Csvr policy workshop 13 june 2011


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  • South Africa has a progressive asylum policy whereby refugees and asylum seekers are encouraged to self-settle and integrate, rather than be confined to camps. A range of protective rights are afforded to international migrants – including refugees and asylum seekers – that include the right to health, and to antiretroviral therapy. However, many challenges are experienced by international migrants as protective policy is not transformed into protective practice. Key here, are the challenges with the backlog at home affairs that presents challenges in accessing documentation and the lack of awareness of the rights of international migrants amongst service providers.
  • A tentative schematic representation of psychosocial pathways
  • A range of rights, including access to basic healthcare, are provided to non-nationals through the Refugee Act (1998) and the South African Constitution. The current HIV/AIDS and STI National Strategic Plan for South Africa (NSP) specifically includes non-nationals – international migrants, refugees and asylum seekers – and outlines their right to HIV prevention, treatment and support. In September 2007, the National Department of Health (NDOH) released a Revenue Directive [i] clarifying that refugees and asylum seekers – with or without a permit – shall be exempt from paying for antiretroviral treatment (ART) in the public sector. A key guiding principle to the successful implementation of the NSP is towards “ensuring equality and non-discrimination against marginalised groups”; refugees, asylum seekers and foreign migrants are specifically mentioned as having “a right to equal access to interventions for HIV prevention, treatment and support” [ii] . [i] Ref: BI 4/29 REFUG/ASYL 8 2007 [ii] Department of Health (2007) HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011. April 2007: Pretoria: Department of Health, p56
  • In September last year, the NDOH released a revenue directive clarifying that refugees and asylum seekers – with or without a permit – have to rhight to access basic health services and ART. They must be assessed according to the current means test, as applied to South African citizens, and must not be charged foreign category fees.
  • The 2006 NDOH memo c larifies that possession of a South African identity booklet is NOT a prerequisite for eligibility for ART. This is important for South African citizens as well as non-citizens.
  • In addition, Dr. Patrick Maduna of Gauteng Health released a memo in early April providing additional clarification that South African identity booklets are NOT a requirement of healthcare, including ART.
  • Csvr policy workshop 13 june 2011

    1. 1. 13 th June 2011 Exploring the psychosocial and health rights of forced migrants in Johannesburg
    2. 2. <ul><li>Introducing the policy brief process </li></ul><ul><li>Current research: ACMS and CSVR </li></ul><ul><ul><li>Exploring health and psychosocial rights </li></ul></ul><ul><ul><li>Legislative framework </li></ul></ul><ul><ul><li>Emerging findings (empirical study) </li></ul></ul><ul><li>Introducing the problem statement </li></ul><ul><li>Stakeholder mapping </li></ul><ul><li>Developing a policy brief </li></ul><ul><ul><li>A participatory approach </li></ul></ul>
    3. 3. <ul><li>Evidence </li></ul><ul><li>Problem statement </li></ul><ul><ul><li>What has been done? </li></ul></ul><ul><ul><ul><li>What is missing? </li></ul></ul></ul><ul><ul><ul><ul><li>What are the possible solutions? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Develop a policy brief to use to advocate for change. </li></ul></ul></ul></ul>Today
    4. 4. <ul><li>What do you think are the key messages? </li></ul><ul><li>Who needs to hear them? </li></ul>
    5. 5. <ul><li>To explore and understand the psychosocial and health rights of forced migrants who currently receive support from the CSVR. </li></ul>
    6. 6. <ul><li>To review the national and international legislation and treaties outlining the psychosocial and health rights of (1) nationals and (2) forced migrants in South Africa. </li></ul><ul><li>To document the experiences of both South African and forced migrant clients who receive support from the CSVR in accessing their psychosocial and health rights. </li></ul><ul><li>To explore the migration trajectories of clients receiving support from the CSVR. </li></ul><ul><li>To determine how clients receiving support from the CSVR overcome challenges they may face in accessing their psychosocial and health rights. </li></ul><ul><li>To document the experiences of CSVR staff in working with clients to uphold their psychosocial and health rights. </li></ul>
    7. 7. <ul><li>Desk review </li></ul><ul><ul><li>Urban forced migrants, health and psychosocial rights </li></ul></ul><ul><ul><li>Legislation, policy, good practices </li></ul></ul><ul><li>Survey with CSVR clients </li></ul><ul><ul><li>Migration and treatment trajectories </li></ul></ul><ul><ul><li>Access to services, “daily stressors” </li></ul></ul><ul><li>In-depth interviews with CSVR clients </li></ul><ul><li>Focus group discussions and interviews with CSVR staff </li></ul><ul><ul><li>Experiences in assisting clients </li></ul></ul><ul><li>Interviews with organisations that refer clients to CSVR </li></ul><ul><ul><li>Experiences in assisting clients </li></ul></ul><ul><ul><li>Referral networks </li></ul></ul>
    8. 8. <ul><li>Migration is a global trend: </li></ul><ul><ul><li>200 million people estimated to be international migrants (those who have crossed borders). </li></ul></ul><ul><ul><li>Approximately 3% of the world’s population. </li></ul></ul><ul><li>Africa: </li></ul><ul><ul><li>17 million international migrants (18% estimated to be refugees). </li></ul></ul><ul><ul><li>Less than 2% of the total African population. </li></ul></ul><ul><li>Southern Africa: </li></ul><ul><ul><li>Home to 9% of continent’s international migrant population. </li></ul></ul><ul><ul><li>Approximately 3% of region estimated to be international migrants. </li></ul></ul>Zlotnick, 2006; Population Division of the Dept. of Economic and Social Affairs of the UN Secretariat, 2005)
    9. 9. <ul><li>In early 2011, a United Nations delegation called on South Africa to </li></ul><ul><li>“ improve social cohesion and measures against discrimination, exploitation, a tendency by the police to ignore the rights of migrants, and the overall lack of a comprehensive immigration policy that incorporates human rights protection .” </li></ul>
    10. 10. <ul><li>South Africa has an integrative asylum policy : </li></ul><ul><ul><li>Refugees and asylum seekers are encouraged to self-settle and integrate. </li></ul></ul><ul><li>A range of rights are afforded: </li></ul><ul><ul><li>Policies exist that assure the right to health – including ART – for refugees , asylum seekers and other cross-border migrants. </li></ul></ul><ul><li>Key challenges to the effective implementation of these policies: </li></ul><ul><ul><li>Restrictive Immigration Policy; </li></ul></ul><ul><ul><li>Backlog at Department of Home Affairs; and </li></ul></ul><ul><ul><li>Lack of awareness of rights: health facilities. </li></ul></ul>An integrative asylum policy
    11. 11. (Figure adapted from UN-HABITAT, 2008: 72) Gini coefficient in selected South African cities
    12. 12. UNHCR Urban Policy, 2009 <ul><li>“ Given the need to prioritize its efforts and allocation of resources, UNHCR will focus on the provision of services to those refugees and asylum seekers whose needs are most acute. While these priorities will vary from city to city, they will usually include: </li></ul><ul><li>providing care and counselling to people with specific needs, especially people with disabilities, those who are traumatized or mentally ill, victims of torture and SGBV, as well as those with complex diseases requiring specialized care; </li></ul><ul><li>UNHCR, 2009: 18 </li></ul>“ These rights include, but are not limited to, the right to life; the right not to be subjected to cruel or degrading treatment or punishment; the right not to be tortured or arbitrarily detained; the right to family unity; the right to adequate food, shelter, health and education, as well as livelihoods opportunities.”
    13. 13. <ul><li>Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. </li></ul>
    14. 14. <ul><li>We consider psychosocial as </li></ul><ul><li>“ pertaining to the influence of social factors on an individual’s mind or behaviour and to the interrelation of behavioural social factors” </li></ul><ul><li>(Oxford English Dictionary) </li></ul><ul><li>These factors have an effect on health as they mediate, condition or modify the effects of socio structural factors on individual health outcomes. </li></ul><ul><li>We consider the psychosocial determinants of health </li></ul><ul><ul><li>This allows us to capture the extent to which health is affected by psychosocial determinants. </li></ul></ul><ul><ul><li>This is a critical aspect to be considered when thinking through access to broader psychosocial and health rights. </li></ul></ul><ul><li>(Martikainen, Bartley and Lahelma, 2002) </li></ul>
    15. 15. A tentative schematic representation of psychosocial pathways. Martikainen P et al. Int. J. Epidemiol. 2002;31:1091-1093 © International Epidemiological Association 2002 e.g. legal and welfare structures e.g. social networks and support that lead to emotional support Stress Social isolation “ If we wish to contribute to the development of policy to improve health, the complex combinations of social, psychological and biological processes that contribute to ill-health need to be clarified.” Martikainen, Bartley and Lahelma, 2002: 1093
    16. 16. <ul><li>The role of daily stressors </li></ul><ul><ul><li>Stressful social and material conditions </li></ul></ul><ul><ul><li>Poverty, social marginalisation, isolation, inadequate housing, changes in family structure </li></ul></ul><ul><ul><li>Data shows that daily stressors have “powerful effects on mental health outcomes” </li></ul></ul><ul><li>Trauma-focussed + psychosocial approach </li></ul><ul><li>Miller and Rasmussen, 2010 </li></ul>
    17. 17. <ul><li>Daily stressors as partially mediating the relationship of armed conflict to mental health and psychosocial status. </li></ul><ul><li>Adapted from Fernando et al., 2010 (in Miller and Rasmussen, 2010). </li></ul>
    18. 18. <ul><ul><li>It is important to undertake a rapid and contextually grounded assessment of locally salient daily stressors before developing mental health and psychosocial interventions. </li></ul></ul><ul><ul><li>Before providing specialised clinical services that target psychological trauma, first address those daily stressors that are particularly salient and can be affected through targeted interventions . </li></ul></ul><ul><ul><li>When specialised mental health interventions are indicated, interventions should go beyond PTSD to address the diverse forms of distress that may result from exposure to war-related violence and loss. </li></ul></ul><ul><ul><li>It is essential to take into account that not all symptoms of trauma are necessarily related to conflict exposure . Even in situations of armed conflict, there are other sources of psychological trauma. </li></ul></ul><ul><li>(Miller and Rasmussen, 2010) </li></ul>
    19. 19. <ul><li>Neuropsychiatric conditions ranked 3 rd in South Africa’s burden of disease (after HIV/AIDS and other infectious diseases). </li></ul><ul><li>Evidence that mental ill-health is strongly associated with poverty and the social deprivation associated with poverty . </li></ul><ul><li>Mental health resources “ chronically under-resourced ”. </li></ul><ul><li>Unmet need : only 28% of people with moderate – severe common mental disorders receive mental healthcare. </li></ul>
    20. 20. <ul><li>Two important documents, 1997: </li></ul><ul><ul><li>White paper for the transformation of the health system in South Africa </li></ul></ul><ul><ul><li>National health policy guidelines for improved mental health in South Africa </li></ul></ul><ul><li>Mental Health Care Act (2002); promulgated in 2004 </li></ul><ul><ul><li>In line with international human rights standards </li></ul></ul><ul><ul><li>Mechanisms for decentralisation and integration of mental health </li></ul></ul><ul><ul><li>Development of community-based care </li></ul></ul>Approved in 1997. Policy not published or widely circulated. No implementation guidelines developed. Unfunded mandate. Percentage of NDOH expenditure devoted to mental health is unknown. Lund et al., 2010; Burns, 2011
    21. 21. Burns, 2011 South Africa has 30% of the number required for national norms of 1 per 100,000
    22. 23. <ul><li>A strong advocacy movement led by persons with mental disabilities. </li></ul><ul><li>Legislative reform to abolish discrimination, outlaw abuse and exploitation and protect personal freedom, dignity and autonomy. </li></ul><ul><li>Legislative reform to inform equality of opportunity, access and participation in all aspects of life. </li></ul><ul><li>Inclusion of mental disability on the agenda of development programmes and targets such as MDGs. </li></ul><ul><li>Mental health and social services reform with equitable funding for resources, infrastructure, and programmes development. </li></ul><ul><li>Removal of barriers to access to health services encountered by persons with mental disabilities. </li></ul><ul><li>Removal of barriers to access to social, family-related, accommodation, educational, occupational and recreational opportunities, and full participation for persons with mental disabilities. </li></ul><ul><li>Service system reform to move away from institutional care toward providing treatment, care, rehabilitation and reintegration within the community. </li></ul>Burns, 2011
    23. 24. 2008
    24. 26. Declaration of cooperation, 2001 Based on a consultation held in 2000. Aimed at promoting evidence-based, holistic and community-based approaches.
    25. 27. <ul><li>Declaration of Psychosocial Rights, 2009 </li></ul>
    26. 28. National Guidelines for Victim Empowerment
    27. 29. <ul><li>South African Constitution; </li></ul><ul><li>Refugee Act (1998); </li></ul><ul><li>HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011 (NSP); </li></ul><ul><li>National Department of Health (NDOH) Memo (2006); </li></ul><ul><li>NDOH Directive (September 2007); and </li></ul><ul><li>Gauteng DOH Letter (April 2008). </li></ul>Protective policy The right to health
    28. 30. NDOH Financial Directive, 2007
    29. 31. <ul><ul><li>Clarifies that possession of a South African identity booklet is NOT a prerequisite for eligibility for ART ; </li></ul></ul><ul><ul><li>Important for South African citizens as well as non-citizens. </li></ul></ul>NDOH memo, 2006
    30. 32. <ul><li>April 2008; </li></ul><ul><li>Additional clarification that South African identity documents are not required for health care, including ART. </li></ul>Letter from Gauteng DOH, 2008
    31. 33. <ul><li>Legislation exists to uphold the right of cross-border migrants to access basic healthcare – including ART – in South Africa. </li></ul><ul><li>(The Constitution, 1996; Refugee Act, 1998; National Health Act, 2004; NDOH Memo, 1996; NDOH Revunue Directive, 2007; Gauteng DOH Memo, 2008; Vearey & Richter, 2008; Vearey, 2008; CoRMSA, 2011; Moyo, 2010; Vearey, 2010; Vearey 2011) </li></ul><ul><li>Despite this, cross-border migrants face challenges in accessing public health services , including ART. </li></ul><ul><li>( Amon & Todrys, 2009; CoRMSA, 2011; Human Rights Watch, 2009a, 2009b; IOM, 2008; Landau, 2006; Moyo, 2010; MSF, 2009; Pursell, 2004; Vearey, 2008; Vearey, 2010; Vearey 2011) </li></ul><ul><ul><li>Cross-border and internal migrants are affected by poor access to healthcare services – as are those who have always resided in JHB. </li></ul></ul><ul><ul><li>Being a cross-border migrant presents additional access challenges : documentation; “being foreign”; language barriers. </li></ul></ul>
    32. 34. <ul><li>Urban forced migrants have the right to basic services, including healthcare and psychosocial services. </li></ul><ul><li>Urban forced migrants experience challenges in accessing healthcare, including trauma and psychosocial services. </li></ul><ul><li>Urban forced migrants experience a range of “daily stressors” that are negatively effecting their mental health status. </li></ul><ul><ul><li>Whilst many of these “daily stressors” are also experienced by South African nationals, particular stressors are unique to forced migrants. </li></ul></ul><ul><ul><li>A range of “daily stressors” are linked to ineffective policy implementation. </li></ul></ul><ul><li>Protective policy is not uniformly implemented. </li></ul><ul><li>Non-governmental services are doing their best to “fill the gap”. </li></ul>
    33. 35. <ul><li>In South Africa, the general population experiences poor access to public healthcare, including mental healthcare and psychosocial services. The urban poor face a range of daily stressors that negatively affect their emotional wellbeing. </li></ul><ul><li>Urban forced migrants in Johannesburg face specific challenges in accessing their right to healthcare, including mental healthcare and psychosocial services (language, documentation, livelihoods, food security, housing etc). </li></ul><ul><li>Additionally urban forced migrants experience specific “daily stressors” that negatively affect their emotional wellbeing. </li></ul><ul><li>Policies designed to protect urban forced migrants are not being effectively implemented in Johannesburg. </li></ul>
    34. 36. <ul><li>Policy brief to be finalised and distributed to participants </li></ul><ul><ul><li>Share with Migrant Health Forum </li></ul></ul><ul><li>CSVR to utilise policy brief in their policy engagement process </li></ul><ul><ul><li>Roundtable with appropriate government and non-governmental stakeholders </li></ul></ul><ul><li>Population Council Seminar – 22 nd June, Wits </li></ul><ul><ul><li>Migrant access to healthcare </li></ul></ul><ul><ul><li>Share policy brief - ?? </li></ul></ul><ul><li>Research process to be completed </li></ul><ul><ul><li>Report to be available in August 2011 </li></ul></ul>