Thirty countries signed a political declaration at an international meeting in Morocco last week calling for the health of refugees and migrants to be included in national health systems and universal health coverage. A total of 50 UN member and observer states attended the talks.

The Rabat Declaration, signed on Friday, is the first official outcome document on the health of refugees to emerge from a series of Global Consultations on the Health of Refugees and Migrants that began in Istanbul in March last year. 

“Universal health coverage is only truly universal if it includes refugees and migrants,” the declaration states. 

The World Health Organization (WHO), UN High Commissioner for Refugees (UNHCR), International Organization for Migration (IOM) and UN Refugee Agency called the declaration “groundbreaking”.

“Member States today have pledged that no one will be left behind when addressing the health needs of those forcibly displaced,” said Raouf Mazou, Assistant High Commissioner for Operations at UNHCR, in a joint press release. 

“Their commitment to not only include refugees, migrants and their hosting communities in national health policies and plans, but to also include them meaningfully in policy health discussions is a significant momentum towards universal health coverage and worthy of global support,” he said.

The declaration also calls for increased international efforts for “the protection of refugees, stateless persons, asylum-seekers and other forcibly displaced persons”, recognizes the “positive role and contributions of migrants and refugees for inclusive growth and sustainable development”, and emphasises the need for regional and national health strategies that “include measures to reach refugees and migrants … with the aim of leaving no one behind”. 

“Refugees and migrants face significant threats to health, and significant barriers to accessing the health services they need,” said WHO Director-General Tedros Adhanom Ghebreyesus. “Protecting the health and dignity of refugees and migrants during their often-dangerous journeys, and in the countries hosting them, is a matter of human rights, and human decency.”

Two previous rounds of international meetings on “migrant health” — concluded in Madrid in 2010 and Colombo in 2017 — did not include “refugees” in their official scope. The Colombo statement, signed by 19 countries at the conclusion of the 2017 round of talks, makes no reference to refugees in its guiding principles. 

WHO spotlights refugee health challenges

A WHO spokesperson described the declaration as the latest in a series of WHO and international actions to recognize refugees’ unique health challenges:

“The declaration comes at a crucial moment after the adoption of the Global Compact for Safe, Orderly and Regular Migration (GCM) and the Global Compact on Refugees (GCR) in 2018, the adoption of the WHO Global Action Plan on Promoting the Health of Refugees and Migrants in 2019 and its extension until 2030 just adopted by the World Health Assembly in May this year, the International Migration Review Forum in 2022 and prior to the Global Refugee Forum in December 2023,” the spokesperson said.

“In the declaration Member States commit to stronger global coordination and collaboration for better health outcomes of refugees and migrants, as well as actions that improve the health of these populations, such as sustainable Universal Health Coverage (UHC) financing mechanisms or health system strengthening; the development of high-quality global research on the health of refugees and migrants; investments in data to develop a monitoring framework; the participation of refugees and migrants in health policy discussions; and cooperation and financial mechanisms to assist the efforts of host countries at the national and local levels.”

Lack of broader country support 

Countries hosting large numbers of refugees were among the leading signatories of the new statement. These include Turkey, Jordan, Morocco, Lebanon and Iran in the Middle East; Libya, Chad, Somalia, and Algeria and Ethiopia in Africa; Guatemala, Honduras and Mexico in Latin America; and India, the Philippines and Thailand in Asia.  

Notably, the USA, Italy, Greece, Romania, Slovakia, and Portugal also supported the declaration. Canada, the United Kingdom, Germany, Norway, Sweden and other countries in Europe that play host to large numbers of refugees were not among the signatories. 

IOM and UNHCR could not be reached for further comment on the implications of the declaration or its political supporters, in time for publication.

In response to the relatively low number of signatories, WHO said that the increased attendance, which has more than doubled since the second consultation in 2017, reflects increased “interest in commitment to improving the health of refugees and migrants and addressing the root causes of poor health outcomes”. 

“This positive trend is very much aligned with the adoption of a resolution to extend the WHO Global Action Plan on Promoting the Health of Refugees and Migrants until 2030, which was put forward by almost 30 governmental co-sponsors,” WHO said. “With the resolution, Member States have seven more years to continue to address the health needs of refugees and migrants, integrate refugee and migrant health in global, regional, and national initiatives, and identify and share challenges, lessons learned, and best practices related to implementing the global action plan.”

WHO’s European Region is currently negotiating a new regional action plan on the health of refugees and migrants, with the participation of the countries of the region, the spokesperson added.

In a landmark WHO report in 2022, the agency noted that migrants and refugees face big hurdles in accessing health services in two-thirds of their host countries. 

The report called for more active integration of migrants and refugees into the national health system schemes of their host countries – saying that their inclusion is critical to meeting 2030 Universal Health Coverage goals. A United Nations High Level Meeting on Universal Health Coverage, is scheduled for September. 

Algeria opposes registration of refugees in health system

During three days of negotiations over the statement in Rabat, Morocco last week (13-15 May), Algeria stirred up controversy when its delegation came out in opposition to a key section of the declaration, which notes the international legal obligation of host countries to register refugees in order for them to access national health systems. 

Algeria is home to an estimated 111,500 refugees from Sub-Saharan Africa and Syria. Around 90,000 of these are Sahrawi refugees who live in five camps near the Saharan desert town of Tindouf, which borders the disputed region of the Western Sahara, Morocco and Mauritania. The Sahrawi are considered by UNHCR to be the “most vulnerable” of the region’s refugees.

The Saharawi region is claimed by Morocco. It is recognized as an independent state known as the Sahrawi Arab Democratic Republic by the Africa Union but not by the United Nations. 

While Algeria did not publicly provide a rationale for its opposition to registration, this is typically seen by many host countries as a step towards the granting of legal refugee asylum status, which they want to discourage.  

Even so, refugees and asylum seekers in Algiers are allowed free access to the national health system, with around 86% of such people in the capital being treated primarily by its public health system, according to UNHCR.

In the harsh deserts of Tindouf, however, Saharawi refugees rely almost entirely on humanitarian assistance. In 2022, UNHCR provided 70% of required medical equipment and supplies in addition to funding training programmes for doctors, nurses and midwives within the camp. The World Food Programme is also responsible for providing essential food supplies across the five camps.  

The UNHCR describes the predicament of Sahrawi refugees as “one of the most protracted refugee situations in the world”, with many Sahrawi having lived in Tindouf for over 45 years.  

Over 150,000 Sahrawi were displaced in a 16-year war with Morocco and Mauritania following Spain’s retreat from its colonial territories in the Western Sahara in 1975 – some of which was the Sahrawi homeland. 

Sahrawi claims are supported by a 1975 International Court of Justice ruling recognizing their claims to self-determination, and a ceasefire agreement negotiated by the UN in 1991 on the condition that a referendum on Sahrawi independence be held. However, the referendum has never been held and the conflict remains unresolved.

See also the WHO Global Health Matters series: How can we ensure that health is a reality for migrants and refugees

Image Credits: International Rescue Committee, Flickr – USAID, Leiv Meir Clancy, European Commission.