CARAM / BCHR: State of health of Migrant 2007- Mandatory testing in Bahrain
State of health of Migrant 2007 Mandatory testing in Bahrain
Mandatory testing Research is made by CARAM network and its member organization The Bahrain Center for Human rights BSHR. It is a part of comprehensive regional report that covers countries of origins and destinations . It is an annual report that included Bahrain for the first time.
1- Migrant-Friendly Testing
A- Informed consent B- Pre-test and post-test counselling C- Confirmatory tests D- Confidentiality of test results E- Referral systems for treatment, care and support F- Financial and Geographical Accessibility G- Language H- Gender and Cultural Sensitivity I- Policy J- Health Education K- Accessibility
2- Bahrain country report
A- Pre-Departure testing B- Testing Procedures and Handling of Results C- Accessibility to treatment, care and support for migrants D- Impact of result E- Reintegration
3- Action to be taken
a- Actions for governments in origin and destination countries b- Actions for health testing facilities c- Action by the privet sector d- Actions for embassies e- Actions for NGOs and CBOs f- Actions for international partners
Migrant-Friendly Testing
Mandatory medical testing is now being used to restrict the movement of migrant workers in the name of public health. The very idea of required testing connotes and reinforces the judgment that migrant workers are carriers of disease and are vectors for the spread of infections like HIV. Under this paradigm, current mandatory medical testing practices are conducted without respect for the rights of migrant workers and are punitive by nature, since failing the tests leads to loss of the right to travel to or stay in a destination country and thus denies them the right to employment.
Although CARAM AND BCHR does not, in any way, support mandatory testing of migrant workers, the reality is that there is currently no political will to abolish testing requirements, which widely includes HIV. As such, CARAM AND BCHR proposes a more humane manner of conducting medical tests among migrant workers: a “migrant-friendly” medical testing that assures the protection of the rights of migrant workers and ensures that their health and well-being is safeguarded.
This framework for “migrant-friendly testing” is characterised as being based on the principles of non-discrimination; is responsive to the contexts of migrants; and is conducted in an enabling environment that provides migrants the ability to make choices that support their health and well-being. In addition and ideally, CARAM AND BCHR believes that, in line with UNAIDS guidelines, testing of migrants should be accompanied by full access to antiretroviral therapy for those who are found to be HIV positive.
The principle of non-discrimination stipulates that migrants are treated in the same way as the general public under prevailing laws and policies regarding HIV testing, and are treated as human beings with full exercise of their human rights no matter which country they are in. Under the context of medical testing, this principle can be manifested in the following conditions:
• Informed consent Full informed consent is obtained from the migrant worker being tested. This means that all information about the health test is communicated to migrants in a way that they understand, considering language and literacy before providing formal consent. Information includes: the process of testing, the risks and benefits of health testing, consequences and implications of the results, and the treatment services available. Other elements of informed consent include how the test results will be communicated and the opportunity for the migrant to ask questions.
• Pre-test and post-test counselling In the conduct of HIV testing, proper pre-test and post-test counselling is provided in a way that migrants understand, taking into consideration their language and literacy level. Pre-test counselling includes basic information regarding HIV transmission, prevention, and the specific vulnerability of migrant workers; the process of testing, and the meaning of HIV test results.
Post-test counselling is provided individually to all migrant workers, regardless of their HIV test result, or at least to all HIV positive results. Post-test counselling for migrant workers with HIV positive test results is aimed at encouraging positive, healthy lifestyles, and providing information on available support services and treatment options. For migrant workers with negative HIV test results, counselling is directed at promoting safer lifestyles to prevent HIV infection, and can be given in a group setting if necessary.
• Confirmatory tests Government Health Institutions, in the form of centralised reference laboratories, have a mechanism for ensuring verification of all test results that render migrant workers unfit to work. Confirmation of test results is free of charge.
• Confidentiality of test results Full details of test results are given directly and only to the migrant worker on an individual basis, especially for an “unfit” result. An option of having a translator during disclosure of results is available with the assurance that confidentiality is observed by all involved. In the current reality where third parties are also provided with such results, these parties are not provided details on the condition found, but only the determination of whether the individual is fit, temporarily unfit or unfit.
• Referral systems for treatment, care and support Health testing is only ethically acceptable in a context where treatment, care and support are available in all stages of migration. Proper referral systems need to be in place at all testing centres to provide migrants with access to treatment, care and support. This requires facilitating contact with service providers and follow-up efforts to ensure migrant workers’ welfare.
Making medical testing responsive to the contexts of migrant workers means that there is acknowledgement of the unique situations migrants face, and that assistance is provided to counteract their vulnerable social position, which is most pronounced when they travel outside their home countries for work. This means fulfilling the following:
• Financial and Geographical Accessibility The location of testing centres in both origin and destination countries is decentralised to allow easier access for migrant workers whose residence or place of work are in geographically remote areas. This minimises transportation and other related costs that migrant workers would otherwise incur if testing centres are all located in the capital.
Testing fees, like all information pertaining to the medical testing process, are presented in a transparent manner to avoid unscrupulous practices by medical testing personnel. This implies a sound monitoring system and an accessible mechanism for redress by relevant regulatory bodies.
In cases where a migrant worker is found “unfit” to work, especially in the destination countries, repatriation costs are provided by employers or sponsors. Upon return to their home countries, repatriated migrant workers receive support or assistance from the Government to ease their reintegration.
• Language Stakeholders involved in the mandatory medical tests are required to explain the process of medical testing to migrant workers in a way that they can understand, considering language and literacy levels. This language requirement is also observed in the provision of counselling services, delivery or disclosure of results and in referring migrant workers to service providers. Although this is particularly important in destination countries where migrant workers may not speak the language of the nationals, the situation in origin countries may also require sensitivity to the language used by migrant workers in relation to ethnicity and terminology. If specific language capacity is not available among the staff of a testing centre, services of skilled independent translators are utilised.
• Gender and Cultural Sensitivity Medical testing centres observe proper gender matching by employing the services of female doctors to conduct examinations for female migrant workers, and male doctors for male migrant workers. In situations where there is a lack of female doctors, other female health personnel – midwives, nurses or others – are present during the course of the examination of female migrant workers.
There is a need to review the requirement of a physical examination that requires migrant workers to fully undress. If this is deemed necessary for medical purposes, then it is conducted with full explanation of every step of the examination process.
Sensitive examination procedures, including those involving the prostate, breast, pelvic or rectal areas, are fully explained to the migrant workers prior to the onset of the whole medical testing process. Such examinations are conducted with respect to privacy and cultural sensitivity.
Medical testing facilities respond to the needs of male and female migrant workers by having separate and sanitary restrooms or toilets, and separate cubicles for physical examinations and the like.
The ultimate goal of creating an enabling environment for migrants to access migrant-friendly testing is to ensure that migrants are able to make informed decisions in all matters pertaining to their health and well-being. As such, there is a need to formulate principles and strategies across the range of issues relating to medical testing for migrants. The following points need to be taken into account.
• Policy Medical testing for migrant workers is conducted in a manner that respects and protects their right to health, particularly, the right to information, privacy, bodily integrity and access to health care services. This can be realised if appropriate and sound policies are in place and are properly implemented in both sending and receiving countries. Such policies need to reflect the provisions enshrined in international conventions that promote and protect migrants’ rights, such as the Migrant Workers Convention. Furthermore, strict and regular monitoring of the implementation of these policies needs to be set up by Governments, with participation from civil society and migrants’ communities.
• Health Education Health education is institutionalised and implemented to improve the health-seeking behaviour of people and to enhance their awareness of their rights as individuals, as migrants and as patients. This way, migrants will be able to proactively seek health-related information and services.
• Accessibility Government-accredited medical testing facilities are accessible to migrants, geographically and financially, and without monopoly. Migrant workers are able to choose the most convenient testing facility s/he can access, without prejudice to quality medical testing facilities and procedures.
Medical testing should not be used simply as a screening mechanism to decide who can work and who cannot. Medical testing is foremost a process to prevent the occurrence of illness; and it is a gateway to access healthcare services, specifically treatment and care. More than a screening process, medical testing should be aimed at benefiting the health and well-being of migrant workers because they have a right to be healthy and they have a right to work productively.
BAHRAIN Report
Bahrain is a major destination country for migrant workers. The country is currently experiencing a construction boom and is promoting its tourism industry, both of which are fuelling the trend of migration to Bahrain for work in the construction and service industries. Another significant form of employment for migrant workers is as domestic workers: this is specifically for females.
Bahrain’s total population of 707,160 includes 268, 951 expatriates (38%) who account for over 50% of the country’s workforce. A major proportion of the migrant worker population comes from India, but there are also significant numbers coming from Bangladesh, Philippines, Indonesia, Pakistan, Nepal, Ethiopia, Eritrea, Somalia, Thailand, Sri Lanka and a number of countries in Eastern Europe. Workers from these countries mainly provide the workforce for 3-D jobs (work that is regarded as dirty, dangerous and demanding), or work in the entertainment sector. Bahrain also receives a smaller number of expatriate workers from the United States, Australia, South Africa and Western Europe, who tend to be employed in well-paid jobs with private companies or in the education sector. This research, however, focuses on migrants employed in the construction sector, as semi-skilled or skilled manual labourers, or as domestic helpers. These are the most vulnerable sectors where migrants find work.
Bahrain, as one of the Gulf Cooperation Council (GCC) member countries, follows the mandatory health testing of migrant workers in line with the rules and regulations of the Gulf Approved Medical Centres Association (GAMCA). Upon arrival, all construction workers and manual labourers are referred to the government’s centralised health facility for migrant workers, Al Razi Health Centre, which is a GAMCA centre. According to the centre’s own records, a total of 87,000 migrant workers were tested in 2006, meaning an average of 350 workers are tested per weekday.
Mandatory health testing for domestic workers is undertaken in a decentralised fashion; tests can be done at local health centres in the area where their employer lives. These health centres are accredited, licensed and operated by the Bahrain Ministry of Health. While the majority of foreign workers are documented, it is widely accepted that there are quite a few ‘floating’ migrants working in Bahrain. These are workers without the required documents, which includes being without a positive health test result. According to NGO workers and health professionals, these undocumented workers have evaded or escaped the testing process out of fear of the consequences of being declared unfit.
PRE-DEPARTURE TESTING
Bahrain does not require migrant workers to undergo pre-departure health testing in their country of origin unless they are from certain Sub-Saharan African countries. While some recruitment agencies and sending countries’ officials recommend and in some cases require it, in our research findings, there was little evidence of a standardised process of pre-departure testing for migrant workers. Some had undergone testing in their home countries and others had not. For example, most Filipinos interviewed stated they had been tested in the Philippines, all Bangladeshis interviewed stated they had not been tested in Bangladesh, and some Indians interviewed stated they had been tested before leaving India, while others had not.
For a number of respondents, pre-departure testing appeared to give a sense of security or legitimacy, but for other workers the fear of being prevented from temporarily migrating for employment made them avoid health testing in their home country or trying to manipulate the results. “They didn’t tell us anything, they gave us eye-test, x-ray and general check up. Because I had done the medical before [I left India] I had no worries.” (Male Indian garage worker)
“If you’re working in this kind of business then you have to be careful. Because we cannot go out of our country if we don’t have all this physical check up already. If you are a legitimate contract worker you have to pass all the tests before you go to Bahrain… But before you go to Bahrain, if you fail there you cannot come here. So you don’t have to worry about it… We are physically fit because we are legitimate – if you are not legitimate then that’s the worry.” (Female Filipina waitress)
“You know, they are supposed to undergo a medical in their own country. In many countries this either does not happen, or workers slip through other channels and avoid it, or are able to manipulate their results [by paying etc]. They probably travel with disease.” (Migrants’ support NGO worker)
To ensure monitoring of testing policies and procedures, GAMCA mandates that testing centres in sending countries undergo annual inspection by the GCC Executive Board Technical Committee for Gulf Countries, to ensure that they follow standards set by the GCC Health Ministries Executive Committee. Additional inspections are carried out if a complaint is filed about a particular centre, or if a high number of workers found unfit in a receiving country are being passed by a centre in a sending country.
“The Gulf Technical committee carries out annual inspections of health centres in sending countries. The centres are inspected to see if they meet standards set by the GCC Health Ministries executive committee. Additional checks are carried out if there are complaints regarding a particular centre, if a consistent number of unfit workers are given fit certificates from a particular centre. These centres will have penalties if they don’t meet the standards.” (GAMCA Official)
ON-SITE Testing Procedures and Handling of Results Following government laws, migrant workers are required to undergo mandatory medical testing only once per employment contract while in Bahrain. This is usually done on arrival. However, if they change employer or sponsor, the worker needs to do the test again . Barbers and those working in the food and beverage sector, in hotels or restaurants, need to test every year.
GAMCA testing guidelines prescribe a series of tests in sending countries, but in Bahrain itself, only a selective number of tests are conducted. All migrant workers in Bahrain are given chest x-rays and examined for pulmonary tuberculosis, but individual tests, including for HIV, vary according to the profession of the migrant worker. Female migrant workers are required to take a pregnancy test. As part of meeting GAMCA requirements, testing centres are obliged to have all equipment necessary to undertake the prescribed tests, meet international standards of quality control, and laboratories must have quality control certification by GAMCA.
GAMCA has established a monitoring process for the inspection of new centres and the evaluation of existing ones. Through this, new licenses can be recommended and old licenses can be renewed or revoked. Penalties including warnings, fines and/or temporary license suspension. An internal Ministry of Health committee monitors both the public and private health centres that provide mandatory health testing services to migrant workers. The private centres must be certified and endorsed by the Ministry of Health, via the Al Razi centre.
A Bahrain Ministry of Health official explained: “We test mainly with a clinical examination: blood pressure, vision, screening for any diseases. Some occupations are given blood test to check for HIV, hepatitis B and C and syphilis. All expatriates are given chest x-rays and checked for pulmonary tuberculosis. Process: go from X-ray station to blood pressure and vision station to physician. Sequence: X-ray, nurses’ station for blood pressure and vision, physician for general check up.”
However, almost none of the workers interviewed were aware of which health conditions or diseases were tested. Most could only state that they underwent a physical check, an X-ray and had a blood sample taken. When asked if they were told what they were tested for, the most common answer is a straight “No,” and most reported having no idea at all about the tests.
“No, we didn't talk about the tests.” (Male Bangladeshi construction worker) “They take the blood, the urine.” (Female Filipina domestic workers)
The research findings indicate that language diversity among health centre staff is low. GAMCA guidelines do not require staff to be able to speak migrants’ languages, although both health professionals and migrant workers mentioned this as an area for potential improvement in the mandatory health testing system. According to a doctor from a private testing centre frequently used by migrant workers, language barriers contribute to the lack of information provided to workers by medical personnel at testing centres.
“Because sometimes I feel there is a gap during the conversation, with the language problem, [this is] a very big problem. So maybe they cannot explain what happened and what to do next.”
With regards to gender and cultural sensitivity, all respondents indicated satisfaction with the process and treatment by staff. All stated that they were segregated according to gender while being tested, and that doctors were gender matched. All responden