Health Entitlement Index for Refugees and Migrants: A Comparative Analysis Across 41 Countries

Giorgi Pkhakadze; Nino Tabagari; Irine Pkhakadze; Salome Glonti; Sulkhan Inaishvili; Shorena Vashadze; Tamari Talakvadze; Ana Bolkvadze; Sofio Kutateladze; Tamar Kraveishvili; Nino Endeladze; Tamari  Janelidze; Magda Kostava

doi:10.66636/gmj.v1.i2.a32

Authors

Giorgi Pkhakadze Public Health Institute of Georgia (PHIG), Tbilisi, Georgia; David Tvildiani Medical University, Tbilisi, Georgia https://orcid.org/0000-0001-7609-4515
Nino Tabagari David Tvildiani Medical University, Tbilisi, Georgia https://orcid.org/0000-0001-8280-9417
Irine Pkhakadze Akaki Tsereteli State University, Kutaisi, Georgia https://orcid.org/0009-0003-8699-2919
Salome Glonti Shota Rustaveli State University, Batumi, Georgia https://orcid.org/0000-0001-9771-5624
Sulkhan Inaishvili Avicenna Batumi Medical University, Batumi, Georgia https://orcid.org/0009-0004-6639-6068
Shorena Vashadze Shota Rustaveli State University, Batumi, Georgia https://orcid.org/0000-0002-1024-7934
Tamari Talakvadze David Tvildiani Medical University, Tbilisi, Georgia https://orcid.org/0009-0002-3007-6738
Ana Bolkvadze Public Health Institute of Georgia (PHIG), Tbilisi, Georgia https://orcid.org/0009-0008-6764-339X
Sofio Kutateladze Public Health Institute of Georgia (PHIG), Tbilisi, Georgia https://orcid.org/0009-0005-2121-1012
Tamar Kraveishvili Public Health Institute of Georgia (PHIG), Tbilisi, Georgia https://orcid.org/0009-0009-2473-2568
Nino Endeladze Georgian Personal Data Protection Association, Tbilisi, Georgia https://orcid.org/0009-0001-1038-6918
Tamari Janelidze Akaki Tsereteli State University, Kutaisi, Georgia https://orcid.org/0009-0008-4840-4422
Magda Kostava Akaki Tsereteli State University, Kutaisi, Georgia https://orcid.org/0000-0003-0131-8363

DOI:

https://doi.org/10.66636/gmj.v1.i2.a32

Keywords:

Universal Health Coverage, Refugees, Migrants, Legal Determinants of Health, Health Governance, Comparative Policy Analysis, Health Entitlement, HEIRM, Migrant Health, Refugee Health

Abstract

Background Universal Health Coverage (UHC) is normatively grounded in universality but operationalized through territorially bounded legal frameworks that condition entitlement on citizenship, residence, and migration status. With more than 281 million international migrants and over 114 million forcibly displaced persons globally, entitlement design has become a structural dimension of health system governance. However, cross-national variation in legal health entitlement for refugees and migrants remains insufficiently operationalized as a measurable comparative construct.

Methods The Health Entitlement Index for Refugees and Migrants (HEIRM) was developed to operationalize statutory health entitlement architecture across six domains: legal access to primary care, emergency care entitlement, preventive service inclusion, enrollment complexity (reverse-coded), financing integration, and firewall protection from immigration enforcement. Forty-one countries representing all six WHO regions were selected through stratified sampling by region and income level. Scoring was anchored in Tier-A statutory sources and Tier-B institutional documentation (January–June 2025). Inter-rater reliability was assessed using Cohen’s kappa coefficient. Ecological associations between HEIRM scores and standardized health system performance indicators—preventable hospitalization rates, emergency department utilization, and out-of-pocket expenditure share—were examined using correlation and partial correlation analyses.

Results HEIRM scores ranged from 6 to 15 (mean 11.3; SD 2.5; maximum possible score 18). Five countries were classified as Inclusive (15–18), 29 as Conditional (9–14), and 7 as Restrictive (0–8). No country achieved the theoretical maximum score of 18. Emergency care entitlement demonstrated the highest cross-national convergence, whereas firewall protections were least consistently codified in statutory frameworks. Higher HEIRM scores were inversely associated with preventable hospitalization rates (r = –0.46; 95% CI –0.69, –0.15; p = 0.006) and emergency department utilization (r = –0.41; 95% CI –0.66, –0.08; p = 0.015). Associations with out-of-pocket expenditure were moderate (r = –0.38; 95% CI –0.64, –0.03; p = 0.032) and attenuated after adjustment for GDP per capita and total health expenditure per capita (partial r = –0.27).

Conclusion Across 41 jurisdictions, legal entitlement architecture emerges as a measurable governance variable associated with system-level equity and efficiency patterns. While emergency guarantees are widespread, preventive inclusion and firewall protections frequently remain status-contingent. In contexts of sustained human mobility, operationalizing UHC requires structural alignment between entitlement design and demographic reality. The HEIRM provides a replicable framework for comparative statutory analysis and a foundation for future longitudinal and multilevel research examining entitlement architecture within evolving health system governance.

Keywords Universal Health Coverage; Refugees; Migrants; Legal Determinants of Health; Health Governance; Comparative Policy Analysis

References

1. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015. https://sdgs.un.org/2030agenda.

2. World Health Organization. Tracking universal health coverage: 2023 global monitoring report. Geneva: WHO; 2023. https://www.who.int/publications/i/item/9789240080379.

3. International Organization for Migration. World Migration Report 2024. Geneva: IOM; 2024. https://worldmigrationreport.iom.int.

4. United Nations High Commissioner for Refugees. Global Trends: Forced Displacement in 2023. Geneva: UNHCR; 2024. https://www.unhcr.org/global-trends.

5. World Health Organization. Promoting the health of refugees and migrants: Global Action Plan 2019–2023. Geneva: WHO; 2019. https://www.who.int/publications/i/item/WHA72-2019-REC-1.

6. International Organization for Migration. IOM Strategic Plan 2024–2028. Geneva: IOM; 2024. https://publications.iom.int/system/files/pdf/pub2023-159-strategic-plan-2024-2028-en.pdf.

7. United Nations. Convention Relating to the Status of Refugees. Geneva: UN; 1951. https://www.unhcr.org/3b66c2aa10.

8. Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet. 2013;381(9873):1235–1245. https://doi.org/10.1016/S0140-6736(12)62086-8.

9. Wickramage K, Vearey J, Zwi AB, Robinson C, Knipper M. Migration and health: a global public health research priority. BMC Public Health. 2018;18:987. https://doi.org/10.1186/s12889-018-5932-5.

10. Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, et al. The UCL–Lancet Commission on Migration and Health: the health of a world on the move. Lancet. 2018;392(10164):2606–2654. https://doi.org/10.1016/S0140-6736(18)32114-7.

11. Legido-Quigley H, Pocock N, Tan ST, Pajin L, Suphanchaimat R, Wickramage K, et al. Healthcare is not universal if undocumented migrants are excluded. BMJ. 2019;366:l4160. https://doi.org/10.1136/bmj.l4160.

12. Chauvin P, Parizot I, Simonnot N. Access to Healthcare for Undocumented Migrants in 11 European Countries. Paris: Médecins du Monde European Observatory on Access to Healthcare; 2009. https://inserm.hal.science/inserm-00419971/file/Rapport_UK_final_couv.pdf.

13. Kluge HHP, Jakab Z, Bartovic J, D’Anna V, Severoni S. Refugee and migrant health in the COVID-19 response. Lancet. 2020;395(10232):1237–1239. https://doi.org/10.1016/S0140-6736(20)30791-1.

14. World Health Organization Regional Office for Europe. ApartTogether survey: preliminary overview of refugees and migrants self-reported impact of COVID-19. Copenhagen: WHO Regional Office for Europe; 2020. https://www.who.int/publications/i/item/9789240017924.

15. European Observatory on Health Systems and Policies. Health systems in transition: country profiles. Copenhagen: WHO Europe; 2019. https://eurohealthobservatory.who.int/publications/health-systems-reviews.

16. Mladovsky P. A framework for analysing migrant health policies in Europe. Health Policy. 2009;93(1):55–63. https://doi.org/10.1016/j.healthpol.2009.05.015.

17. Bozorgmehr K, Razum O. Effect of restricting access to health care on health expenditures among asylum-seekers and refugees: a quasi-experimental study in Germany, 1994–2013. PLoS ONE. 2015;10(7):e0131483. https://doi.org/10.1371/journal.pone.0131483.

18. Rosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. Eur J Public Health. 2013;23(3):356–360. https://doi.org/10.1093/eurpub/cks053.

19. Ansari Z, Haider SI, Ansari H, de Gooyer T, Sindall C. Patient characteristics associated with hospitalisations for ambulatory care sensitive conditions in Victoria, Australia. BMC Health Serv Res. 2012;12:475. https://doi.org/10.1186/1472-6963-12-475.

20. Herd P, Moynihan DP. Administrative Burden: Policymaking by Other Means. New York: Russell Sage Foundation; 2018. ISBN 978-0-87154-444-2. https://doi.org/10.7758/9781610448789.

21. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91(8):602–611. https://doi.org/10.2471/BLT.12.113985.

22. Hacker K, Anies M, Folb BL, Zallman L. Barriers to health care for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015;8:175–183. https://doi.org/10.2147/RMHP.S70173.

23. Castles S, de Haas H, Miller MJ. The Age of Migration: International Population Movements in the Modern World. 6th ed. New York: Guilford Press; 2020. ISBN 978-1-4625-4296-5.

24. McMichael C. Climate change-related migration and infectious disease. Virulence. 2015;6(6):548–553. https://doi.org/10.1080/21505594.2015.1021539.

25. Organisation for Economic Co-operation and Development. International Migration Outlook 2023. Paris: OECD Publishing; 2023. https://doi.org/10.1787/b0f40584-en.

26. Spiegel P, Khalifa A, Mateen FJ. Cancer in refugees in Jordan and Syria between 2009 and 2012: challenges and the way forward in humanitarian emergencies. Lancet Oncol. 2014;15(7):e290–e297. https://doi.org/10.1016/S1470-2045(14)70067-1.

27. Organisation for Economic Co-operation and Development. OECD Health Statistics 2023. Paris: OECD Publishing; 2023. https://www.oecd.org/health/health-data.htm.

28. Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet. 2015;385(9980):1910–1912. https://doi.org/10.1016/S0140-6736(15)60755-3.

29. Morgenstern H. Ecologic studies in epidemiology: concepts, principles, and methods. Annu Rev Public Health. 1995;16:61–81. https://doi.org/10.1146/annurev.pu.16.050195.000425.

30. World Health Organization. Global Health Expenditure Database. Geneva: WHO; 2023. https://apps.who.int/nha/database.

31. Solano G, Huddleston T. Migrant Integration Policy Index 2020 — Health Strand. Barcelona/Brussels: CIDOB and Migration Policy Group; 2020. https://www.mipex.eu/health.

32. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37–46. https://doi.org/10.1177/001316446002000104.

33. Saltelli A. Composite indicators between analysis and advocacy. Soc Indic Res. 2007;81(1):65–77. https://doi.org/10.1007/s11205-006-0024-9.

34. Martinez O, Wu E, Sandfort T, Dodge B, Carballo-Dieguez A, Pinto R, et al. Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review. J Immigr Minor Health. 2015;17(3):947–970. https://doi.org/10.1007/s10903-013-9968-4.

35. Esping-Andersen G. The Three Worlds of Welfare Capitalism. Princeton (NJ): Princeton University Press; 1990. ISBN 978-0-691-02857-6.

36. Norredam M, Nielsen SS, Krasnik A. Migrants’ utilization of somatic healthcare services in Europe — a systematic review. Eur J Public Health. 2010;20(5):555–563. https://doi.org/10.1093/eurpub/ckp195.

37. Giannoni M, Franzini L, Masiero G. Migrant integration policies and health inequalities in Europe. BMC Public Health. 2016;16:463. https://doi.org/10.1186/s12889-016-3095-9.

38. Phillimore J. Migrant maternity in an era of superdiversity: new migrants’ access to, and experience of, antenatal care in the West Midlands, UK. Soc Sci Med. 2016;148:152–159. https://doi.org/10.1016/j.socscimed.2015.11.030.

39. World Health Organization. Global strategy on digital health 2020–2025. Geneva: WHO; 2021. https://www.who.int/publications/i/item/9789240020924.

40. Blanchet K, Nam SL, Ramalingam B, Pozo-Martin F. Governance and capacity to manage resilience of health systems: towards a new conceptual framework. Int J Health Policy Manag. 2017;6(8):431–435. https://doi.org/10.15171/ijhpm.2017.36.

41. Pavli A, Maltezou HC. Health problems of newly arrived migrants and refugees in Europe. J Travel Med. 2017;24(4):tax016. https://doi.org/10.1093/jtm/tax016.

42. Dustmann C, Frattini T. The fiscal effects of immigration to the UK. Econ J. 2014;124(580):F593–F643. https://doi.org/10.1111/ecoj.12181.

43. European Commission. eHealth Network Guidelines on the digital interoperability of cross-border health services. Brussels: European Commission; 2022. https://health.ec.europa.eu/ehealth-digital-health-and-care/electronic-cross-border-health-services_en.

44. Hanefeld J, Mayhew S, Legido-Quigley H, Martineau F, Karanikolos M, Blanchet K, et al. Towards an understanding of resilience: responding to health systems shocks. Health Policy Plan. 2018;33(3):355–367. https://doi.org/10.1093/heapol/czx183.

45. De Vito E, de Waure C, Specchia ML, Parente P, Azzolini E, Frisicale EM, et al. Are undocumented migrants’ entitlements and barriers to healthcare a public health challenge for the European Union? Public Health Rev. 2016;37:13. https://doi.org/10.1186/s40985-016-0026-3.

46. World Bank. Moving for Prosperity: Global Migration and Labor Markets. Washington (DC): World Bank; 2018. https://doi.org/10.1596/978-1-4648-1281-1.

47. Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis E, Garcés-Ferrer J, et al. Migrants’ and refugees’ health status and healthcare in Europe: a scoping literature review. BMC Public Health. 2020;20:1039. https://doi.org/10.1186/s12889-020-08749-8.

48. Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet. 2019;393(10183):1857–1910. https://doi.org/10.1016/S0140-6736(19)30233-8.

49. Bozorgmehr K, Biddle L, Razum O, Roberts B. Health policy and systems responses to forced migration: an introduction. In: Bozorgmehr K, Roberts B, Razum O, Biddle L, editors. Health Policy and Systems Responses to Forced Migration. Cham: Springer; 2020. p. 1–18. https://doi.org/10.1007/978-3-030-33812-1_1.

50. Hintermeier M, Gottlieb N, Oppenberg J, Mohsenpour A, Flores S, Rohleder S, et al. COVID-19 among migrants, refugees, and IDPs: a synthesis of the global empirical literature. Eur J Public Health. 2022;32(Suppl 3):ckac131.517. https://doi.org/10.1093/eurpub/ckac131.517.

51. World Health Organization Council on the Economics of Health for All. Health for All: Transforming economies to deliver what matters — final report. Geneva: WHO; 2023. https://www.who.int/publications/i/item/9789240080973.

52. World Health Organization. World report on the health of refugees and migrants. Geneva: WHO; 2022. https://www.who.int/publications/i/item/9789240054462.

53. Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018;391(10117):241–250. https://doi.org/10.1016/S0140-6736(17)31869-X.

54. Forsgren L, Tediosi F, Blanchet K, Saulnier DD. Health systems resilience in practice: a scoping review to identify strategies for building resilience. BMC Health Serv Res. 2022;22:1173. https://doi.org/10.1186/s12913-022-08544-8.

55. Spain. Ley General de Sanidad 14/1986, as amended by Real Decreto-Ley 7/2018. Boletín Oficial del Estado. https://www.boe.es/.

56. Germany. Asylbewerberleistungsgesetz (Asylum Seekers’ Benefits Act); Sozialgesetzbuch V; Allgemeines Gleichbehandlungsgesetz. Federal Law Gazette. https://www.gesetze-im-internet.de/.

57. France. Code de la sécurité sociale; Aide Médicale d’État (AME); Protection Universelle Maladie (PUMa). https://www.legifrance.gouv.fr/.

58. Italy. Decreto Legislativo 286/1998 (Testo Unico Immigrazione); Decreto Legislativo 502/1992 on Servizio Sanitario Nazionale. Gazzetta Ufficiale della Repubblica Italiana. https://www.gazzettaufficiale.it/.

59. Sweden. Lag (2013:407) om hälso- och sjukvård till vissa utlänningar som vistas i Sverige utan nödvändiga tillstånd. https://www.riksdagen.se/.

60. Portugal. Decreto-Lei 67/2004; Despacho 25360/2001; Portaria 147/2017 on Serviço Nacional de Saúde access. https://dre.pt/.

61. Greece. Law 4368/2016 on uninsured access to public health services; Law 4636/2019 (International Protection Code). Government Gazette of the Hellenic Republic. https://www.et.gr/.

62. Poland. Act of 27 August 2004 on healthcare services financed from public funds. Journal of Laws of the Republic of Poland. https://isap.sejm.gov.pl/.

63. Hungary. Act CLIV of 1997 on Healthcare; Act LXXX of 2007 on Asylum. https://njt.hu/.

64. Netherlands. Zorgverzekeringswet 2006; Regeling onverzekerbare vreemdelingen; Vreemdelingenwet 2000. https://wetten.overheid.nl/.

65. Belgium. Loi-programme 1999 (Aide Médicale Urgente); Loi du 12 janvier 2007 on reception of asylum seekers. https://www.ejustice.just.fgov.be/.

66. Denmark. Sundhedsloven (Health Act); Udlændingeloven (Aliens Act). https://www.retsinformation.dk/.

67. Austria. Allgemeines Sozialversicherungsgesetz (ASVG); Grundversorgungsvereinbarung (Federal Basic Care Agreement). Federal Law Gazette I No. 80/2004. https://www.ris.bka.gv.at/.

68. Georgia. Law of Georgia on International Protection; Law on Health Care; Government Resolution on Universal Health Care Programme. Legislative Herald of Georgia (Matsne). https://matsne.gov.ge/.

69. Türkiye. Law on Foreigners and International Protection No. 6458; Temporary Protection Regulation. Official Gazette of the Republic of Türkiye. https://www.mevzuat.gov.tr/.

70. Jordan. Ministry of Health Circulars on Refugee Health Access; UNHCR–MOH Cooperation Framework. https://help.unhcr.org/jordan/.

71. Lebanon. Ministry of Public Health Primary Health Care Network Framework; UNHCR Referral Care Guidelines. https://help.unhcr.org/lebanon/.

72. Egypt. Memorandum of Understanding between Ministry of Health and Population and UNHCR; Ministry of Health decrees on refugee access. https://help.unhcr.org/egypt/.

73. South Africa. Constitution of the Republic of South Africa, 1996; National Health Act 61 of 2003. https://www.gov.za/documents/constitution-republic-south-africa-1996.

74. Ethiopia. Refugees Proclamation No. 1110/2019. Federal Negarit Gazette. https://www.refworld.org/legal/decreees/natlegbod/2019/en/30352.

75. Nigeria. National Health Act 2014. Federal Republic of Nigeria Official Gazette. https://ngfrepository.org.ng:8443/jspui/handle/123456789/3159.

76. Ghana. National Health Insurance Act 2012 (Act 852). Republic of Ghana. https://www.nhis.gov.gh/.

77. Uganda. Health Sector Integrated Refugee Response Plan, 2019–2024. Republic of Uganda Ministry of Health. https://globalcompactrefugees.org/sites/default/files/2019-12/Uganda-%20Health%20sector%20integrated%20refugee%20response%20plan%2C%202019-2024_0.pdf.

78. Rwanda. Law Governing Community-Based Health Insurance (CBHI/Mutuelles de Santé). Republic of Rwanda Official Gazette. https://www.moh.gov.rw/.

79. Thailand. National Health Security Act B.E. 2545 (2002). Government of Thailand. https://www.hiso.or.th/hiso/picture/reportHealth/thf2007/thp2005_9eng.pdf.

80. Bangladesh. National Health Policy 2011; Rohingya Response Health Sector Framework. Government of Bangladesh. https://mohfw.gov.bd/.

81. Australia. Health Insurance Act 1973 (Medicare Act). Federal Register of Legislation. https://www.legislation.gov.au/Series/C2004A01606.

82. New Zealand. Health and Disability Services Eligibility Direction 2011. Ministry of Health New Zealand. https://www.health.govt.nz/.

83. Japan. National Health Insurance Act; Immigration Control and Refugee Recognition Act. Government of Japan. https://www.japaneselawtranslation.go.jp/.

84. Canada. Interim Federal Health Program (IFHP). Government of Canada. https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care.html.

85. United States. Emergency Medical Treatment and Labor Act (EMTALA). U.S. Code 42 §1395dd. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.24.

86. Mexico. Constitución Política de los Estados Unidos Mexicanos, Artículo 4; Ley General de Salud. Government of Mexico. https://mexico.justia.com/federales/leyes/ley-general-de-salud/titulo-primero/capitulo-unico/.

87. Brazil. Constituição da República Federativa do Brasil, Art. 196; Sistema Único de Saúde (SUS). http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm.

88. Colombia. Ley 1751 de 2015 (Ley Estatutaria de Salud); Estatuto Temporal de Protección para Migrantes Venezolanos (ETPV). https://www.funcionpublica.gov.co/.

89. Peru. Ley Marco de Aseguramiento Universal en Salud; Sistema Integral de Salud (SIS) regulations. https://www.gob.pe/sis.

90. Ecuador. Constitución de la República del Ecuador; Ministry of Public Health Universal Access Framework. https://www.salud.gob.ec/.

91. Voorend K, Alvarado D. Barriers to healthcare access for immigrants in Costa Rica and Uruguay. J Int Migr Integr. 2022;24(2):747–771. https://doi.org/10.1007/s12134-022-00972-z.

92. Panama. Constitución Política de la República de Panamá; Ministry of Government (ONPAR) Refugee Access Guide. https://www.mingob.gob.pa/.

93. Argentina. Ley 25.871 (Ley de Migraciones), as amended by Decreto de Necesidad y Urgencia 366/2025. Official Gazette of the Argentine Republic. https://www.boletinoficial.gob.ar/.

94. Chile. Ley 21.325 (Ley de Migración y Extranjería), 2021; Decreto Supremo 296 (Reglamento). Government of Chile. https://www.bcn.cl/leychile/.

Health Entitlement Index for Refugees and Migrants: A Comparative Analysis Across 41 Countries

Authors

DOI:

Keywords:

Abstract

References

Downloads

Published

How to Cite

Issue

Section

License

Similar Articles

Most read articles by the same author(s)

Make a Submission

Language

Follow GMJ

Information

LATEST ARTICLES

INDEXING

Discoverability & Integration

Announcements

Georgian Medical Journal Included in the SJIF Journals Master List and Under Evaluation for SJIF 2026

GMJ Preprint Policy Published — Manuscripts from medRxiv Welcome

GMJ Partner Platform