Capturing the evidence on access to essential antibiotics in refugee and migrant populations

Overview

The fourth report of the Global Evidence Review on Health and Migration (GEHM) series synthesizes available evidence on access to essential antibiotics in refugee and migrant populations. The report captures evidence across four themes related to antibiotic access and use: access, appropriate use, barriers to access and use, and interventions to improve access and use.

Findings of the report suggest that access to and use of antibiotics by refugee and migrant populations is heterogeneous and is significantly influenced by the health systems of the host countries, as well as by non-health policies and factors. Evidence on access to antibiotics, antibiotic use compared with the host population and quality of available antibiotics is almost non-existent for refugee camp settings and for migrants residing in low- and middle-income countries (LMICs). Given the variability in health systems across countries with different income levels, refugees and migrants face a wide range of barriers in obtaining health services and, by extension, in accessing and using antibiotics.

The report provides policy considerations for equitable access and appropriate use of antibiotics among refugee and migrant populations in five areas: global governance, research and surveillance, and barriers to seeking formal care, utilizing formal care and receiving adequate and quality care. 

Executive summary

Antimicrobial resistance (AMR) is a complex global health challenge, with significant implications for human health, social well-being and economic development. Bacterial AMR alone causes over 1.27 million deaths annually worldwide. Although the development of resistance in pathogens is natural and unavoidable, the emergence of AMR has been accelerated by decades of overuse of antimicrobials across sectors, prematurely rendering these drugs less effective in treating common infections.

Maintaining the ability to treat serious infections requires a balance between equitable access to and appropriate use of existing and new antimicrobial medicines for all. International refugee and migrant populations may be particularly vulnerable to rising AMR; the draft global action plan for the promotion of the health of refugees and migrants underscores the importance of appropriate antibiotic use and prevention of AMR. The number of international refugees and migrants has grown significantly since the early 2000s, reaching an estimated 281 million, or about 3.5% of the global population, in 2020.

The conditions under which refugees and migrants leave their countries of origin and transit to their destination countries may lead to increased infections, as well as to disruptions and barriers to health care access.

This Report, the fourth in the Global Evidence Review on Health and Migration (GEHM) series, synthesizes the available evidence across four themes related to antibiotic access and use:
(i) access,
(ii) appropriate use,
(iii) barriers to access and use, and
(iv) interventions to improve access and use.

It provides policy considerations for equitable access and appropriate use of antibiotics among refugee and migrant populations. A scoping review found scarce evidence on access and use of antibiotics by refugees and migrants and that existing research largely focuses on migrants residing in high-income contexts; therefore, generalizability of the findings is limited. However, the available evidence suggests that access to and use of antibiotics by refugee and migrant populations is heterogeneous and is significantly influenced by the health systems of the host countries, as well as by non-health policies and factors. Evidence on access to antibiotics, antibiotic use compared with the host population and quality of available antibiotics is almost non-existent for refugee camp settings and for migrants residing in low- and middle-income countries (LMICs). Differences in health systems, legal entitlements and drug reimbursement programmes have resulted in variable levels of access to antibiotics for refugees and migrants across high-income countries (HIC). Systemic factors in the countries of origin, transit and destination play a major role in determining patient behaviours and facilitating access to and appropriate use of antibiotics. The review identified no evidence on the direct or indirect impact of the COVID-19 pandemic on access to antibiotics in refugee and migrant populations.

Given the variability in health systems across countries with different income levels, refugees and migrants face a wide range of barriers in obtaining health services and, by extension, in accessing and using antibiotics. Previous unsatisfactory experiences with formal care can act as a barrier to refugees’ and migrants’ desire for formal care, as can norms and preferences that encourage self-medication and the ease of informal access to antibiotics. Those refugees and migrants who do desire care may face barriers related to stigmatization, fear of deportation or language, and may also be unable to reach formal care due to financial and time constraints. Moreover, lack of knowledge about antibiotics and their appropriate use may contribute to the unnecessary or incorrect use of antibiotics. Aspects of the health system that can create barriers to access to and appropriate use of antibiotics include long waiting times and limited capacity of health services, high health care costs, diagnostic uncertainty, and lack of translated materials or interpreter services.

Policy considerations

This GEHM synthesized the available evidence on barriers to antibiotic access and appropriate use refugees and migrants, and on interventions implemented to address these barriers. Based on its findings, policy considerations are given in five areas: global governance, global data collection, and overcoming national-level barriers to seeking formal care, utilizing formal care and receiving adequate and quality care.

Global governance

• Strengthen engagement between key institutions for coordinated global governance.
• Align and integrate action plans for a coherent framework and concerted action.
• Establish financial arrangements in LMIC markets for equitable antimicrobial access and use.

Global data collection: research and surveillance

• Strengthen surveillance systems for data-driven and evidence-informed policy solutions.
• Support research to fill substantial knowledge gaps.
• Overcoming national-level barriers to seeking formal care
• Facilitate access to care by improving language accessibility.
• Monitor and support the provision of migrant- and refugee-sensitive cultural training for health care personnel.
• Improve migrants’ and refugees’ knowledge of antibiotics through communitybased initiatives.

Overcoming national-level barriers to utilizing formal care

• Remove status-related barriers to care.
• Ensure that essential antibiotics are affordable.
• Improve knowledge of and registration for entitlements to care.
• Avoid restrictions that limit access to antibiotics for vulnerable populations.
• Overcoming national-level barriers to receiving adequate and quality care
• Ensure access to the tools necessary for optimal case management in vulnerable populations.