusion in the school setting help to ensure that children can also use health services (through coordination between the Ministry of Education and the Ministry of Health) and be in an environment where their health can be nurtured (e.g., children may be more likely to receive psychosocial support through the school counseling department, where available). From this perspective, access is understood as an effective possibility and inclusion, as an active approach to serving diverse backgrounds and needs. Here, the focus is on the adherence of Ecuador's educational policies and practices to non-discrimination principles, examining their role in facilitating migrants' access to education, also with a view to ensuring better health (physical and mental) of students.

Underlying determinants of health: Social, economic, legal, and political determinants of health may be addressed through policies and programs, with particular attention to conditions of critical importance such as the COVID-19 pandemic. Here, the focus is on how access to schooling and student retention are ensured together with measures to support students’ health.

Public policies and law as a lever for health equity: Legal frameworks and public policies may have an indirect impact on health equity by promoting inclusivity in the education system. The focus here is on legal resolutions explicitly guaranteeing inclusion in the school system, addressing discrimination, and upholding equity.

In our analysis, we also incorporate health promoting school (HPS) principles, based on the premise that the right to health extends beyond the availability of and access to health care and social services for school-age children and youth. The right to health requires a more comprehensive understanding of health, its promotion, and development. Therefore, an approach addressing underlying health determinants is essential. The HPS model, grounded in a socio-ecological perspective, recognizes the school as a setting to address wider health determinants (Macnab, Gagnon and Stewart, 2014). In the HPS perspective, well-being refers to a holistic understanding of health (i.e., positive physical and mental health outcomes within a health promoting environment). The HPS approach considers six dimensions of well-being: healthy policies, physical and social environment, community connections, health services, and individual skills and action competencies (Moynihan, Jourdan and Mannix McNamara, 2016). This model proposes integrating health services within the school setting, linking health considerations with educational objectives and prioritizing health promotion efforts. A health promoting school also considers the unique needs, resources, and cultural and local dynamics of the school and its community (WHO and UNESCO, 2021).

Analytical sample

This research is part of a larger project examining the health and well-being of migrants in four Andean countries. For this study, extracts from interviews and policy documents specifically related to children's education and well-being were selected. Data sources included: 31 key informant interviews; 13 policy documents and 12 laws and agreements approved or ratified by the Ecuadorian government that were in force in 2022 and were national in scope; and publicly available demographic data for foreign nationals. Key informants included government officials from the health and education sectors, ranging from the high-level authorities working at the national level to medium levels of decision-making (e.g., regional health department officials), practitioners such as teachers, and medical doctors. We also interviewed consultants or workers from intergovernmental organizations, international cooperation agencies, and civil society representatives. Key informants were selected based on their position or experience in education or health relevant to migrant populations in Ecuador. Further details regarding key informants are presented in Supplementary Table 1.

Content analysis

We conducted a thematic analysis (Braun and Clarke, 2006) of transcribed key informant interviews and policy documents, to identify common themes. Within documents, we conducted a search for the following key terms in Spanish: education, educational, school, and schooling. Additionally, we included terms that refer to priority populations according to the Constitution such as child, boy, girl, adolescent, minor, son, daughter, and orphan. We also explored terms relevant to health and education, including health, mental health, physical health, psychosocial, emotional state, nutrition, and well-being. Finally, we considered terms related to human rights, such as integration, inclusion, and access.

Sections of text using these search terms were extracted and labeled with a phrase or set of phrases describing the context in which they were linked such as the right to education, inclusion, xenophobia/discrimination, the right to health, well-being, human rights, food and nutrition, legal framework and policies, cultural changes, barriers to education, school attrition, and health-education partnerships. Next, selected texts were grouped into the four main categories of our analytical framework and were evaluated to identify agreements among the interviewees. Subsequently, these excerpts were grouped into thematic subcategories. In this phase, interviewees' ideas were compared and contrasted with policy documents. The main ideas were identified by selecting patterns of responses from informants and mentions in policy documents. Finally, informant quotes that were representative of agreements among interviewees were highlighted. When translating quotes into English, we respected the original syntax, which we acknowledge may be difficult to understand in some instances.

Results

The first set of results relate to Ecuador's 2008 Constitution guaranteing the right of migrants to health and education. Several laws and policies refer to how these rights can be protected, although with different opportunities and challenges (Fig. 1). While the Code of Childhood and Adolescence (2003) grants protection and assistance for refugee-seeking children, it does not include other types of migrants. The Organic Law of Human Mobility protects emergency health care of migrants regardless of their status. In 2018, ten governments in the region (including Ecuador) agreed to articulate a regional strategy (known as the Quito Agreement or Proceso de Quito) to address the crisis triggered by the mobilization of high numbers of Venezuelan migrants and refugee-seeking nationals (Proceso de Quito, 2018). In 2020, three policies were approved to guarantee access to education for vulnerable populations and updated the protocols to address school violence. However, these were limited in scope and it took a Constitutional Court sentence to set a specific legal precedent guaranteeing the right of migrants to education, regardless of their status. In 2021, the Ministry of Education made further provisions to give unrestricted access to schooling for migrants and other vulnerable populations (see Supplementary Table 2 for dates on which laws and policies were issued).

Fig. 1.

Relevant principles, laws, and policies to migrant children's right to health and education.

Out of the 4.3 million pre-school & school-age children in the country, nearly 2 % (80,074) are not Ecuadorian nationals. The number of Venezuelan students (55,759) indicates that about 70 % of non-Ecuadorian students have only recently arrived in the country. When comparing the number of children ages 3–18 formally registered as residing in Ecuador with pre-school and school registration, we can see that almost 15,000 students are not registered as being in the country but attend school. National statistics also show that school violence is a growing problem in Ecuador. According to a study by the Ministry of Education (2015), 22.8 % of students between the ages of 11 and 18 acknowledged being bullied at school (Ministry of Education, 2015). Partly in response, the 2021 reform to the Organic Law of Intercultural Education made racism and xenophobia a serious school violation. It appeared to be an attempt to counteract discrimination in general, but also against migrant students in particular, in view of the high number of children who recently arrived in the country. The capacity of the educational system to respond to these issues is important to consider. For instance, Ecuador has an estimated deficit of 4000 school counselors (Freire García, 2023), with only 1 school counselor for every 400 students.

The perspectives of interviewees varied depending on the sector in which they worked and on whether they were practitioners or decision makers (see Table 1). Interviews revealed that the health sector, in general, does not seem to view education as a condition for health or a setting for health promotion, from health workers to decision makers at local and national levels. In contrast, informants from or working with the education sector at the local level recognized the importance of interdisciplinary health and education work aimed at better identifying migrant students’ needs. However, at the national level, informants focus on reducing barriers to access to education, and on academic achievement. National and local government agencies’ informants mentioned the importance of education as part of a broader effort to guarantee the rights of migrant populations. International and non-profit (NGO) organizations emphasized the integration of migrants into the local population through schools as a way to reduce xenophobia. Lastly, representatives from migrant-serving civil society groups focus on a variety of issues, including health, food, and housing.

Table 1.

Characterization of the main statements made by interviewees.

Interviewees	Main statements
Local Government Health Sector
GL 1	Civil society participation in prevention and campaigns in educational institutions. Focus on eradicating childhood malnutrition.
GL 8	Attention to migrant population with the same rights as the Ecuadorian population.
GL 6	Need for training for teachers, parents, and mobile students.
GL 2	No mention of schools in relation to health.
GL 10	No mention of schools in relation to health.
GL 5	No mention of schools in relation to health.
Local Government Education Sector
GL 9	Collaborative work with educational institutions and families. Training and guidance for teachers and students. Attention to students with disabilities and special cases.
GL 4	Care in early childhood centers and municipal schools for children of migrants. Universality of health, education, and other services regardless of nationality or documentation. Need for allocation of resources from the national government and municipalities to ensure rights. Importance of recognizing and guaranteeing rights for the integration into city development plans.
GL 3	Impact of migration on the educational sphere. Need for teacher preparation to instill values and address xenophobia. Challenges and solutions in the integration of migrant students. Importance of parental involvement in education and justification of absences. Inclusion of all children without discrimination. Changes in perceptions towards migrant students. Shared responsibilities among parents, teachers, and government. Need for training of teachers, parents, and migrant students. Deficiencies in state services and the role of NGOs.
Local Government
GL 7	Free services for migrants and the need for projects focused on housing, employment, health, and education.
GN 3	Ecuador as a country committed to human rights and having international recognition for hosting refugees. Coordination of health care, education, and other services. Protection of human rights among migration population. Focus on equal rights for migrants. Common challenges in gender issues, family reunification, and child care.
Central Government Education Sector
GN 4	Work to eliminate access barriers to education for the migrant population. Educational institutions as a protective factor. Responses to virtual education needs and the restructuring of the learning process. Strategies for the adaptation of migrant children at all levels.
Central Government Health Sector
GN 1	No mention of schools in relation to health.
GN 2	No mention of schools in relation to health.
International organizations and NGOs
SC 3	Recognition of rights of mobile people. Xenophobia at the border and the need for awareness.
ONG-N 1	No mention of schools in relation to health.
ONG-I 2	Identification of specific issues of the migrant population. Partial implementation of policies in education and health sectors. Responses to virtual education needs and the restructuring of the learning process. Strategies for the adaptation of migrant children at all levels. Elimination of administrative barriers and document requests for migrant enrollment in schools. Focus on the care and adaptation of migrant children at various levels. Training courses for teachers and administrative staff to address discrimination and xenophobia.
ONG-I 1	Challenges in education, health, and protection systems due to immigration. Work required to address xenophobia in the education system. Policy advances with Agreement 26 for the educational inclusion of migrants. Recognition of migrants’ human rights and enactment of human rights principles. Family separation and violation of human rights of children and their families.
OIG 2	No mention of schools in relation to health.
OIG 3	Challenges posed by the recruitment of children by criminal groups. Rescue structure, work with families, and reintegration of children. Closure of schools and transition to virtuality. Loss of access to education and connectivity problems. Absence of clear policies for refugees in health and education.
CI 1 and CI 2	The Venezuelan migration crisis affects education and health systems. Integration of the migrant population in health and education policies. Services for mobile children: health (such as medical checkups), education. Need for studies on child malnutrition in the migrant population.
OIG 1	No mention of schools in relation to health.
OIG 5	No mention of schools in relation to health.
OIG 6 −1 and OIG 6 −2	The program focuses on access to the right to education for refugee and other mobile children. Emphasis on the importance of preventing gender-based violence and ensuring inclusion in the formal education system. Importance of mproving inclusion and developing tools for the socio-emotional health of teachers and children. The program addresses challenges related to violence in schools and the involvement of children and adolescents in criminal groups.
OIG 4	Highlights success in providing access to education for migrant girls, boys, and adolescents. Points out the impact of the pandemic on the migrant population, including job loss of parents and restricted access to education.
Leaders of migration organizations/civil society
SC 2	No mention of schools in relation to health.
SC 3	No mention of schools in relation to health.
SC 1	Obstacles to obtaining educational degrees due to irregular (without documentation) migration status. Need for more decisive government actions in complex cases. Migration of entire families with limitations in educational and employment competences. Emphasis on rights to health, education, identity, and advocacy.
SC 5	No mention of schools in relation to health.

Human rights principles

Right to education and relationship with health

Interviewees consistently reiterated that the national government is committed to upholding the right to education and health, as enshrined in the Constitution, and recognizes these are fundamental human rights irrespective of citizenship. The Ecuadorian government appears committed to the protection of human rights of migrant populations, earning recognition for having granted refugee status to the highest number of people in the region. Informants emphasized that migration is a human right supported by international agreements. For example, the Ministry of Foreign Affairs highlighted its cooperation with national institutions to address the health, education, and social needs of migrants. The Ministry of Health emphasized the use of a 17-digit medical record code in lieu of an ID card to access services, guaranteeing rights equivalent to those of any other Ecuadorian national.

“We seek to ensure that health, education and other services are universally accessible, regardless of whether you are Venezuelan, Colombian or of any other nationality, and regardless of whether or not you have documentation.” Local government official (GL 5)

Additional ideas to protect human rights principles mentioned in the interviews were that educational access for migrant students has improved during and after the pandemic due to a reform of the educational system. Regarding the right to health, informants mentioned that schools in Ecuador are developing more comprehensive care protocols for mobile children and adolescents, recognizing the need for health services for all their family members, emphasizing the promotion of their rights, and mandating schools to offer psychosocial support to allow for a better adaptation of migrant students.

“The typical characteristic of Venezuelan migration is the migration of a war without there being a war. That is to say, the mother, the father, the five children, the sick grandmother, the old man with cancer, the dog are fleeing; therefore, the problem is magnified since it is not only necessary to give urgent attention to one migrant, but to the whole family". Migrant Alliance official (SC 1).

Discrimination and health

We found that different actors, especially NGOs and migrant leaders, emphasized the need to ensure equal rights and access to services for the migrant population. They also stressed the importance of treating migrants with respect and recognition of their rights. Concurrently, they also acknowledged a lack of effective implementation of human rights approaches, discrimination in medical care due to lack of documentation, and xenophobic behaviors in border areas, including within health care facilities. Key informants noted that the local population considers that migrants divert resources and attention away from them, which triggers acts of xenophobia. Informants emphasized the importance of addressing discrimination in health care, particularly for women and the LGBTQ+ community (while noting the absence of specific plans for migrant pregnant women). Finally, the discrepancy between officials' claims regarding equal access to health and the reality of discrimination faced by migrant populations was highlighted.

"The migrant population faces obstacles in accessing health services due to discrimination. While it is possible that, when asking a director or minister of health, they may claim that there is equal access, the reality in health service delivery shows that migrants often do not receive the care they need due to discriminatory practices." International NGO officer (OIG 4)

Law and public policies as a lever for health equity

Universal and free access

Interviewees emphasized the significance of universal and free access to basic services like health and education for everyone, regardless of their migration status. They underscored how these rights were constitutionally protected, along with the fact that services are provided free of charge for the migrant population. Additionally, there was an emphasis on raising awareness about these rights among the population and overcoming potential barriers, such as the fear of deportation.

“As ministries, our services are free, which means that people, in this case migrants, who we know come from a low economic status, do not have to spend their scarce resources on health care.” Local government official (GL 7)

Legal framework, inclusive policies, and inter-institutional coordination

The Rules to the Law of Intercultural Education (Ecuadorian Government, 2017) provide special protection to displaced children, who are categorized as vulnerable and with special education needs. Key informants acknowledged the importance of having a constitutional guarantee of interculturality in education, but they also pointed out the need for an improved application and enforcement of this and related official instruments, such as the Law of Human Mobility. They also highlighted how important it is for these policies to be aligned with human rights principles. Recommendations given by interviewees included strengthening intersectoral collaboration and creating specific policies to address the unique needs of migrant populations.

“I think the law and policies exist; the problem is that they are not implemented. Ecuador has a constitution that promotes the rights of human beings, but in every field they are not applied, the problem requires that the competent institutions achieve the fulfillment of such policies” International NGO officer (NGO I-2).

Interviewees advocated for regulations that ensure policies benefit both local and migrant populations. Suggested measures included creating inclusive education and training programs for migrant populations, with particular emphasis on local and national approaches to ensure comprehensive and coordinated initiatives.

Cultural change and discrimination

Most informants mentioned the discrimination challenges faced by migrants. They expressed concerns about the unequal distribution of resources, with some perceiving that foreign populations may be receiving more attention and assistance than the local population. This perception can in turn lead to discrimination against migrants and tensions between the local and migrant populations. The challenges also include the lack of clarity and awareness among the migrant population about their rights and the services available to them. Some interviewees highlighted instances of verbal aggression towards health personnel, reflecting the need for community education and awareness campaigns.

“People have found out that somehow there is more attention for the foreign population, and this causes the social problem of discrimination, because the NGOs pay them rent, give them cards, food, studies and other things, while our population is also hungry; plus, there are even foreigners who are more violent and possessive.” Local government official (GL 7)

“All human beings have the same duties and rights, no matter what country we are in.” Venezuelan leader in Tulcán (SC 5)

Interviewees emphasized the need for educating both the local population and health personnel about the rights of migrants and the difficult situation of this population, to avoid misunderstandings and conflicts in the provision of health and education services.

Underlying determinants of health

Overcoming barriers to education

Starting in 2020, there were several policy changes beginning with school students not being required to have uniforms or textbooks (not provided by the government), which previously was a strict condition for attendance (Ministry of Education, 2020). Also, students became allowed to enroll at any moment of the academic year, be assigned to a grade by age if they did not have school documentation, and receive special support to update their skills and knowledge to successfully complete the grade (Ministry of Education, 2020). These changes also allowed students to change schools if they made a request, provided there were places available (Ministry of Education, 2020).

Despite these provisions, several barriers to access to education remain. Interviewees mentioned the importance of first addressing economic needs: without a family income, children cannot attend school. Concurrently, work demands can limit parents’ involvement in their children's education. Also, several of the interviews highlighted the impact of the pandemic on student access to health and education services. Food insecurity and “problematic family coexistence” were viewed as having an influence on education because they prevent student well-being, which for informants are more prevalent problems in the migrant population.

“We could say that people who are migrants do not have better health conditions because they are not eating well.” NGO worker (OIG 4)

Interviewees suggested the need to provide training for teachers, parents, and students on migration as a human right. They also emphasized the importance of reducing discrimination against migrants and the necessity of strengthening programs for eradicating child malnutrition, for local and migrant populations alike.

Although the Ecuadorian government considered the provision of school meals important for students’ nutritional status during the pandemic, it provided them with ultra-processed foods (Torres and Lopez-Cevallos, 2022). Furthermore, interventions appeared to be episodic, not systematic. A Ministry of Education official in a border town (GL 3) said their office worked to find cooperation agencies that would donate food, school supplies, and uniforms to schools with the highest concentrations of migrant children. Such a type of limited handouts where criticized by representatives from an international NGO (OIG 4) and a cooperation agency (CI 1, CI 2), who highlighted the need for structural solutions. Although the cost of transportation is an additional educational barrier, informants did not mention the need for supporting student transportation to schools.

School attrition

The interviews described how, after the pandemic, the end of online education created problems such as bullying and xenophobia and an increase in student dropout rates. Also, informants said adolescent migrant girls dropped out more so than boys since they are responsible for taking care of the home and of their younger siblings and grandparents (while their parents work). They also mentioned a new problem caused by the recruitment of adolescents by criminal groups.

“A crisis [emerged] related to issues of violence in schools and the coercion of children and adolescents by criminal groups, which generates new forms of abuse but also [impedes] access to education.” International Organization Official (OIG 6)

“Adolescent women left school because they had to devote themselves to taking care of the home, family, siblings, and grandparents so that their parents could go to work.” NGO worker (OIG 4)

Informants highlighted the effects of sexual violence and exploitation on girls and adolescents, who have limited health system support and legal protection mechanisms (in a country with a weak justice system). They drop out of school once they have an unwanted pregnancy or become sexually exploited by criminal groups. A Ministry of Education official (GN 4) said their office had yet to define how to address the risks of sexual violence and exploitation through both prevention and protection measures.

Finally, confirming the findings of a UNESCO (2021) report, interviewees mentioned that access to education is affected by migration status because, despite access to schools being universal, obtaining a degree is dependent upon having documentation. Correspondingly, informants stated that migrants may lack a document certifying their studies when they finish, which limits their access to higher education or jobs that may help them improve their living conditions. Therefore, informants emphasized the need to create pathways for people to regularize their status.

Central elements of students’ right to health

Views on school as a health setting

In general, health sector informants did not mention coordination efforts with schools or joint work with the education sector more broadly. They explained that health personnel doing home visits can identify the need of migrants for food, vaccinations, and treatment and refer migrants to government programs that can help them meet those needs. However, while the Comprehensive Health Care Model (MAIS, in Spanish) stipulates extramural activities of health facilities should include school visits (Ministry of Health, 2013), interviewees did not mention school visits by health personnel, except for one health promotion worker.

"The most specific [visits] are the extramural visits, which are planned two days or a week in advance and in coordination with companies, NGOs, or educational facilities, or a sweep is made of a certain sector, and everyone is seen." Health promoter (GL 2).

Moreover, the Comprehensive Health Care Model for Schools (MAIS-CE, in Spanish), which was approved in 2018 for implementation within the education system, was described as “not yet implemented” by an intergovernmental agency informant (OIG 5). A Ministry of Education official (GN 4) concurred, saying that the implementation plan was still in its initial stages, with the Ministry of Health first working on “linking” individual health facilities to schools.

Other limitations include the lack of a sexual education program in schools, which would be the responsibility of the Ministry of Education, while the Ministry of Health has yet to address the diverse needs of children and adolescents in this respect beyond the prevention of unwanted pregnancies. Despite the limited number of school counselors, the Ministry of Education mandates schools to conduct a psychosocial assessment and provide psychosocial follow-up and support through the advisory department (DECE) and tutors, respectively, to foreign students (Ministry of Education, 2020; 2021).

Health-education partnerships

The interviewees, including officials from NGOs and the education sector, recognized the importance of cooperation with the health sector, citing examples such as strategies for migrant children to be referred from health centers to the educational system, psychosocial support, and vaccination campaigns.

“The Ministry of Health has these extramural activities, for example, vaccination or dental campaigns are carried out in educational institutions.” Central Government (GN 4)

Key informants mentioned alliances with international cooperation and intergovernmental agencies to create strategies against xenophobia and discrimination to be disseminated in schools, including the uptake of UNESCO recommendations emphasizing work in schools on socioemotional skills that impact the individual and their environment. Nevertheless, education sector informants did not acknowledge the specific needs of migrants with mental illnesses, overlooking the fact that these individuals often carry traumas and experiences that can lead to mental health issues requiring specialized care.

“I think the main conflict is that they [Ministry of Health facilities] have access to specialized mental health care, which we as the Ministry of Education do not provide.” Central Government (GN 4)

Other pending issues include the strengthening of the health system and the streamlining of resource allocation. The urgency of expanding the health workforce seemed to take center stage, but the emphasis remained on proposals to implement training and workshops to improve services. During interviews, two programs were mentioned: 1) the 'Education is Inclusion Awareness Program' (Sensibilízate, educación es inclusión), a short-lived media campaign in 2020 financed by UNESCO and the Norwegian Refugee Council (NRC); and 2) the 'We Breathe Inclusiveness' Program (Respiramos inclusión), in operation since 2015 and funded by World Vision, the Permanent Committee for the Defense of Human Rights (CDH), and UNHCR. This program, for instance, included specific guidelines for teachers (UNESCO, 2021).

Lastly, informants emphasized a great need for robust communication between countries. Delving into the interviews, responses unravel the bureaucratic intricacies hindering the care of migrant children.

“If there was a network, at least of these three countries between Venezuela, Colombia, and Ecuador, the complexity of both migrant children and the elderly would be somehow protected if there was a health connection between the three countries.” Central Government (GL 1)

Discussion

Our study examined the inclusion of migrants in Ecuador's school system as a fundamental condition for the promotion of their health and well-being, analyzing relevant policy documents and key-informant interviews and applying a human rights perspective. We find that, although the 2008 Ecuadorian Constitution and migration laws protect (in theory) the right of migrants to health and education, key informants argue that these laws are being poorly implemented. Furthermore, they mentioned that the health sector generally does not consider education as relevant to health. In contrast, the education sector at the national and local levels and non-profit organizations (NGOs) seem to better recognize the importance of coordination across the health and education sectors, including school-based initiatives for migrant inclusion.

The pandemic-related school closures' effect on migrant students was also mentioned during interviews, considering that access to education was limited and technology-dependent. Remote education was described as having a protective effect of reducing school-based instances of bullying, discrimination, and xenophobia. Nevertheless, informants highlighted the crucial role schools can play in protecting migrant children's rights, and highlighted the importance of understanding how schools can act as key players in addressing migrant students' well-being.

In our study, decision makers and practitioners emphasized the principle stated in the Constitution that migrants have the same rights as Ecuadorian nationals to education and health. However, civil society and other informants underscored that this principle was not necessarily upheld in practice. During interviews, informants voiced their concerns of operating in a very resource-constrained environment. While there may be formal equality under Ecuadorian law, and the principle of right to health might be upheld, there is limited access to health and social services for migrant populations. It is important to note that, although the Constitution considers children a priority group, informants did not mention children without being specifically prompted. We should note as a limitation that all interviewees were adults, and their comments and examples largely referred to their or others’ experiences or perspectives. Representatives from the Ministry of Education and UNESCO were an exception, probably because they have a mandate to work with school-aged children. Future research should discuss these issues with migrant children and youth themselves.

In interviews with government officials from national to local levels, informants repeatedly cited the legal framework of equality (e.g., the Constitution, ministerial agreements) guaranteeing the use of government services by all, irrespective of migration status, as the guiding principle for all actions. However, certain government decisions during the pandemic revealed that exceptions to the law were made. For example, migrants were initially placed at the end of the COVID-19 vaccination queue (phase three) and were excluded from government cash transfers to the most impoverished people.

Concerning migrant children's access to school, students could only enroll at the beginning of the school year (before the Covid-19 pandemic). In practice, this meant that migrant children were subjected to rules that effectively discriminated against them, leaving them out of the school system if they had arrived in the country after classes had begun. Reforms allowed children without personal or educational documentation as proof of the last grade they approved to enroll based on their age, and teachers are expected to prepare a “recovery or catch-up plan” for them. Although UNESCO and the Ministry of Education informants emphasized the planning of different programs to give mental health support to students or to ensure inclusion in schools without discrimination, they did not have evidence of the programs’ implementation or impact.

The Sustainable Development Goals (SDGs) for 2030 (Nicolai, Wales and Aiazzi, 2017) recognize the significance of education in promoting the well-being of migrants as a key goal. They emphasized that extensive and unexpected migration flows can disrupt education systems, place migrant and refugee children at a disadvantage, and create tensions within host communities. Successfully addressing these challenges within the SDGs necessitates a thoughtful combination of proactive planning and the allocation of contingency funds. The SDGs highlight the crucial role of education in fostering social integration, facilitating economic mobility, and improving learning outcomes, while also emphasizing the need to prevent the segregation of migrant children (United Nations, 2023). Our analysis illustrates that while Ecuador's legal framework is aligned with SDG goals, its implementation remains incomplete.

Conclusions and policy implications

Our study provides evidence of the limited realization of the rights to health and education for migrant children in Ecuador. Although informants speak of the need for cooperation across the health and education sectors, the Ministry of Education works independently and links to the Ministry of Health only to refer children who may need health services, not as part of a school-based health promotion plan. Concurrently, the Ministry of Health does not appear to view schools as a setting for health, and extramural activities of health departments and clinics in the public health system do not commonly include school visits or other activities together with schools.

While policies and practices in Ecuador support the inclusion of migrant children in schools regardless of their status, the absence of data hinders the assessment of inclusiveness or discrimination within schools and their impacts on student health and well-being. With a shortage of school counselors and a high incidence of bullying, the actual effects of this inclusion on children's well-being may be limited. National evaluations that could reveal the effects of laws and policies related to migrant inclusion on schooling conditions, the implementation of programs targeting migrant students, and education quality are nonexistent.

Ecuador's formal obligation for schools to admit migrant students regardless of their legal status can be considered a noteworthy example for other countries. It represents an opportunity to provide support migrant children's health and well-being within the school setting. However, resource constraints and stigma mean that access to schools may not be enough to limit exposing migrant children and their families to discrimination.

There are two main steps that the government of Ecuador can take in the short- and mid- term to address the needs of migrant school children without having to make major reforms or create new programs: 1) Comply with Ministry of Education standards on the number of counselors in public schools to provide regular support to all students regardless of their migration status and the more recently mandated specific support to migrant children; and 2) Schedule regular visits to public schools by Ministry of Health service providers and additional coordinated activities as stipulated in both the MAIS and MAIS-CE guidelines. In addition, the Ministry of Education should collect and analyze data on how social determinants of health may be addressed through the school setting (e.g., using a health promoting approach), to contribute to the well-being of all students.

Ethical approval

Ethics committee approval (P22–048E) was obtained from the Universidad San Francisco de Quito Institutional Review Board.

CRediT authorship contribution statement

Irene Torres: Writing – review & editing, Writing – original draft, Validation, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Mariana Pinto-Alvarez: Writing – review & editing, Writing – original draft, Validation, Formal analysis. Daniel F. López-Cevallos: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.