Abstract

In 2018, the Pan American Health Organization (PAHO) established mass migration as a priority health issue in national, sub-regional, and regional agendas (¹1. Pan American Health Organization/World Health Organization. Guidance document on migration and health [Internet]. 2019. [cited 2022 Jun 28] Available from: https://www.paho.org/hq/index.php?option=com_docman&view=download&slug=guidance-document-on-migration-and-health&Itemid=270&lang=en
https://www.paho.org/hq/index.php?option... ). In recent years, two simultaneous mass migratory phenomena in the Americas are occurring as people from Central American countries and Venezuela migrate to other countries in the Region.

As of December 2022, approximately 7.13 million Venezuelan refugees and migrants had left their country, with 5.99 million relocating to other countries in Latin America and the Caribbean (²2. Refugees and Migrants from Venezuela (R4V) [Internet]. [cited 2022 Jun 28]. Available from: https://www.r4v.info/en/refugeeandmigrants
https://www.r4v.info/en/refugeeandmigran... ). Colombia, Peru, and Ecuador bear the heaviest burden of migration, with over 4.47 million migrants from Venezuela currently being hosted in those countries. The United Nations Refugee Agency has called this “the largest displacement of people in the history of Latin America” with Venezuelan migration second only to Syria (³3. United Nations High Commissioner for Refugees. Refugee Statistics [Internet]. [cited 2022 Jun 28]. Available from: https://www.unhcr.org/refugee-statistics/
https://www.unhcr.org/refugee-statistics... ).

By late 2020, there were an estimated 715 000 refugees and asylum seekers globally from Central America and Mexico en route to the United States and Canada; there has been a sharp increase since January 2022 which is estimated could result in half a million migrants requiring humanitarian assistance (⁴4. International Organization for Migration. Migration data in Central America [Internet]. In: Migration data portal. [cited 2022 Jun 28]. Available from: https://www.migrationdataportal.org/regional-data-overview/migration-data-central-america
https://www.migrationdataportal.org/regi... ,⁵5. International Federation of Red Cross and Red Crescent Societies. 210,000 migrants need urgent life-saving assistance and protection in Central America and Mexico [Internet]. [cited 2022 Dec 19]. Available from: https://www.ifrc.org/press-release/ifrc-210000-migrants-need-urgent-life-saving-assistance-and-protection-central
https://www.ifrc.org/press-release/ifrc-... ). Most of the refugees and asylum seekers from the Region were from three countries in particular: Guatemala, Honduras, and El Salvador, also known as the Northern Triangle, with a notable increase of individuals from Nicaragua, as well as from Cuba, Haiti, and Venezuela (⁴4. International Organization for Migration. Migration data in Central America [Internet]. In: Migration data portal. [cited 2022 Jun 28]. Available from: https://www.migrationdataportal.org/regional-data-overview/migration-data-central-america
https://www.migrationdataportal.org/regi... ,⁵5. International Federation of Red Cross and Red Crescent Societies. 210,000 migrants need urgent life-saving assistance and protection in Central America and Mexico [Internet]. [cited 2022 Dec 19]. Available from: https://www.ifrc.org/press-release/ifrc-210000-migrants-need-urgent-life-saving-assistance-and-protection-central
https://www.ifrc.org/press-release/ifrc-... ). According to Doctors Without Borders, about half a million people flee violence and poverty from Central America towards North America each year (⁶6. Médecins Sans Frontières. Central American Migration in depth. [Internet]. [cited 2022 Jun 28]. Available from: https://www.msf.org/central-american-migration-depth
https://www.msf.org/central-american-mig... ).

Sexual and reproductive health and rights (SRHR) are integral to health and ensuring access to sexual and reproductive health services among migrants remains an important public health priority (⁷7. United Nations. A/RES/71/1: New York Declaration for Refugees and Migrants:24. [cited 2022 Jun 28]. Available from: https://www.un.org/en/development/desa/population/migration/generalassembly/docs/globalcompact/A_RES_71_1.pdf
https://www.un.org/en/development/desa/p... ). There is evidence suggesting that migrants may have limited access to sexual and reproductive health services and may face specific threats to their SRHR (⁸8. World Health Organization. Promoting the health of refugees and migrants. Draft global action plan, 2019-2023. Report by the Director-General. [Internet]. 2019 Apr. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_25-en.pdf
https://apps.who.int/gb/ebwha/pdf_files/... –¹⁰10. Brizuela V, Kapilashrami A, Bonet M, Khosla R, Kobeissi L, Say L, et al. Sexual and reproductive health and rights of migrants: strengthening regional research capacity. Bull World Health Organ. 2021 May;99(5):402–4.). Sex and gender-defined roles impact the experience of migrants and refugees everywhere; women and girls are significantly affected in both sudden and slow-onset humanitarian crises and face multiple SRHR challenges, as do lesbian, gay, bisexual, transgender, queer, and intersex persons (LGBTQI+) and sexual minorities (¹¹11. Singh NS, Aryasinghe S, Smith J, Khosla R, Say L, Blanchet K. A long way to go: a systematic review to assess the utilisation of sexual and reproductive health services during humanitarian crises. BMJ Glob Health. 2018 May;3(2):e000682.–¹³13. World Health Organization. World report on the health of refugees and migrants [Internet]. Geneva: World Health Organization; 2022 [cited 2022 Dec 19]. Available from: https://www.who.int/publications-detail-redirect/9789240054462
https://www.who.int/publications-detail-... ). These challenges are often associated with increased exposure to sexual and gender-based violence, increased rates of complications during pregnancy and post-pregnancy, complications due to unsafe abortions, and increased rates and suboptimal management of sexually transmitted infections and HIV/AIDS, among others (⁹9. Kobeissi L, Nair M, Evers ES, Han MD, Aboubaker S, Say L, et al. Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings. Confl Health. 2021 Mar;15(1):10.–¹¹11. Singh NS, Aryasinghe S, Smith J, Khosla R, Say L, Blanchet K. A long way to go: a systematic review to assess the utilisation of sexual and reproductive health services during humanitarian crises. BMJ Glob Health. 2018 May;3(2):e000682.).

The mass migration observed in Latin America has added pressure on the health systems of countries receiving these sudden influxes of people in a short timeframe (¹⁴14. Pan American Health Organization/World Health Organization. Regional ministerial meeting on mass migration and health [Internet]. Washington DC: PAHO; 2018 Nov p. 17. Available from: https://www.paho.org/en/file/52172/download?token=glbwhgQX
https://www.paho.org/en/file/52172/downl... ). The need for context-specific and locally led evidence generation on issues related to health and mass migration has become paramount. This is particularly relevant for migrants’ SRHR, risks of infectious diseases, and with regards to the health system capacity to address their needs.

RESEARCH AND RESEARCH CAPACITY STRENGTHENING FOR HEALTH SYSTEM RESPONSE

In an effort to strengthen health system response and to better understand the SRHR needs of migrants from Venezuela and Central America, a collaborative call for research proposals was issued in 2019. The call was led by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) through the HRP Alliance for research capacity strengthening, in collaboration with the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), the Alliance for Health Policy and Systems Research (AHPSR), the Latin American Center of Perinatology, Women and Reproductive Health (CLAP) part of the Pan American Health Organization (PAHO), and the HRP Alliance regional research capacity strengthening hub at the Centro de Pesquisas em Saúde Reprodutiva de Campinas (CEMICAMP).

Twelve proposals focusing on implementation research and individual and institutional research capacity strengthening were selected out of a total of 66 received. Projects were reviewed by two individuals independently using a pre-established rubric: one reviewer was staff of one of the organizations leading the call while the second was an external reviewer recruited for their expertise on the topic. Scientific merit, relevance, innovation, cost-efficiency, potential for capacity strengthening for the institution, and feasibility were evaluated. The selected projects were from teams affiliated with research institutions, universities, and/or ministries of health in countries affected by the migration crisis. Grants were awarded for an average of USD 36 600 to be completed within 12 months. All projects were approved by local ethics review committees and PAHO’s ethics review committee (PAHOERC). Eleven projects from eight countries–Brazil, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, and Peru–were finally implemented. Research teams were encouraged to include young researchers and female researchers in their teams; seven out of the 11 projects had female PIs.

The onset of COVID-19 in the Region further compounded the existing challenges that migrants face, and in particular given the strict lockdown measures implemented coupled with high caseloads of COVID-19 infections (¹⁵15. Vélez CM, Aguilera B, Kapiriri L, Essue BM, Nouvet E, Sandman L, et al. An analysis of how health systems integrated priority-setting in the pandemic planning in a sample of Latin America and the Caribbean countries. Health Res Policy Syst. 2022 May 31;20(1):58.–¹⁸18. Ratto MC, Cabrera JM, Zacharías D, Azerrat JM. The effectiveness of government measures during the first wave of the outbreak. Soc Sci Q. 2021 Sep;102(5):2088–105.). It also delayed initiation of studies, selected in early February 2020, just weeks before the pandemic was declared by the World Health Organization (¹⁹19. Palmero A, Carracedo S, Cabrera N, Bianchini A. Governance frameworks for COVID-19 research ethics review and oversight in Latin America: an exploratory study. BMC Med Ethics. 2021 Nov 6;22(1):147.,²⁰20. WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020 [Internet]. [cited 2020 Apr 16]. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/dg/speeches/detail/w... ). Many ethics committees were focusing solely on COVID-19 related projects during early stages of the pandemic, and lockdown and other safety protocols forced teams to adjust their protocols to novel recruitment of participants.

This supplement collects main findings from the 11 implemented studies. Using qualitative and quantitative methods–through interviews, surveys, and desk reviews–projects highlighted the barriers and facilitators that migrants face in accessing care, and presented information relating to abortion and sex work among migrants.

BARRIERS IN ACCESSING CARE BY MIGRANTS FROM VENEZUELA AND CENTRAL AMERICA

Several articles focused on the barriers that migrants from Venezuela faced in different settings. Mocelin and colleagues highlighted how language, out-of-pocket expenses relating to accessing care, and COVID-19 challenges acted as barriers to access HIV/AIDS and syphilis treatment in Brazil (²¹21. Mocelin HJS, Jezus SV, Negri LSA, Borges BJP, Silva AI, Maciel ELN. Barreiras e facilitadores do enfrentamento de HIV/aids e sífilis por venezuelanas residentes no Brasil. Rev Panam Salud Publica. 2023;47:e3. https://doi.org/10.26633/RPSP.2023.3
https://doi.org/10.26633/RPSP.2023.3... ). On the other hand, the Brazilian universal health system and other health policies acted as facilitators to access care. Ortiz Ruiz et al exposed the vulnerability faced by migrants in Cali, Colombia, with regards to their life conditions as well as the need for sexual and reproductive health information, especially among LGBTQI⁺ migrants (²²22. Ortiz-Ruiz N, Díaz-Grajales C, López-Paz Y, Zamudio-Espinosa DC, Espinosa-Mosquera L. Necesidades en salud sexual y reproductiva en migrantes de origen venezolano en el municipio de Cali (Colombia). Rev Panam Salud Publica. 2023;47:e4. https://doi.org/10.26633/RPSP.2023.4
https://doi.org/10.26633/RPSP.2023.4... ). They highlighted the curtailed social integration into Colombian society, particularly among undocumented migrants from Venezuela. Guijarro et al showed that most healthcare professionals in Quito, Ecuador did not feel migrants faced discrimination in accessing care yet agreed that migrant women faced greater barriers to access SRHR services (²³23. Guijarro S, Torres AL, Montero G, García M, Sabay H, Iribarren S et al. Perspectives of health practitioners on the challenges to accessing sexual and reproductive health care services for Venezuelan migrant women during the COVID-19 pandemic in Quito, Ecuador. Rev Panam Salud Publica. 2023;47:e58. https://doi.org/10.26633/RPSP.2023.58
https://doi.org/10.26633/RPSP.2023.58... ). Similarly, Pesantes et al presented positive experiences reported by women from Venezuela needing access to maternal health services in two municipalities in Lima, Peru despite some challenges from the health system, such as maternal health policies (²⁴24. Pesantes MA, Cortez Farfan L, Scaramutti C, Portocarrero J, Haghparast-Bidgoli H, Miranda J. Respondiendo a las necesidades de salud sexual y reproductiva de las migrantes venezolanas en Lima. Rev Panam Salud Publica. 2023;47 (forthcoming).).

With regards to migrants from Central America, Herrera Ortiz et al found that about one third of migrants in Chiapas, Mexico, had antibodies for HSV-2 and about 11% presented antibodies for T. pallidum (17% among men and 3% among women) where about 3% had active syphilis infection (²⁵25. Herrera-Ortiz A, Sanchez-Aleman M, García-Cisneros S, Olamendi-Portugal ML; Vergara-Ortega DN, Rincón León H. Alta seroprevalencia de sífilis y herpes genital en migrantes en tránsito en Chiapas, México. Rev Panam Salud Publica. 2023;47 (forthcoming).). Letona et al exposed some of the challenges women and girls in the Northern Triangle in Guatemala faced during their migratory trajectory (²⁶26. Letona P, Felker-Kantor E, Wheeler J. Sexual and reproductive health of migrant women and girls from the Northern Triangle of Central America. Rev Panam Salud Publica. 2023;47:e59.). These included limited access to menstrual pads and hygiene products, SRHR and antenatal information and services, exposure to transactional sex and sexual violence, and increased risk of sexually transmitted infections. In the article by Llanes et al many barriers and some facilitators to accessing SRHR services were identified by migrants from Central America living in shelters in Tijuana, Mexico (²⁷27. Llanes-Díaz N, Bojórquez-Chapela I y Odgers-Ortiz O. Oferta de servicios de salud sexual y reproductiva a personas migrantes centroamericanas en Tijuana. Rev Panam Salud Publica. 2023;47:e56. https://doi.org/10.26633/RPSP.2023.56
https://doi.org/10.26633/RPSP.2023.56... ). However, some of these were perceived differently by healthcare providers and migrants, i.e., proximity to shelters was perceived as a facilitator by providers but not by migrants. Lastly, Alvarado Ascencio et al found that most of existing health information systems in El Salvador do not collect information on migratory status and most national policies do not specify actions towards the health of migrants, acting as barriers to implementing WHO guidelines regarding the health of migrants and refugees (²⁸28. Alvarado Ascencio N, Castro Montoya A, Mendoza Salguero G. Desafíos que enfrenta El Salvador para cumplir los lineamientos de la Organización Panamericana de la Salud sobre migración y salud. Rev Panam Salud Publica. 2023;47 (forthcoming).).

RESPONDING TO SENSITIVE ISSUES AMONG MIGRANTS: ABORTION AND SEX WORK

Quintero et al uncovered barriers in access to abortion and related SRHR services among migrants from Venezuela in Colombia, namely lack of information and mistreatment when accessing care, as well as personal attitudes towards abortion (²⁹29. Quintero LD, Osorio Osorio H, Bojorquez-Chapela I, Isaza L, Acosta-Reyes J, Fernández-Niño JA. Interrupción voluntaria del embarazo y salud sexual y reproductiva en mujeres migrantes en Barranquilla. Rev Panam Salud Publica. 2023;47:e49. https://doi.org/10.26633/RPSP.2023.49
https://doi.org/10.26633/RPSP.2023.49... ). Restrepo Pineda et al found that condom use was not consistent among sex workers and even less likely among Venezuelan male sex workers whose precarious financial situation led them to riskier, yet more profitable, practices (³⁰30. Restrepo Pineda JE, Villegas Rojas S. Factores asociados con el uso del condón en trabajadoras y trabajadores sexuales de origen venezolano en Colombia. Rev Panam Salud Publica. 2023;47:e2. https://doi.org/10.26633/RPSP.2023.2
https://doi.org/10.26633/RPSP.2023.2... ). Paulino Ramirez et al exposed feelings of depression and isolation among migrants from Venezuela turning to sex work to survive in the Dominican Republic (³¹31. Paulino-Ramírez R, Felker Kantor E, Faccini M, Rodríguez-Lauzurique RM, Canario De La Torre M, Henríquez-Cross A, et al. Healthcare access and migration experiences among Venezuelan female sex workers living in the Dominican Republic. Rev Panam Salud Publica. 2023;47:e55. https://doi.org/10.26633/RPSP.2023.55
https://doi.org/10.26633/RPSP.2023.55... ).

CONCLUSION

The evidence emerging from this special issue highlights the specific needs of Latin American migrants with regards to health system response to sexual and reproductive health and infectious diseases. While policies relating to the health of refugees and migrants and efforts to strengthen health systems in host countries exist, migrants in Latin America still face a myriad of challenges when navigating health systems in addressing their SRHR needs. The COVID-19 pandemic further exacerbated these challenges. Specific SRHR actionable policies are needed to ensure the needs of migrants are fully met.

Disclaimer.

The author holds sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health or those of the Pan American Health Organization. Authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO).

Acknowledgements.

The authors would like to thank the 59 individuals who reviewed the research proposals for their time and assessments, and their continued commitment towards improved global health. They would also like to thank Dr. Carla Saenz and Ms. Marcie Neil, from PAHOERC who provided training and invaluable support during protocol development and through the ethics approval processes. The authors would also like to thank CEMICAMP, who coordinated the grant call and supported the research teams over the past two years through protocol development, project implementation, and results analyses and write-up, and particularly Dr. Vilma Zotareli who led the grantees teams seamlessly throughout.

REFERENCES

Publication Dates

History