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International urban migrants:  linkages between access to ART and survivalist livelihood strategies in the City of Johannesburg, South Africa
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International urban migrants: linkages between access to ART and survivalist livelihood strategies in the City of Johannesburg, South Africa


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  • The theoretical framework for this intervention drew on work done on urban livelihoods, Paulo Friere’s adult learning, social anthropology and the reflect methodology. Sustainable Livelihoods is a people-centred, participatory and responsive approach to development. SL based programmes starts from where individuals, households and communities currently are, in relation to their livelihoods, and builds from there. This ensures that people - and their current, existing strengths (assets) - are built upon. Stresses are chronic – they include hunger, the fear of violence, unemployment Shocks , are acute - such as shack fires, evictions, rape, theft. Assets – whether they are financial (grants or microfinance loans), physical (a house that does not leak), social (community groups), act as buffers - they enable an individual, household or community to cope with , and recover from , stresses and shocks A SL approach involves assisting individuals to obtain additional assets (strengths) and build these in order to access and obtain additional resources. By continuously building and developing this asset base, an individual is better able to cope with shocks and stresses encountered on a daily basis. ---------------------------- Need to be imaginitave, creative Multi-disciplinary Adult educations Participatroy rural appraisals Reflect Social anth Livelihoods Understand and draw to create a strong theoretical framework Adjusted from various literature etc S ustainable livelihoods (SL) is a people-centred, participatory and responsive approach to development. A sustainable livelihood is “ a livelihood that can cope with and recover from stresses and shocks and maintain or enhance its capabilities and assets both now and in the future…. ” (Carney, 1998)
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    • 1. International urban migrants: linkages between access to ART and survivalist livelihood strategies in the City of Johannesburg, South Africa Jo Vearey PhD Student, School of Public Health Doctoral Research Fellow, Forced Migration Studies Programme University of the Witwatersrand [email_address] 29 th May 2008
    • 2. Overview of presentation
      • Background
      • Methods
      • Key findings
      • A revised livelihoods framework for urban migrants
      • Key messages
      • Recommendations
    • 3. Migration and the City of Johannesburg
      • Estimated population of nearly 3.9 million;
      • The City has grown by 20.5% since 2001;
      • Average growth rate of 4.16% per year;
      • Estimated that the population will reach 5.2 million by 2015.
      (City of Johannesburg, 2008)
      • In certain inner-city neighbourhoods, one quarter to half of residents are estimated to be international migrants (Landau, 2006; Leggett, 2003).
    • 4. International migrants
      • Labour migrants: work permits;
      • Refugees and asylum seekers;
      • Other: study permits; visitor permits; and
      • Undocumented migrants.
      • Immigration act makes it difficult for lower-skilled workers to legalise their stay in South Africa.
    • 5.
      • South Africa has an integrative urban asylum policy :
        • No camps;
        • Refugees and asylum seekers are encouraged to self- settle and integrate;
        • This includes the right to healthcare and the right to employment.
      • Challenges exist:
        • The Department of Home Affairs has a backlog of applications and serious barriers to accessing documentation exist (e.g. CoRMSA, 2007; Landau, 2006).
        • There is a lack of awareness of the rights of refugees and asylum seekers within the public health sector and employers (e.g. CoRMSA, 2007; Pursell, 2006).
      Asylum policy
    • 6. Methods: Johannesburg inner-city
      • African Cities Survey (2006)
        • Johannesburg, Maputo, Lubumbashi and Nairobi
        • Household survey within purposively selected inner-city suburbs;
        • n = 847 (656 international migrants, 191 South Africans)
        • Livelihoods data
      • ART Access Study (2007)
        • Assessing non-citizen access to ART
        • Cross-sectional survey
        • Four purposively selected sites in international migrant-dense areas:
          • 2 governmental, 2 non-governmental
        • n = 449
      • Semi-structured interviews with migrant ART clients (2008)
        • Currently working in the informal economy
        • Currently well
        • n = 19 (plus 4 with South African ART clients)
    • 7. Key findings
      • The importance of the informal economy for international urban migrants;
      • The challenges international migrants face in accessing ART in the public sector; and
      • The linkages between upholding the right to access ART and the ability to maintain a survivalist livelihood.
    • 8. The importance of the informal economy for urban migrants
      • African Cities Survey (2006)
      • Most report coming to JHB for economic opportunity (37%);
      • 33% report having paid someone else since arriving in South Africa; and
      • Almost half of all respondents support others by sending money outside of Johannesburg.
    • 9. Urban migrant livelihoods African Cities Survey, 2006
    • 10. Non-citizens face challenges in accessing ART in the public sector
      • Protective policies do exist – the right to health, including ART:
      • South African Constitution;
      • Refugee Act (1998);
      • HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011 (NSP);
      • National Department of Health (NDOH) Memo (2007);
      • NDOH Directive (September 2007); and
      • Gauteng DOH Letter (April 2008).
    • 11. Health migration and adherence
      • Health migrants?
      • These individuals are not health migrants :
        • Mostly first tested for HIV in South Africa (76%) and found out their status in South Africa (80%);
        • Came to South Africa for other reasons;
        • Have been here for a period of time before discovering their status.
      • Adherence?
      • Migrant ART clients are no more likely than South African clients to not collect (p = 0.675) or not take (p = 0.404) their medication
    • 12. Like South Africans, these migrants are most likely to test only when sick (Chi-squared; P = 0.122)
    • 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 .
      Migrants are accessing ART in the non-governmental sector Government sites Non-governmental
    • 14. A dual healthcare system
      • International migrants 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. The linkages between upholding the right to access ART and maintaining a survivalist livelihood
      • Importance of ART on maintaining (if treatment was initiated before an individual was sick) or regaining (if treatment began after an episode of sickness) livelihood; and
      • The importance of starting ART early : the need for early testing.
    • 16. A revised sustainable livelihoods framework for urban migrants
    • 17. ASSETS (strengths) Resources Stresses Shocks financial physical human social hunger violence evictions unemployment sickness
      • Urban migrants
        • Refugees
        • Asylum seekers
        • Undocumented migrants
        • Labour migrants
        • Other: study/visitor permits
      HIV provision of remittances ART Legislation Protective policy housing - - - buffer - - -
    • 18. Key messages
      • HIV and international migration involve all dimensions of urban policy;
      • It is important to understand migrant livelihood strategies in order to improve interventions (De Vriese, 2006):
        • The importance of the informal economy.
      • Migrants can benefit the cities they reside within (Jacobsen, 2006);
      • HIV is an urban public health challenge:
        • Ensuring access to the continuum of HIV-related services – including ART -enables fragile livelihoods to be maintained;
        • Relevance to all urban migrants and citizens; and
        • Ensuring access to ART is upheld for all who need it within South Africa will have a population-level benefit.
      • Access to ART – particularly early access - facilitates livelihood strategies, enabling individuals to support themselves, and others:
        • ART is an essential resource for all urban migrants.
    • 19. Recommendations (1)
      • Policies must be implemented uniformly across the public health sector. Local and provincial health departments must:
      • Provide appropriate training on rights of international migrants
        • Include institutional managers.
      • Audit institutional level policies
        • Put mechanisms in place to ensure institutional policies are in line with national directives, policy and values.
      • Investigate and appropriately discipline public health care officials who contravene official policy
        • At all levels – including institutional managers.
    • 20. Recommendations (2)
      • A clear coherent policy to guide the informal economy is required ;
      • Local government must work to recognise:
        • The importance of the informal economy
        • The contribution that international migrants are able to make to local economies, including the employment of others.
      • The positive incorporation of all international migrants into cities is required:
        • The role of developmental local government must be strengthened;
        • Need to actively engage with, target and involve international migrant communities; and
        • The livelihoods framework can assist in identifying the range of government departments that must be involved.
    • 21. Acknowledgements
      • Xolani Tshabalala for conducting the qualitative interviews with ART clients;
      • All study participants, including survey respondents and ART clients;
      • Study sites;
      • Forced Migration Studies Programme;
      • Second economy strategy for funding the qualitative interviews.