Learning from the COVID-19 pandemic response to strengthen undocumented migrant-sensitive health systems: case studies from four countries

Summary

Undocumented migrants are a vulnerable population group in the context of the COVID-19 pandemic due to increased risk of infection, severe morbidity, and mortality. In this Personal View, we analyze the COVID-19 pandemic responses, particularly vaccination campaigns, vis à vis undocumented migrants, and discuss lessons learned. Our empirical observations as clinicians and public health practitioners in Italy, Switzerland, France, and the United States are supplemented by a literature review, and presented through country case studies focusing on Governance, Service Delivery, and Information. We propose recommendations to capitalize on the COVID-19 pandemic response as an entry point to strengthen migrant-sensitive provisions into health system frameworks, by: providing specific guidance in health policies and plans; developing tailored implementation approaches with outreach and mobile services, with translated and socio-culturally adapted information, and engagement of migrant communities and third sector actors; and developing systematic monitoring & evaluation systems with disaggregated migrant data from National Health Service and third sector providers.

Background

In July 2020, a dyspneic undocumented patient from Latin America presented to a COVID-19 testing in Milan, Italy. Despite oxygen saturation below 80%, the patient was reluctant to seek hospital care, citing concerns about medical bills and immigration repercussions. A bilingual nurse reassured her and she agreed to be transported to the Emergency Department, where she was intubated.

In our experience as clinicians and public health practitioners from Italy, Switzerland, France and the US i.e., countries with large undocumented migrants’ populations, this could have been any of our patients. We have worked with undocumented migrants for years and in 2020, we joined forces to share practical experiences on how to care about undocumented migrants amidst the pandemic and to generate multi-centric evidence from the field. We found that despite diverse contexts, our observations resonated deeply with each other in terms of common challenges and potential solutions. We do also share a deep sense of engagement against health inequalities and were reunited in the context of worsening political conditions for immigrants. Early in the COVID-19 pandemic, it became evident that undocumented migrants were among the most vulnerable groups. Infection, severe morbidity, and mortality rates due to SARS-CoV-2 are reportedly higher among foreign-born individuals than in the native population.1, 2, 3, 4, 5 Limited language and socio-culturally sensitive risk communication, precarious and crowded housing, poor occupational protections, pre-existing barriers to healthcare, inexistent social safety nets, and institutional mistrust contributed to high exposure, and delays in diagnosis and treatment.6, 7, 8, 9 Despite commitments to universal health coverage,¹⁰ undocumented migrants were often excluded from health services in varying degrees depending on country and service type.^11,12 This de jure-de facto gap posed significant challenges to effective and equitable response to the COVID-19 pandemic.

In this Personal View, we analyze key elements of the COVID-19 pandemic response, particularly the vaccination campaign, and identify lessons learnt to integrate and strengthen migrant-sensitive provisions into health system frameworks. Our views are based on our own empirical observations as clinicians and public health practitioners in Italy, Switzerland, France, and the United States i.e., countries with large undocumented migrants' populations, and are supplemented through literature review. We discuss them through country case studies focusing on Governance, Service Delivery, and Information, i.e., three selected Health System building blocks based on the World Health Organization's framework, as a global reference to guide analysis by components and core functions.¹³

Search strategy and selection criteria

We conducted a structured literature review based on PRISMA guidelines to identify information about COVID-19 and undocumented migrants. We searched peer-reviewed journals indexed through PubMed from January 2020 to September 2022 with the following combination of search terms: (undocumented migrant OR migrant) AND (COVID-19 OR SARS-CoV-2) AND (health system) AND (vaccine OR vaccination OR immunization). Articles published in peer-reviewed journals were supplemented through grey literature and the authors’ own files. Papers published in English, French, Spanish, Italian, and German were reviewed. The final reference list was generated based on relevance to the scope of this Personal View and comprised of total 48 items, including: 23 peer-reviewed articles; 4 international/national legal texts; 4 state-of-the-art technical guidance reports and toolkits by WHO and UNICEF on COVID-19 vaccination demand, health systems frameworks, and integration of migrant data into health information systems; 2 technical reports by national health authorities; 13 technical reports and communications from academia and third sector actors; and 1 newspaper article. We acknowledge limitations mostly due to systemic lack of information on health service delivery disaggregated by migrant status.

The COVID-19 pandemic response: analysis through country case studies

Table 1 summarizes our analysis of the COVID-19 pandemic response, particularly the vaccination campaign, across three selected Health System building blocks and migrant-specific features in Italy, Switzerland, France, and the United States.

• 1.Governance: unrestricted eligibility for access to healthcare; data firewall against reporting to Immigration authorities; policies and plans with specific guidance on migrants.
• 2.Service Delivery: targeted outreach including mobile clinics and vaccination outposts; translated and socio-culturally sensitive information; engagement with migrant communities; partnership with third sector actors.
• 3.Information: data disaggregation by migrant status; integration of data from third sector actors in health management information systems; systematic analysis and reporting of migrant-specific data.

Table 1.

Overview of migrant-sensitive health systems: analysis of the COVID-19 pandemic response through country case studies.

Migrant-sensitive features by Health System building block	Score estimation, by country
	Italy	Switzerland	France	United States
Governance
Unrestricted eligibility for access to healthcare	Partial	Partial	Partial	No
Firewall against reporting healthcare to Immigration authorities	Yes	Yes	Yes	Yes
Policies and Plans with specific guidance on migrants	No	No	No	No
Service delivery
Targeted outreach, mobile clinics, and outposts	Partial	Partial	Partial	Partial
Digital accessibility (health bookings and certificates)	No	No	No	No
Translated and socio-culturally sensitive health information	Partial	Partial	Partial	Partial
Engagement of migrant communities	Partial	Partial	Partial	Partial
Partnership with third sector healthcare providers	Partial	Partial	Partial	Partial
Information
Data disaggregation by migrant status	Partial	No	No	No
Integration of data from third sector providers in health information systems	No	No	No	No
Systematic analysis and reporting of migrant-specific data	No	No	No	No

Governance: policies for undocumented migrants’ access to health services

Italy

Before the COVID-19 pandemic, undocumented migrants were eligible for emergency and essential health services (i.e., for maternity, children >18 years of age, vaccination, international prophylaxis, and infectious disease prophylaxis, diagnosis, and therapy) through the National Health Service (NHS) with a separate registration code and firewall for personal data to safeguard against reporting to Immigration authorities. As part of provisions set by the state of emergency, the Government granted free access to COVID-19 health services for all and, as a decentralized health system, the national policy was operationalized at sub-national level through the COVID-19 Pandemic Response and Vaccination Plans. However, these lacked guidance to tailor interventions to the specific needs of undocumented migrants.^14,15

Switzerland

In the pre-pandemic era, undocumented migrants may apply for the mandatory private health insurance required to access to healthcare. Yet, only 10% are effectively insured, because of financial and administrative barriers.¹⁶ Strategies to ensure effective undocumented migrants' access to healthcare widely differed across cantons, with three observable patterns: inclusive, fragmented and exclusive. Geneva and Vaud were the only cantons providing inclusive policies which translated into a stringent firewall for personal data safeguard, the provision of the full package of health services covered by the mandatory private health insurance, usually in public sector facilities. Most other cantons restrict access to emergency and maternity care in public hospitals. These health policy differences reflect variation in other non-health policies targeting undocumented migrants and may contribute to the gradient in undocumented migrants' mortality across cantons.¹⁷ As a Federal State with completely decentralized health system governance, regional COVID-19 response policy varied widely. Only few cantons adopted a proactive and inclusive strategy to alleviate financial and administrative barriers to testing, treatment, and vaccination for uninsured migrants. For instance, the Geneva canton granted undocumented migrants full access, free of charge, to healthcare including specialized and inpatient care since the pandemic's early phase. The majority of other cantons usually limited access to emergency care only.¹⁸

France

Before the COVID-19 pandemic, undocumented migrants accessed the majority of health services except some planned health care, through State Medical Aid (AME), though at high administrative cost and with variable facility-level implementation. Only about 50% of undocumented migrants are estimated to manage to access AME.¹⁹ Undocumented migrants without AME accessed healthcare in public emergency departments, only in case of life-threatening conditions, including COVID-19 immunization from June 2020. However, increased police controls during lockdowns dampened care utilization among undocumented migrants fearing fines or arrest.²⁰ During the first lockdown, laws were passed to extend temporary residence permits. Paradoxically, citing concerns that shelters and informal settlements could propagate the virus, some were forcedly closed or vacated, while detention centers remained operational.^21,22

Finally, despite evidence on disproportionate risks due to COVID-19 among undocumented migrants, the government voted for more restrictive access to AME from 1st January 2021.²³

The French government is now taking a strong political stand against undocumented migrants conditions: at the end of 2022, a ministerial direction asked temporary shelters to report undocumented migrants, making the union of social housing plead against this direction; a law to reinforce deportation of undocumented migrants is also about to be passed.²⁴

United States

Before the COVID-19 pandemic, undocumented migrants had very limited access to subsidized healthcare.²⁵ The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) passed in 1996 excludes undocumented immigrants from receiving benefits other than public health or emergency health services required by the 1986 Emergency Medical Treatment and Labor Act (EMTALA).²⁶ Consequently, undocumented immigrants have not been eligible for coverage under Medicaid or able to purchase health insurance through the Affordable Care Act marketplaces that were implemented in 2014.¹²

The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) included health provisions for pandemic control, including coverage for COVID-19 testing and treatment, without immigration or insurance-related restrictions.²⁷ The CARES-Act expanded free access to COVID-19 care to undocumented migrants without health insurance, and mitigated out-of-pocket expenses for those who lost employer-based insurance during the pandemic. Despite this critical response, immigration concerns persisted. In the US, patient information is heavily protected under the Health Insurance Portability and Accountability Act, which prohibits disclosure, including immigration status, without the patient's consent. Nonetheless, in a 2020 survey among Spanish-speaking non-citizen Latinos in the US, a third of respondents reported that seeking COVID-19 health services could result in serious immigration consequences.²⁸

Service delivery: coverage of undocumented migrants in COVID-19 vaccination campaigns

Italy

As the COVID-19 Pandemic Response and Vaccination Plan did not provide guidance to tailor service delivery to the specific needs of undocumented migrants, ad hoc initiatives were undertaken at local level, yet with largely undocumented and unsystematic modalities and coverage.²⁶

The NHS opted for a national mass vaccination campaign through fixed delivery strategy at designated hubs and occasionally organized vaccination rounds for undocumented migrants through mobile or fixed sites in collaboration with third sector actors (i.e., actors other than the public and private sectors, thus including non-governmental organizations, charities, civil society organizations, etc.). However, these activities were ad hoc and unsystematic without integration in Vaccination Plans.²⁹ Furthermore, limited dissemination of translated and socio-culturally sensitive information through active engagement of community networks hampered vaccination demand and uptake.³⁰ In addition, COVID-19 vaccination appointments were booked online or by telephone and required NHS registration code often not readily available to undocumented migrants. Lack of access to internet and or telephone was an underlying barrier for booking a vaccination appointment and receiving a COVID certificate, further curtailing access to jobs and shelters.¹⁵

To improve access, third sector actors mobilized to support ad hoc vaccination rounds, facilitate bookings, and disseminate information to promote vaccination demand and uptake. However, they were not systematically integrated as complementary implementation partners. This affected coverage, as they provide an important share of health services for undocumented migrants.²⁶

Switzerland

The initial phase of the national immunization program prioritized eligibility based on biomedical risks rather than behavioral and social factors. It required individuals to register with a valid health insurance card number which formally excluded most undocumented migrants. Subsequently, the Federal administration alleviated these requirements which gave cantons more flexibility in the implementation of vaccination strategies targeting socially marginalized groups. Yet, in absence of specific guidance about undocumented migrants’ eligibility to vaccination, there was significant heterogeneity in their accessibility to COVID-19 vaccination across regions, leading to geographical disparities in vaccination coverage.³¹ Third Sector actors or benevolent health practitioners have sometimes complemented the limited range of health services. For instance, the Geneva and Vaud cantons implemented specific vaccination activities for undocumented migrants through a joined effort by health departments, public hospitals, and local community organizations.³² Key features to overcome fear and mistrust included culturally and linguistically-adapted communication, strong support and brokerage from third sector actors, simplified administrative requirements, including addressing the digital divide through face-to-face booking, and explicit support from local governments. It is likely that concomitant implementation of non-health programs (food, housing, financial support) facilitated vaccination uptake.³³

France

The COVID-19 vaccination plan included a gradual extension of eligibility from December 2020 to May 2021. Despite growing evidence on migrants and specifically undocumented migrants being more exposed, prioritization was based on biomedical factors.³⁴ Moreover, until August 2021, access remained challenging for undocumented migrants, due to multiple barriers.³⁵ A national health insurance registration code was required, while most undocumented migrants do not have one. Furthermore, the online appointment system implied language and digital literacy barriers, without mitigation measures. This impacted on coverage rates and on the issuance of COVID-19 certificates. Those without certificate were excluded from services such as transportation and accommodation. To improve access for undocumented migrants, some public facilities facilitated face-to-face appointments and conducted outreach vaccination rounds, with third sector actors taking up an important role through service delivery and demand generation,³⁶ while others provided outreach vaccinations with community health workers to address trust issues.

United States

Significant heterogeneity in COVID-19 vaccination coverage by state was observed, despite uniform federal governance and financial incentives. Federal guidance emphasized the importance of ensuring access to all, regardless of immigration status, but each state set their own identification requirements. During the initial phase of vaccination roll out, 31 out of 50 states required proof of state residency or employment for vaccination.³⁷ A nationally representative study showed that in May 2021 approximately two thirds of undocumented migrants were concerned about the out-of-pocket costs, impact on immigration status, or social security or government ID requirements.³⁸ Migrants from Latin America reported difficulty obtaining vaccine information in Spanish and registering through digital portals, and most were unaware that in the US the vaccine was available for free.

Local examples of success include Baltimore, where a coalition of NGOs working with undocumented migrants, local governance, and health systems, met regularly to improve vaccination access. Tangible outcomes included: i. Strengthening of the multi-lingual workforce by training migrants as community health workers and cultural brokers, ii. Implementing low- barrier walk-in mobile vaccination clinics at easily accessible community sites (e.g. churches, supermarkets, street corners), and iii. Integrating other social services, such as cash assistance and food distribution, to vaccination programs. Non-traditional methods were deployed for public health communications, such as crowdsourcing contests and collaboration with social media influencers.^39,40 As of July 2022, 85·5% of Latinos, the largest immigrant group in Baltimore, were vaccinated, compared to 67% nationally.⁴¹

Information: integration of migrant-sensitive indicators in health information systems

Italy

The national/sub-national health management information system (HMIS) collects NHS data including both healthcare and surveillance, de facto disaggregated by migrant status as identifiable through a nationality and NHS registration code (i.e., standard code for Italians and documented migrants versus temporary code for undocumented migrants). However, specific data relative to undocumented migrants is not systematically monitored and evaluated through analysis, reporting, and improvement measurement. Furthermore, HMIS does not integrate data from third sector actors. However, COVID-19 vaccination rounds conducted ad hoc for undocumented migrants were unique, insofar called upon third sector actors and transferred standardized data to the NHS for integration in the HMIS. So, this now contains a wealth of information about COVID-19 vaccination in undocumented migrants, i.e., NHS standard fixed vaccination hubs versus ad hoc outreach vaccination points with third sector actor engagement. Yet, these data are merged in the overall HMIS data flow, losing their original disaggregation by migration status and not being analyzed.

Switzerland

The Swiss HMIS is decentralized at canton level and heterogeneous in terms of indicators collected except for communicable diseases. No specific variable allows to identify migrants at risk of poorer health status, such as rejected asylum seeker and undocumented migrants. This important information currently only originates from institutional databases (usually from public hospitals) and research projects. The lack of disaggregation by residence and migration status in the national/subnational HMIS posed a significant challenge in monitoring COVID-19 infection and immunization coverage rates among marginalized population groups. Local surveys conducted in ad-hoc and relatively small samples of undocumented migrants were the only available sources of information to guide pandemic response actions, but likely failed to capture the actual situation in an accurate and timely manner.^18,30

France

There is no single health information system in France, and few of them collect data related to country of origin. For instance, the national health insurance information system does not collect country of origin, and only information on French-born versus foreign-born is available. In general, migrant administrative status and ethnicity is considered as highly sensitive data and cannot be collected, hindering the availability of disaggregated data.

United States

Country of origin or migration status is not systematically collected through public health surveillance, including mandatory case reporting by health care providers or laboratories. Although electronic health information systems have been widely adopted by health entities throughout the US, there is no nationwide system, and interoperable access is limited. There are no standard migration measures included in routine clinical assessments, other than language proficiency as recommended by the Joint Commission, the organization that accredits and certifies healthcare organizations in the US. Language proficiency surveys conducted on limited samples have raised concerns about profound inequities but were not designed to address policy decisions in real time.^30,42

Lessons learned

Governance: integrating migrant-sensitive provisions in health policies, plans and programs

Recognizing the need for an inclusive approach, some countries expanded COVID-19 health services and implemented policy modifications to alleviate concerns about immigration repercussions. However, implementation varied at sub-national level, due to lack of policy guidance and specific provisions in institutional frameworks and programs, thus resulting in over-reliance on ad hoc and unsystematic initiatives by third sector actors. Lack of policy guidance and limited coordination between NHS and third sector healthcare providers were major challenges to developing and implementing migrant-sensitive measures for COVID-19 pandemic response.¹⁵ Setting explicit provisions for undocumented migrants is necessary for effective and equitable COVID-19 pandemic response.

Service delivery: engaging migrant communities and integrating third sector actors as key partners for tailored risk communication, service promotion, and outreach service delivery

COVID-19 Response and Vaccination Plans did not make specific provisions to facilitate coverage in undocumented migrants across key components such as risk communication, service promotion, and outreach service delivery. A major issue was the lack of mobile vaccination services generalized availability, as a tailored delivery strategy for people on the move. Vaccination campaigns mostly operated through fixed delivery strategy, while targeted outreach is more effective for people on the move, though mobile clinics and outposts in high-concentration transit areas. Furthermore, services were designed and implemented based on biomedical risk factors alone, without taking behavioral and social risk factors into sufficient consideration, particularly for vaccine hesitancy.⁴³ As a result, there was a lack of development and translation of socio-culturally sensitive information for dissemination through the most used sources such as community network. Finally, there was limited engagement of migrant communities and third sector actors, as key partners with knowledge, access and capacity to improve vaccination accessibility and uptake.^30,44 Their engagement was ad hoc and unsystematic, despite evidence that Community advocates and leaders along with locally active third sector actors are competent, credible and hence instrumental in designing, promoting, and supporting accessible migrant-sensitive services addressing both supply and demand side barriers through mobile clinics and translated, socio-culturally sensitive information. As such, they need to be systematically integrated in Plans as complementary implementation partners.

Information: systematic monitoring & evaluation of data disaggregated by migrant status in health management information systems

Information about undocumented migrants health is mostly based on ad hoc surveys at selected health facilities, while there is a lack of systematic monitoring and evaluation with collection and analysis of migrant-specific data, including country of origin and language proficiency.^45,46 As a result, leveraging metrics including determinants of COVID-19 vaccination uptake and under-vaccination in undocumented migrants is challenging.⁴⁷ Ad hoc initiatives at local level and with third sector actors addressing digital barriers and integrating data in the HMIS are mostly not documented, missing valuable information to guide evidence-informed strategies and actions to deliver outreach vaccination services and generate demand to increase vaccination uptake, thus contributing towards more effective, equitable, and resilient health system and service delivery.

Recommendations

Our experience in Europe and the US highlight both policy and practice gaps in COVID-19 pandemic response including vaccination among undocumented migrants. Despite commitment to universal health coverage, the country case studies point to varying degrees of exclusion and unresponsiveness regarding health needs among undocumented migrants. This leads to ad hoc and patchy approaches, and ultimately results in low and inequitable service coverage including vaccination, besides lacking information for monitoring and evaluation. It is important to capitalize on the COVID-19 pandemic as an entry point for migrant-sensitive health system strengthening. Many undocumented migrants who had not previously engaged with the health system sought COVID-19 health services including vaccination. This could build trust at individual and community levels and be leveraged to develop migrant-sensitive public health frameworks and interventions. The following recommendations could help build more effective, resilient, and equitable health systems and services with migrant-sensitive provisions that are essential for public health not only in the context of the COVID vaccination policies but also in the future to better address the migrant health needs, in particular, the access to health data.

Governance (for health authorities)

• (i)Evaluate sustainable policy and financing changes: Reversal to pre-pandemic exclusionary policies and practices may erode hard-earned community trust and threaten future public health responses. Changes adopted during the pandemic need to be evaluated in terms of public health effectiveness and sustainability in the short and long terms.
• (ii)Provide specific policy guidance on migrants: Health policies, strategies, and plans at central and decentralized levels should explicitly identify migrants (including undocumented migrants) among vulnerable groups, and unpack guidance about types and characteristics of health services that ought to be made available and accessible.

Service delivery (for health authorities, migrant communities, and third sector actors)

• (i)Sustain multi-stakeholder partnerships to bridge the policy-implementation gap: Collaboration between government and third sector actors should be strengthened beyond the pandemic, for complementarity and synergy to integrate migrant-sensitive provisions in health system and service delivery frameworks, including outreach.
• (ii)Expand grassroots and community engagement: Train and support trusted community partners, local leaders and influencers including religious leaders and peers to co-develop interventions including implementing locally adapted service delivery through outreach and mobile clinics/outposts, along with translating and amplifying socio-culturally sensitive public health messages through word of mouth, community and social networks.
• (iii)Integrate health and welfare services: plan and implement integrated intervention packages including healthcare and welfare services for shelter, legal assistance, psychological care, and food aid.
• (iv)Strengthen the healthcare workforce: Investment in capacity building expanded opportunities for migrants to join the health workforce during the COVID-19 pandemic and should be sustained with linguistically and socio-culturally sensitive care.

Information (for health authorities)

• (i)Develop systematic monitoring & evaluation of migrant-specific data in Health Management Information Systems: Scaling up effective responses requires high quality data for evidence-informed planning, budgeting, and implementation. Systematic data collection and analysis is key to inform and guide action, by identifying unmet needs, design relevant interventions, and monitor progress. This should be undertaken cautiously, compliant with patient information safeguard and community engagement.
• (ii)Consider migration, and its documented/undocumented status, as a social determinant of health: Advocate to regularize undocumented migrants' effective access to healthcare as a public health intervention. Without a formal and legal engagement with such an approach, country commitment to universal coverage would constitute only a lip service, while other policies converge towards actually excluding undocumented migrants from all social kind of safety nets, encompassing health.

Contributors

All authors conceptualized the article.

EG and KRP conducted the literature review and drafted the manuscript.

JC and YJ contributed to and proofread the manuscript.

All authors endorse full responsibility for the content.

Role of the funding sources

KP received funding from the NIH (grants RO1MD017364; RO1DA045556-04S1; U01MD017412).

Declaration of interests

Authors declare no conflict of interest.