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Integrative asylum policy within South Africa: investigating access to ART services for refugees and asylum seekers within a complex urban environment Presentation Transcript

  • 1. Integrative asylum policy within South Africa: investigating access to ART services for refugees and asylum seekers within a complex urban environment Jo Vearey PhD Student, School of Public Health Doctoral Research Fellow, Forced Migration Studies Programme University of the Witwatersrand [email_address] http://migration.org.za Reproductive Health in Emergencies Conference 2008, Kampala 20 th June 2008
  • 2. Overview of presentation
    • Background;
    • Aims;
    • Methods;
    • Key findings; and
    • Key recommendations.
  • 3. An integrative asylum policy
    • South Africa has an integrative asylum policy :
      • Refugees and asylum seekers are encouraged to self-settle and integrate ;
    • A range of rights are afforded:
      • Policies exist that assure the right to health – including ART – for refugees , asylum seekers and other international migrants ;
    • Key challenges to the effective implementation of these policies:
      • Backlog at Department of Home Affairs; and
      • Lack of awareness of rights: service providers.
  • 4. Current context: Johannesburg
    • Violence against international migrants (May 2008);
    • As a result, estimates of:
      • 200,000 displaced;
      • 25,000 – 35,000 Mozambicans and Zimbabweans fled South Africa
    • Establishment of temporary shelters and camps …….
    • The majority of international migrants remain self-settled .
  • 5. Johannesburg – a complex urban environment
    • Estimated population of nearly 3.9 million;
    • In certain inner-city neighbourhoods, one quarter to half of residents are estimated to be international migrants (Landau, 2006; Leggett, 2003):
      • Asylum seekers;
      • Refugees;
      • Work/study/visitor permits;
      • Undocumented migrants.
    • The context of HIV in urban environments provides an additional challenge: prevention, testing, treatment, support.
  • 6. Study aims
    • To understand the extent to which different categories of migrants are able to access ART in Johannesburg and the barriers that may hinder their access.
    • To provide recommendations to institutions and Provincial Department of Health (DoH) .
    • To test common assumptions that relate to the presence of international migrants in South Africa:
      • Health migrants?
      • Adherence?
  • 7. Methods
    • 4 ART sites in Johannesburg inner-city were purposively selected from migrant dense areas: 2 government sites; 2 non-governmental
    • Desk-based literature and policy review ;
    • Semi-structured interviews with health care providers (n = 34);
    • 1 focus group discussion with 8 refugee HIV counsellors; and
    • Cross-sectional survey questionnaire conducted with a random sample of citizen and migrant ART clients (n = 449).
  • 8.
    • Key findings
  • 9. Health migrants?
    • These individuals are not health migrants :
      • Discovered their status in South Africa (80%);
      • Mostly first tested for HIV in South Africa (76%);
      • Came to South Africa for other reasons
        • Qualitative follow up study;
      • Have been here for a period of time before discovering their status.
  • 10. Continuity of treatment
    • In this study, 20% of international migrants reported initiating ART in another country …..
      • Appears that other reasons (economic) are the reason for movement;
      • Further research needed – is access to ART (becoming) a determinant of migration?
        • Qualitative follow up study;
      • Continuity of treatment .
  • 11. Like South Africans, international migrants are most likely to test only when sick (Chi-squared; P = 0.122)
  • 12. International migrant clients are no more likely than South Africans to not collect or not take their ART (Chi-squared; p = 0.404)
  • 13.
    • Only 22% of all non-citizens interviewed were accessing ART at government sites;
    • The difference between the two government sites can be explained by the differences in institutional policy .
    International migrants are accessing ART in the non-governmental sector Government sites Non-governmental
  • 14. A dual healthcare system
    • 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 for the delivery of ART: public and NGO, 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.
  • 15. Summary
    • Whilst the numbers of international migrants in need of ART are small, they are significant ;
    • Existing protective legislation is not applied uniformly across public institutions;
    • The resultant dual healthcare system presents challenges ; and
    • HIV is a public health challenge : ensuring access to ART is upheld for all who need it within South Africa will have a population-level benefit.
  • 16. Key recommendations
    • The right to health for all migrants, regardless of status, must be upheld.
    • As is the case for South African citizens, campaigns must be implemented to encourage early HIV testing for non-citizens.
    • NDoH must work to ensure, through training, that protective frameworks and policies are applied uniformly across all public institutions.
    • There is a need for assessment and monitoring of ART access (continuity of treatment) given recent displacement and establishment of temporary camps and shelters.
  • 17. Acknowledgements
    • All study participants, both healthcare providers and ART clients
    • Study sites
      • Support to the research and dissemination
    • Forced Migration Studies Programme
      • Fieldworkers (survey)
      • Dr. Ingrid Palmary
    • Lawyers for Human Rights
    • Ford Foundation