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

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