Moving upstream: Changing policy scripts on migrant and ethnic minority health

This article uses the concept of ‘policy scripts’ to explore the aims and assumptions underlying policies on migrant and ethnic minority health. Firstly, it analyses the shift in health policies from ‘downstream’ approaches (emphasising health care for the sick and injured) to ‘upstream’ ones (emphasising health protection for the whole population). The field of migrant health has been relatively slow to move upstream. Two factors appear to have impeded this shift: (a) the reluctance of the ‘social determinants of health’ movement to regard migrant status and ethnicity as important causes of health inequities; and (b) the one-sided emphasis on short-term emergency health provisions for migrants arising from the recent increase in forced migration worldwide, in particular the sudden peak in mixed migration to the EU in 2015. The article contends that (a) the usual arguments against treating migration and ethnicity as health determinants do not stand up to critical examination; and (b) the overwhelming emphasis on unauthorised entrants which characterises current discussions of migration policy, including health, is out of all proportion to their volume relative to that of other migrants. Fortunately, recent policy initiatives at UN level have the potential to restore the balance between ‘upstream’ and ‘downstream’ approaches, as well as between unauthorised entry and ‘routine’ migration.