Key findings of research studies on migrants’ access to health in South Africa: challenging common assumptions

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  • The Forced Migration Studies Programme runs a Migrant Rights Monitoring Project. This includes a ‘Public Service Access Survey’ that is examining access to education, housing, healthcare for international migrants. Preliminary findings indicate that: Less than half of all respondents have ever needed healthcare Zimbabweans are the group least likely to ever need healthcare
  • Of those that have reported trying to access public healthcare, however, Nearly 30% report having experienced problems Of these, 28% reported language problems 22% report being denied treatment because of documents And 21% report being denied treatment for being ‘foreign’
  • An additional study, run through the FMSP and the Monitoring project, examined access to ART in inner-city Johannesburg. This study found that Individuals in need of ART do not generally migrate to South Africa in order to access treatment : Discovered their status in South Africa (80%); Tested when sick (like South Africans, p = 0.122); Mostly first tested for HIV in South Africa (76%); Came to South Africa for other reasons; and Have been here for a period of time before discovering their status.
  • However, 20% of international migrants reported initiating ART in another country ….. It a ppears 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 is essential – regardless of reasons for movement. To this end, guidelines relating to continuity of treatment do exist.

Transcript

  • 1. Key findings of research studies on migrants’ access to health in South Africa: challenging common assumptions SADC Parliamentary Forum Parliamentary Strategies for ensuring equitable access of migrants to public health services in the SADC region 21 st October 2009 Jo Vearey [email_address] Presented by: Tara Polzer [email_address] http://migration.org.za/ University of the Witwatersrand Forced Migration Studies Programme Health and Migration Initiative
  • 2. Overview
    • Cross-border migrants and healthcare provision: a global challenge ;
    • Assumptions linking migration, health and health-seeking ;
    • Some data on migrant health in South Africa : this includes (but is not limited to) migrant access to public healthcare services;
    • Recommendations to policy makers and practitioners.
  • 3. The South African context: protective policy exists to ensure access to public health for cross-border migrants, 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 (2006);
    • NDOH Directive (September 2007); and
    • Gauteng DOH Letter (April 2008).
  • 4. Defining cross-border migrants
    • Asylum seekers (Section 22 permit);
    • Refugees (Section 24 permit);
    • Other: work permits, study permits; visitor permits; and
    • Undocumented migrants.
    Immigration act makes it difficult for lower-skilled workers to legalise their stay in South Africa. Challenges at Home Affairs: access to documentation is problematic.
  • 5. Health-seeking migrants?
    • 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.
  • 6. Public health
    • 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.
  • 7. Prevailing assumptions Migration is linked to seeking healthcare. Provision of healthcare will result in a ‘flood of migrants’. Migrants are ‘unable to adhere to ART’.
  • 8. Some recent/ongoing studies
    • 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).
  • 9.
    • Migrant Rights Monitoring Project (MRMP): National Public Service Access Survey
    • Forced Migration Studies Programme
    • Data collection period: 2007 – 2008
  • 10.
    • Reporting period: 2007 – 2008
      • 3,182 respondents ;
      • NGO service providers (59%) and
      • Refugee Reception Offices (41%).
    Migrant access to health care MRMP ‘National Public Service Access Survey’
  • 11. Migrant access to health care MRMP ‘National Public Service Access Survey’ n = 3,182
  • 12. Migrant access to health care MRMP ‘National Public Service Access Survey’
    • Under half of all respondents report ever needing healthcare since their arrival in South Africa:
      • 45%; n = 1,403.
  • 13.
    • 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.
    Migrant access to health care MRMP ‘National Public Service Access Survey’
  • 14. Migrant access to health care MRMP ‘National Public Service Access Survey’
    • 30% (n = 396) report having experienced problems when trying to access public health care.
  • 15. Problems experienced when trying to access public health services n = 396; 542 responses (multi-answer)
  • 16. Migrant access to health care MRMP ‘National Public Service Access Survey’
    • Documentation status is related to the likelihood of experiencing a problem:
        • Undocumented migrants (38%);
        • Asylum seekers – Section 22 (31%);
        • Other documented migrants (28%);
        • Refugees – Section 24 (24%).
  • 17.
    • RENEWAL household survey
    • Forced Migration Studies Programme
    • Data collection period: 2008
  • 18. RENEWAL survey: summary of key findings
    • 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
  • 19.
    • 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 .
    RENEWAL survey: summary of key findings
  • 20.
    • Non-citizen access to ART in inner-city Johannesburg
    • Forced Migration Studies Programme
    • Data collection: 2007
  • 21. Health migrants? Findings from ART access study
    • Individuals in need of ART do not generally migrate to South Africa in order to access treatment :
      • Discovered their status in South Africa (80%);
      • Mostly first tested for HIV in South Africa (76%);
      • Tested when sick (like South Africans, p = 0.122);
      • Came to South Africa for other reasons;
      • Have been here for a period of time before discovering their status.
    • Cross-sectional survey
    • Four ART sites in inner-city Johannesburg (2 government; 2 NGO)
    • n = 449
  • 22. Continuity of treatment Findings from ART access study
    • 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 .
  • 23. 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, 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.
  • 24.
    • Successful outcomes amongst displaced persons receiving antiretroviral therapy in Johannesburg, South Africa
    • McCarthy, K. et al (2009)
    • RHRU
    • Data collection period: March 2004 – Feb 2007
  • 25. Successful outcomes amongst displaced persons receiving antiretroviral therapy in Johannesburg, South Africa
    • 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.
  • 26. Successful outcomes amongst displaced persons receiving antiretroviral therapy in Johannesburg, South Africa
    • 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 .
  • 27. Key messages Data does not support the assumption that all migrants seek healthcare. Migrants report that they would ‘return home’ if they were too sick to work. Migration is linked to seeking healthcare. Provision of healthcare will result in a ‘flood of migrants’. Migrants are ‘unable to adhere to ART’. Migrant health is more than access to healthcare services.
  • 28. Summary
    • Whilst the numbers of international migrants in need of healthcare and ART are small, they are significant ;
    • Existing protective legislation is not applied uniformly across public institutions;
    • The objectives outlined within the National Strategic Plan for STIs and HIV&AIDS need to be implemented;
    • Upholding the right to health for all within South Africa will have a population-level benefit;
    • There is a need to better understand linked livelihood systems and sickness that cross borders in the context of migration and HIV.
  • 29. Recommendations
    • To implement the WHA Resolution on the Health of Migrants:
    • Consider health within the broader linked agenda of migration and development;
    • To address the social determinants of migrant health;
    • Strengthen the availability of data to inform intersectoral, evidence-based, regional policies.
    Develop regional frameworks to address migration and health: (draft) SADC framework on communicable diseases and mobility An urgent need to implement a public health approach to the health of migrants.
  • 30. Acknowledgements
    • All research participants
    • FMSP/MRMP
      • Tara Polzer
      • Tesfalem Araia
      • Lorena Nunez
    • Atlantic Philanthropies
    • Lawyers for Human Rights & Ford Foundation
    • RENEWAL & IDRC
    • Partner organisations involved in the MRMP survey
    • Nazareth House
    • Dr. Kerrigan McCarthy (RHRU)
    • Members of the Migrant Health Forum (RHRU, Johannesburg)
    • migration.org.za
  • 31. Key findings of research studies on migrants’ access to health in South Africa: challenging common assumptions SADC Parliamentary Forum Parliamentary Strategies for ensuring equitable access of migrants to public health services in the SADC region 21 st October 2009 Jo Vearey [email_address] Presented by: Tara Polzer [email_address] http://migration.org.za/ University of the Witwatersrand Forced Migration Studies Programme Health and Migration Initiative