England and Australia are considered standard-bearers of universal access to health services, with the former’s National Health Service (NHS) recognized as a global brand and the latter’s Medicare seen as a leader in the Asia-Pacific region. However, through the exclusion of migrant and refugee groups, each is failing to deliver true universality in their health services. These exclusions breach both their own national policies and of international commitments they have made.

While the marginalization of mobile populations is not a new phenomenon, in recent years there has been a global increase in anti-migrant rhetoric, and such health care exclusions reflect a global trend in which undocumented migrants, refugees and asylum seekers are denied rights.

They are also increasingly excluded in the interpretation of phrases such as ‘leave no one behind’ and ‘universal health coverage’, commonly used by UN bodies and member states, despite explicit language in UN declarations that commits countries to include mobile groups.

Giving all people – including undocumented migrants and asylum seekers – access to health care is essential not just for the health of the migrant groups but also the public health of the populations that host them. In a world with almost one billion people on the move, failing to take account of such mobility leaves services ill-equipped and will result in missed early and preventative treatment, an increased burden on services and a susceptibility to the spread of infectious disease.

England

While in the three other nations of the UK, the health services are accountable to the devolved government, the central UK government is responsible for the NHS in England, where there are considerably greater restrictions in access.

Undocumented migrants and refused asylum seekers are entitled to access all health care services if doctors deem it clinically urgent or immediately necessary to provide it. However, the Home Office’s ‘hostile environment’ policies towards undocumented migrants, implemented aggressively and without training for clinical staff, are leading to the inappropriate denial of urgent and clearly necessary care.

One example is the case of Elfreda Spencer, whose treatment for myeloma was delayed for one year, allowing the disease to progress, resulting in her death.

In England, these policies, which closely link health care and immigration enforcement, are also deterring people from seeking health care they are entitled to. For example, medical bills received by migrants contain threats to inform immigration enforcement of their details if balances are not cleared in a certain timeframe. Of particular concern, the NGO Maternity Action has demonstrated that such a link to immigration officials results in the deterrence of pregnant women from seeking care during their pregnancy.

Almost all leading medical organizations in the United Kingdom have raised concerns about these policies, highlighting the negative impact on public health and the lack of financial justification for their implementation. Many have highlighted that undocument migrants use just and estimated 0.3% of the NHS budget and have pointed to international evidence that suggests that restrictive health care policies may cost the system more.

Australia

In Australia, all people who seek refuge by boat are held, and have their cases processed offshore in Papua New Guinea (PNG) and Nauru, at a cost of almost A$5 billion between 2013 and 2017. Through this international agreement, in place since 2013, Australia has committed to arrange and pay for the care for the refugees, including health services ‘to a standard of care broadly comparable to that available to the general Australian community under the public health system’.

However, the standard of care made available to the refugees is far from comparable to that available to the general population in Australia. Findings against the current care provision contractor on PNG, Pacific International Hospital, which took over in the last year, are particularly damning.

For instance, an Australian coroner investigating the 2014 death from a treatable leg infection of an asylum seeker held in PNG concluded that the contractor lacked ‘necessary clinical skills’, and provided ‘inadequate’ care. The coroner’s report, issued in 2018, found the company had also, in other cases, denied care, withheld pain relief, distributed expired medication and had generally poor standards of care, with broken or missing equipment and medication, and services often closed when they were supposed to be open.

This has also been reiterated by the Royal Australasian College of Physicians, which has appealed to the Australian government to end its policies of offshore processing immediately, due to health implications for asylum seekers. This echoes concerns of the medical community around the government’s ongoing attempts to repeal the ‘Medivac’ legislation, which enables emergency medical evacuation from PNG and Nauru.

Bad policy

Both governments have signed up to UN Sustainable Development Goals commitment to ‘safe and orderly migration’, an essential component of which is access to health care. The vision for this was laid out in a global action plan on promoting the health of refugees and migrants, agreed by member states at the 2019 World Health Assembly.

However, rather than allow national policies to be informed by such international plans and the evidence put forward by leading health professionals and medical organizations, the unsubstantiated framing of migrants as a security risk and economic burden has curtailed migrant and refugee access to health care.

The inclusion of migrants and refugees within universal access to health services is not merely a matter of human rights. Despite being framed as a financial burden, ensuring access for all people may reduce costs on health services through prevention of costly later-stage medical complications, increased transmission of infections and inefficient administrative costs of determining eligibility.

Thailand provides an example of a middle-income country that recognized this, successfully including all migrants and refugees in its health reforms in 2002. Alongside entitling all residents to join the universal coverage scheme, the country also ensured that services were ‘migrant friendly’, including through the provision of translators. A key justification for the approach was the economic benefit of ensuring a healthy migrant population, including the undocumented population.

The denial of quality health services to refugees and undocumented migrants is a poor policy choice. Governments may find it tempting to gain political capital through excluding these groups, but providing adequate access to health services is part of both governments’ commitments made at the national and international levels. Not only are inclusive health services feasible to implement and good for the health of migrants and refugees, in the long term, they are safer for public health and may save money.

England and Australia are considered standard-bearers of universal access to health services, with the former’s National Health Service (NHS) recognized as a global brand and the latter’s Medicare seen as a leader in the Asia-Pacific region. However, through the exclusion of migrant and refugee groups, each is failing to deliver true universality in their health services. These exclusions breach both their own national policies and of international commitments they have made.

While the marginalization of mobile populations is not a new phenomenon, in recent years there has been a global increase in anti-migrant rhetoric, and such health care exclusions reflect a global trend in which undocumented migrants, refugees and asylum seekers are denied rights.

They are also increasingly excluded in the interpretation of phrases such as ‘leave no one behind’ and ‘universal health coverage’, commonly used by UN bodies and member states, despite explicit language in UN declarations that commits countries to include mobile groups.

Giving all people – including undocumented migrants and asylum seekers – access to health care is essential not just for the health of the migrant groups but also the public health of the populations that host them. In a world with almost one billion people on the move, failing to take account of such mobility leaves services ill-equipped and will result in missed early and preventative treatment, an increased burden on services and a susceptibility to the spread of infectious disease.

England

While in the three other nations of the UK, the health services are accountable to the devolved government, the central UK government is responsible for the NHS in England, where there are considerably greater restrictions in access.

Undocumented migrants and refused asylum seekers are entitled to access all health care services if doctors deem it clinically urgent or immediately necessary to provide it. However, the Home Office’s ‘hostile environment’ policies towards undocumented migrants, implemented aggressively and without training for clinical staff, are leading to the inappropriate denial of urgent and clearly necessary care.

One example is the case of Elfreda Spencer, whose treatment for myeloma was delayed for one year, allowing the disease to progress, resulting in her death.

In England, these policies, which closely link health care and immigration enforcement, are also deterring people from seeking health care they are entitled to. For example, medical bills received by migrants contain threats to inform immigration enforcement of their details if balances are not cleared in a certain timeframe. Of particular concern, the NGO Maternity Action has demonstrated that such a link to immigration officials results in the deterrence of pregnant women from seeking care during their pregnancy.

Almost all leading medical organizations in the United Kingdom have raised concerns about these policies, highlighting the negative impact on public health and the lack of financial justification for their implementation. Many have highlighted that undocument migrants use just and estimated 0.3% of the NHS budget and have pointed to international evidence that suggests that restrictive health care policies may cost the system more.

Australia

In Australia, all people who seek refuge by boat are held, and have their cases processed offshore in Papua New Guinea (PNG) and Nauru, at a cost of almost A$5 billion between 2013 and 2017. Through this international agreement, in place since 2013, Australia has committed to arrange and pay for the care for the refugees, including health services ‘to a standard of care broadly comparable to that available to the general Australian community under the public health system’.

However, the standard of care made available to the refugees is far from comparable to that available to the general population in Australia. Findings against the current care provision contractor on PNG, Pacific International Hospital, which took over in the last year, are particularly damning.

For instance, an Australian coroner investigating the 2014 death from a treatable leg infection of an asylum seeker held in PNG concluded that the contractor lacked ‘necessary clinical skills’, and provided ‘inadequate’ care. The coroner’s report, issued in 2018, found the company had also, in other cases, denied care, withheld pain relief, distributed expired medication and had generally poor standards of care, with broken or missing equipment and medication, and services often closed when they were supposed to be open.

This has also been reiterated by the Royal Australasian College of Physicians, which has appealed to the Australian government to end its policies of offshore processing immediately, due to health implications for asylum seekers. This echoes concerns of the medical community around the government’s ongoing attempts to repeal the ‘Medivac’ legislation, which enables emergency medical evacuation from PNG and Nauru.

Bad policy

Both governments have signed up to UN Sustainable Development Goals commitment to ‘safe and orderly migration’, an essential component of which is access to health care. The vision for this was laid out in a global action plan on promoting the health of refugees and migrants, agreed by member states at the 2019 World Health Assembly.

However, rather than allow national policies to be informed by such international plans and the evidence put forward by leading health professionals and medical organizations, the unsubstantiated framing of migrants as a security risk and economic burden has curtailed migrant and refugee access to health care.

The inclusion of migrants and refugees within universal access to health services is not merely a matter of human rights. Despite being framed as a financial burden, ensuring access for all people may reduce costs on health services through prevention of costly later-stage medical complications, increased transmission of infections and inefficient administrative costs of determining eligibility.

Thailand provides an example of a middle-income country that recognized this, successfully including all migrants and refugees in its health reforms in 2002. Alongside entitling all residents to join the universal coverage scheme, the country also ensured that services were ‘migrant friendly’, including through the provision of translators. A key justification for the approach was the economic benefit of ensuring a healthy migrant population, including the undocumented population.

The denial of quality health services to refugees and undocumented migrants is a poor policy choice. Governments may find it tempting to gain political capital through excluding these groups, but providing adequate access to health services is part of both governments’ commitments made at the national and international levels. Not only are inclusive health services feasible to implement and good for the health of migrants and refugees, in the long term, they are safer for public health and may save money.

Asia’s political class learnt many lessons on digital governance in 2019, not all of them positive.

The prolonged protests in Hong Kong and India, led by disaffected young citizenry and enabled by social media tools, powerfully demonstrated how things could spiral out of control when the virtual and the real streets come together.

Not surprisingly, governments across the region are taking a step back. Instead of placing the citizen at the heart of digital public policy – with privacy, trust, security and inclusion as drivers of digital governance – Asian governments are focusing instead on surveillance and command and control, which contradicts the spirit of a decentralized Internet and undermines citizen’s rights.

Asia’s digital governance is fragmenting from the global norm and morphing into two platforms with remarkably similar characteristics.

One is a China-driven model aptly called the Great Firewall where surveillance of citizens is an explicit objective and any external material deemed to be subversive is kept out. A complementary model has also emerged more recently, which can best be described as China-light, which seeks to emulate the control aspects of the Great Firewall.

There are of course overlaps between emulators of the China model (this list includes Vietnam, Myanmar, Cambodia and Laos) and those pursuing China-light (Singapore, India, Indonesia, Bangladesh, Sri Lanka, the Philippines, Thailand and Malaysia). A common thread running through these two approaches, which differ only in intensity and scope, is the belief that the state is best positioned to police social media and protect the rights of citizens.

This was not how it was supposed to be. A decade ago, Asian political leaders spoke about the virtues of an open internet. Such talk has faded, and a narrowing of Asia’s digital space is taking place against a backdrop of an intensifying trade war between America and China, where regional supply chains run the risk of a decoupling into distinct Sino and American spheres, upending Asia’s durable economic model of the past few decades.

Digital fragmentation in the world’s fastest growing region, with five G20 members, will complicate efforts to build global governance and standards.

Asia’s digital landscape

Asian governments, including democratic ones, have developed an unhealthy obsession with what their citizens are up to on a daily basis. Their solution is round-the-clock monitoring in cities and towns, powered by new surveillance technologies.

Name tagging and facial recognition to track movement of citizens has become pervasive across the region, with China emerging as the preferred source of technology, knowledge, and techniques. While India’s Supreme Court has ruled that privacy is a fundamental right, translating this into concrete citizen’s protections will be difficult with the Modi government eager to emulate China’s approach.

Asian governments are also following China in requiring that their citizen’s data be housed within national borders and are rebelling against the established practice of data offshoring.

In the post-Snowden era and amidst increasing cyber risks, there are rational national security reasons for why governments may want to ring-fence customer data within national boundaries. However, Asian governments are paying little or no attention to how companies are using customer data within national boundaries, with widespread abuses going unchecked.

Global standards are still evolving and there is a strong case here for a uniform regional approach, perhaps via ASEAN or APEC, on standards governing customer privacy, payments, data collection and handling. Big tech companies and platforms operate across much of Asia and a regional approach will curb their current instinct of conducting regulatory arbitrage.

There is a genuine problem in Asia, as elsewhere in the world, with the proliferation of fake news and extremism. But instead of addressing the source of this problem, governments are clamping down by generously expanding the definition of fake news (Singapore) or by shutting down the internet altogether (India, Sri Lanka, and China being serial offenders).

As disseminators of news of all stripes, including the fake variant, the big tech firms have a primary responsibility in policing their platforms. However, the regulatory capacity of many Asian governments to monitor this is weak and in crisis situations, governments prefer to shut the pipes altogether.

Digitalization of course is not all about surveillance and holds the promise of driving inclusion. There is considerable hype within Asia on the promise of fintech as an enabler of this inclusion.

Hong Kong and Singapore are licensing new digital banks, India’s UPI (unified payments interface) is reducing friction in domestic payments and China’s BAT companies (Baidu, Alibaba, Tencent) are disrupting traditional commerce and payments, and seeking to expand in the region.

However, there is an elite focus in many of these initiatives, with the target market being the region’s rising middle class rather than those at the bottom of the income ladder. Making fintech work for all will require micro-initiatives with the support of NGOs, local governments and small enterprises, with the objective of digitalizing microfinance.

Here developing Asia will again benefit from learning from each other and in building regional approaches. India’s Aadhar for example, with appropriate security safeguards, is a model for Asia in terms of building digital identity.

Given differing regional and national objectives, it is difficult to imagine a global accord for digital governance any time soon. However, by signing on to the Regional Comprehensive Economic Partnership (RCEP) and the Comprehensive and Progressive Agreement for Transpacific Partnership (CPTPP, the successor to the TPP), Asia has consistently demonstrated its leadership in trade and regional governance.

This is why the region needs to come together to ensure that the promise and potential of digitalization flows evenly and equitably to the region, with the region’s 3.8 billion citizens at the heart, rather than at the margins of sensible public policy.