01  Vearey  S A H A R A  I O M  Session 3  Dec 2009
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01 Vearey S A H A R A I O M Session 3 Dec 2009






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01  Vearey  S A H A R A  I O M  Session 3  Dec 2009 01 Vearey S A H A R A I O M Session 3 Dec 2009 Presentation Transcript

  • Challenging common assumptions around migration and health in South Africa SAHARA 3rd December 2009 Jo Vearey jovearey@gmail.com http://migration.org.za/
  • Cross-border migrants and healthcare provision: a global challenge; Assumptions linking migration, health and health- seeking; Some data on migrant health in Southern Africa: this includes (but is not limited to) migrant access to public healthcare services; Recommendations to policy makers and practitioners.
  • Patterns: Social determinants of Linkages to “home” health and migration: Health Migration as a determinant of health Determinants of movements. Health a determinant of migration Urban as a determinant of health Place: Livelihoods and health systems. Urban and rural origin/destination Urban - periphery and centre Socio-cultural dimensions Border areas. of health: Culture and religion Meanings and interpretations Data: Illness experiences Survey datasets Strategies and health seeking In depth qualitative studies. behaviours. View slide
  • Internal and cross-border migration: Different forms of migration and different reasons for migration are found to determine migration experiences; impacts on health. The need for a regional lens: Essential to view migration as a connecting process. Recognising migration as a livelihood strategy that connects the (urban) migrant with another household “back home” Sickness negatively affects this interlinked livelhood system. Zimbabwean “humanitarian migration”: FMSP Report (Nov 2009): Zimbabwean humanitarian migration into South Africa: Inadequate regional responses View slide
  • Zimbabwean migrants struggle to access Asylum seekers (Section 22 permit); passports and travel documents within Zimbabwe: presents challenges in crossing Refugees (Section 24 permit); the border Special dispensation permits for Other: Zimbabweans havestudy permits; visitor work permits, not been made permits; and available. Challenges at Home Affairs: Undocumented migrants. problematic. access to documentation is Immigration act makes it difficult for lower- skilled workers to legalise their stay in South Africa.
  • 1. South African Constitution; 2. Refugee Act (1998); 3. HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011 (NSP); 4. National Department of Health (NDOH) Memo (2006); 5. NDOH Directive (September 2007); and 6. Gauteng DOH Letter (April 2008).
  • Actively denying healthcare to cross-border migrants can have negative impacts: In terms of infectious diseases: the inability to access appropriate and timely care may ultimately place the host population at risk; This could place an even greater burden upon the health system.
  • An historical perspective; Discourse of risk and blame: ‘Plague’; ‘Invasion’; context of HIV; Globally, ‘foreigners’ are often blamed by governments for introducing and spreading disease: ‘disease carriers’. Geographic/national boundaries historically a first line of defence against disease.
  • Prevailing assumptions associate migration with the spread of diseases, including HIV; Cross-border migrants are perceived as travelling in order to seek healthcare and – in the context of HIV – antiretroviral treatment (ART); Fears often voiced from the host population relating to the ‘additional burden’ that will be placed on the public sector.
  • Migration is linked to seeking healthcare. Provision of healthcare will result in a ‘flood of migrants’. Migrants are ‘unable to adhere to ART’.
  • Migrant Rights Monitoring Project - National (FMSP); RENEWAL survey – JHB (FMSP): Zimbabwean migrants and healthcare utilisation (MA, FMSP); Inner-city survey - JHB (Population Council); Investigating non-citizen access to ART - JHB (FMSP); Nazareth House clinical study - JHB (RHRU); IOM studies; MSF monitoring data (JHB, Musina); Barriers to health access - National (Human Rights Watch); Post-May 2008 (humanitarian response and challenges).
  • Migrant Rights Monitoring Project (MRMP): National Public Service Access Survey Forced Migration Studies Programme Data collection period: 2007 – 2008
  • Reporting period: 2007 – 2008 3,182 respondents; NGO service providers (59%) and Refugee Reception Offices (41%).
  • Relative frequency (%) 0 10 20 30 40 50 60 70 Asylum seeker (Section 22) Refugee (Section 24) Undocumented Other temporary Reported documentation status Permanent residence South African identity n = 3,182
  • Under half of all respondents report ever needing healthcare since their arrival in South Africa: 45%; n = 1,403.
  • Length of stay is associated with ever needing healthcare: – The longer a respondent has been in South Africa, the more likely they will report needing healthcare; Recent arrivals do not report requiring healthcare services. The longer an individual is in the country, the likelihood of encountering a health access challenge decreases.
  • 30% (n = 396) report having experienced problems when trying to access public health care.
  • Frequency (number of responses) 120 100 80 60 40 20 0 Treated badly Language Denied Denied Treated badly Could not by a nurse problem treatment treatment by clerk access because of because treatment due documents foreign to cost Problems encountered n = 396; 542 responses (multi-answer)
  • Documentation status is related to the likelihood of experiencing a problem: 1. Undocumented migrants (38%); 2. Asylum seekers – Section 22 (31%); 3. Other documented migrants (28%); 4. Refugees – Section 24 (24%).
  • RENEWAL household survey Forced Migration Studies Programme Data collection period: 2008
  • Investigating linkages between migration, HIV and food security through a livelihoods lens; JHB inner-city and one urban informal settlement: n = 487 (1,533 individuals) 31% (n = 150) are cross-border migrants ▪ n = 118 are Zimbabwean migrants
  • Cross-border (and internal) migrants travelled to Johannesburg mostly for economic reasons; No-one reported coming to Johannesburg for health reasons; Respondents indicated that they would: Return home if they became too sick to work; Not bring a sick relative to Johannesburg; ▪ They would send money home or return home to care for a sick relative.
  • Non-citizen access to ART in inner-city Johannesburg Vearey, J. (2008) Migration, Access to ART, and Survivalist Livelihood Strategies in Johannesburg. African Journal of AIDS Research 7 (3), pp. 361 – 374 Data collection: 2007
  • Individuals in need of ART do not generally migrate to South Africa in order to access treatment: • Cross-sectional survey Discovered their status in South Africa (80%); • Four ART sites in inner-city MostlyJohannesburgin South Africa (76%); 2 first tested for HIV (2 government; NGO) Tested when sick (like South Africans, p = 0.122); • n = 449 Came to South Africa for other reasons; Have been here for a period of time before discovering their status.
  • In this study, 20% of cross-border migrants reported initiating ART in another country….. Appears that other reasons (economic) are the reason for movement; Continuity of treatment.
  • Non-citizens are referred out of the public sector and into the NGO sector: Reasons for this include not having a South African identity booklet and ‘being foreign’; This goes against existing legislation. A dual healthcare system exists, presenting a range of challenges: Logistical issues: cross-referral, loss to follow up, workload pressure; Falsification of documents… impact on adherence The responsibility of the public sector is being met by NGO providers.
  • Successful outcomes amongst foreigners receiving antiretroviral therapy in Johannesburg, South Africa K McCarthy, M F Chersich, J Vearey , G Meyer-Rath, A Jaffer, S Simpwalo and W D F Venter (2009) International Journal of STD & AIDS 20 858-862 Data collection period: March 2004 – Feb 2007
  • Record review of all clients enrolled at a NGO clinic: 2004 - 2007; Compared self-identified non-citizens and citizens. Of 1354 adults enrolled: 569 (42%) self-identified as non-citizens.
  • Compared with citizens, non-citizens had: Fewer admissions to inpatient facilities; Fewer missed appointments for ART initiation; Faster mean time to initiation; Better retention in care; and Lower mortality. Non-citizens were less likely to fail ART than citizens. Evidence for good response to ART amongst non-citizens supports the recommendation of UNHCR that ART should not be withheld from displaced persons.
  • lthc are. hea king Data does not support the assumption see that all migrants seeko ink ed t healthcare. sult n is l ill re ratio are w nts’. lthc gra Mig f hea they Migrants report thatof miwould o on if they d ‘return visi a ‘floo were too sick to Pro home’ in work. dhe re to a e to u nabl are ‘ ART’. ants Migr Migrant health is more than access to healthcare services.
  • 1. Whilst the numbers of international migrants in need of healthcare and ART are small, they are significant; 2. Existing protective legislation is not applied uniformly across public institutions; 3. The objectives outlined within the National Strategic Plan for STIs and HIV&AIDS need to be implemented; 4. Upholding the right to health for all within South Africa will have a population-level benefit; 5. There is a need to better understand linked livelihood systems and sickness that cross borders in the context of migration and HIV.
  • To implement the WHA Resolution on the Health of Governments need to engage with – and Migrants: understand - migration and population • Consider health within the broader linked agenda of growth. migration and development; • To address the social determinants of migrant health; • Strengthen the availability of dataato inform An urgent need to implement public health intersectoral, evidence-based, regional policies. approach to the health of migrants. Develop regional frameworks to address migration and health: (draft) SADC framework on communicable diseases and mobility
  • All research participants Nazareth House FMSP/MRMP Tara Polzer Dr. Kerrigan McCarthy (RHRU) Tesfalem Araia Lorena Nunez Members of the Migrant Health Forum (RHRU, Johannesburg) Atlantic Philanthropies Lawyers for Human Rights & Ford Foundation migration.org.za RENEWAL & IDRC Partner organisations involved in the MRMP survey
  • Challenging common assumptions around migration and health in South Africa SAHARA 3rd December 2009 Jo Vearey jovearey@gmail.com http://migration.org.za/