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Bangladesh

Health Vulnerabilities of Migrants from Bangladesh - Baseline Assessment

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Executive Summary

Aims: This study aimed to understand the health vulnerabilities of departing and returnee migrants in Bangladesh in order to inform policy and programme development regarding the health of migrants in South Asia. It was conducted as part of the IOM project, ‘Strengthening Government’s Capacity of Selected South Asian Countries to address the Health of Migrants through a Multi-sectoral Approach’ that is being implemented in Bangladesh, Nepal and Pakistan from 2013 to 2015.

Methodology: The study population consisted of departing and returnee migrants (those preparing to leave and those residing in the country of origin for no longer than 12 months following a period of migration aboard for work) and their spouses in Bangladesh. The study employed a mixed-methods approach that combines both quantitative and qualitative methodology. For quantitative data collection, interviews were conducted using a structured questionnaire, while qualitative data was collected through Key Informant Interviews (KII) with relevant government, international organizations and community-based organizations and Focus Group Discussions (FGD) with returnee migrants and their spouses. A multistage cluster sampling technique was used for the quantitative sampling. Qualitative participants were recruited through snowball and network recruitment. Research tools were pre-tested and translations of the tools into Bangla or Bengali languages were validated. Informed consent was sought from all the study respondents and participants before incorporating them under this study.

Results: This study interviewed 424 respondents for the quantitative survey, consisting of 206 departing and 218 returnee migrants; 357 male and 67 female respondents. More than 80 per cent of respondents were 35 years of age or younger, almost two thirds were married. More than 80 per cent of departing migrants and about 50 per cent of returnee migrants had no formal education or having completed primary education only. Relatives were the most prominent source of assistance during the migration process (82% and 77% respectively) for both departing and returnee migrants.

Using a condom for preventing pregnancy was a main concern for sex with regular partners such as spouses and girlfriends or boyfriends (60-84%). Preventing STI or HIV transmission was more important for casual or commercial partners (50%). While abroad, only six per cent (14 respondents) of 218 studied returnees indicated that they ever had sexual intercourse while they were staying abroad. Seven per cent of returnee migrants had experienced forced sexual intercourse while abroad, of which almost all were women.

The majority of Bangladeshi departing and returnee migrants (84%) indicated that health-care services were available in their home communities in Bangladesh, while 66 per cent reported that they could access public health services any time. The majority had access to services at an affordable rate within their communities while just over a quarter of departing and returnee migrants experienced financial difficulties accessing health-care in Bangladesh. Availability of the doctor was the most commonly cited barrier to health-care access among all migrants (56%), followed by unaffordable costs (39%) and long distances (29%). As for HIV and STI services, only twelve per cent were aware of HIV/STI testing and fourteen per cent were are aware of HIV care and treatment services in their communities. Departing migrants showed higher reliance on private facilities while most of returnee migrants relied on government centres at the community level.

Regarding accessing to health services in destination countries, half of the surveyed returnee migrants were aware of places where they could access care and treatment. Government facilities were most commonly mentioned (49%), followed by a private facility (31%). 28 per cent of migrants perceived health-care abroad to be easily affordable or affordable. Among those that sought health-care, the most common form of health-care financing was out-of-pocket payments, with 61 per cent of patients paying health-care services by themselves. Health insurance accounted for only one per cent of all health-care financing; however 12 per cent of returning migrants had insurance.

As respondents of the survey were documented migrants and sampling was coordinated through the Bureau of Manpower, Employment and Training (BMET), a high proportion (87%) of Bangladeshi migrants who participated in the survey underwent a medical examination which is mandatory prior to their departure.

The majority of Bangladeshi migrants who participated in this study perceived themselves not to be at risk of Tuberculosis (TB), HIV, STIs or Hepatitis C, and 85 per cent had no pre-departure health orientation, training or counselling. Because of perceived low risk and costs, migrants generally did not seek health-care upon their return. One third of the returnee migrants did not think or were not unaware that there are some diseases that can be transmitted to their partners or family. Of the 62 per cent of returnees that were aware of communicable diseases, 93 per cent mentioned HIV/AIDS and STIs.

Bangladeshi migrants received health related information mostly from television (87%) followed by health-care facilities or doctors (44%), newspaper and billboard/signboard/poster (both 30%).

However, more than a third of them faced difficulties understanding the content. Television, friends/ relatives, and newspapers were the main sources of HIV and health information when they were in destination countries. Returnee migrants were generally not exposed to any migrant-targeted health communication materials in the country of destination.

Results from the qualitative study found that there were no health services specifically targeting departing or returning migrants in Bangladesh. According to stakeholders, Government Organizations do not offer curative or palliative health-care services specifically targeting inbound or outbound migrants only. Pre-departure mandatory medical examinations are carried out as a component of bilateral agreements with countries of destination, such as Malaysia or countries of the Gulf Cooperation Council (GCC). Only health facilities located in Dhaka are licensed by GCC to provide medical certificates, which poses a financial and time burden for potential migrants that live in more remote areas. The pre-departure orientation was only provided to regular migrants going through regular recruiting agencies. The present migration policy does not include health issues, while the relatively new health policy of Bangladesh does not cover migrant issues. While the strategic plan for HIV mentions migrants as a vulnerable group, it fails to detail an implementing policy.

Recommendations: The major recommendations from the study include the need for Government of Bangladesh to improve migrant-friendly services for departing and returning migrants, such as tailored sexual and reproductive services and psychosocial counselling. Health-care quality and provider competency requires further development and training, including preventing discrimination towards patients with a migration background. More steps should be taken at the national level to implement universal health coverage and prevent out-of-pocket expenditures of Bangladeshi migrants while abroad. Government of Bangladesh needs to develop a regulatory mechanism to effectively monitor the activities of private health providers, recruitment agencies, and medical testing centres. More pressure should be applied to employers and recruitment agencies to ensure migrants receive fair, equitable, comprehensive, and acceptable pre-departure health examination and orientations, and health-care in the country of destination. Employers should further ensure adherence to ethical and safe working conditions and comply with international standards of occupational health and safely. Radio and television, including ‘Deshi’ channels, should be harnessed for effective health communications that encourage health-care seeking. As a foundation for these suggestions, Government of Bangladesh should review the compliance of the ratified global migration related conventions and incorporate health as an essential and ‘nonnegotiable’ component in bilateral agreements. Government of Bangladesh should implement migrant-friendly services through participatory and transparent planning inclusive of migrant and local health provider representatives, and harnesses the guidance and comparative advantages of relevant NGOs.