24 th  August 2011 Migration and health in Johannesburg Implications for the GDS 2040 Jo Vearey, PhD [email_address]
<ul><li>What is migration and who are migrants in Johannesburg? </li></ul><ul><li>What are the linkages between migration ...
<ul><li>“ ......migration is not a random individual choice.  People who migrate are highly organised and travel well-worn...
<ul><li>Migration involves the movement of people; young, old, men, women, families. </li></ul><ul><li>People move for a r...
FMSP and UNOCHA, 2009
Percentage of international migrants living in urban settlement by District Municipality FMSP and UNOCHA, 2009
 
<ul><li>Urban growth </li></ul><ul><li>Estimated population of approximately  3.8 million ; </li></ul><ul><li>The City has...
Internal  AND  cross-border migration
NDOH Financial Directive, 2007
<ul><li>Legislation exists to uphold the right of cross-border migrants to access basic healthcare – including ART – in So...
<ul><li>Reasons for moving to Johannesburg: </li></ul><ul><ul><li>Both cross-border migrants and South African migrants re...
<ul><li>Urbanisation experiences : </li></ul><ul><ul><li>Cross-border migrants tend to have a better urbanisation experien...
<ul><li>Social networks : </li></ul><ul><ul><li>Various studies have highlighted the strength of the social networks of cr...
<ul><li>Livelihood strategies: </li></ul><ul><ul><li>Cross-border migrants are more likely to be earning an income than So...
<ul><li>Education levels : </li></ul><ul><ul><li>Cross-border migrants have been found to have higher education levels tha...
<ul><li>Cross-border migrants have the right to basic services, including healthcare, ART and psychosocial services. </li>...
 
<ul><li>Ensure that all city officials understand migration and its implications for urban health </li></ul><ul><ul><li>Pl...
<ul><li>Understand social determinants of urban health </li></ul><ul><ul><li>Migration, environment, housing </li></ul></u...
24 th  August 2011 Migration and health in Johannesburg Implications for the GDS 2040 Jo Vearey, PhD [email_address]
<ul><li>South Africa has an  integrative asylum policy : </li></ul><ul><ul><li>Refugees and asylum seekers are encouraged ...
UNHCR Urban Policy, 2009 <ul><li>“ Given the need to prioritize its efforts and allocation of resources, UNHCR will focus ...
<ul><li>South African Constitution;  </li></ul><ul><li>Refugee Act (1998); </li></ul><ul><li>HIV & AIDS and STI Strategic ...
NDOH Financial Directive, 2007
<ul><ul><li>Clarifies that  possession of a South African identity booklet is NOT a prerequisite for eligibility for ART ;...
<ul><li>April 2008; </li></ul><ul><li>Additional clarification that  South African identity documents are not required  fo...
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Migration and health in Johannesburg

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Input made to the City of Johannnesburg's Growth and Development Strategy 2040.

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  • 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.
  • Simply show as e.g. of type of data available at a national level. This can be used at national, provincial and district level for implementation of programmes etc.
  • Simply show as e.g. of type of data available at a national level. This can be used at national, provincial and district level for implementation of programmes etc.
  • The process of migration can affect the health of migrants. It is the context of migration that is the challenge; not being a migrant per se. There are various phases which need to be considered when thinking about HIV responses – migration is a continuum and responses need to engage with this. Especially continuity of care. This is applicable to BOTH internal AND cross-border migrant groups.
  • 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.
  • 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 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 &amp; 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.
  • Migration and health in Johannesburg

    1. 1. 24 th August 2011 Migration and health in Johannesburg Implications for the GDS 2040 Jo Vearey, PhD [email_address]
    2. 2. <ul><li>What is migration and who are migrants in Johannesburg? </li></ul><ul><li>What are the linkages between migration and urban health? </li></ul><ul><ul><li>What are the current social and health service gaps in Johannesburg? </li></ul></ul><ul><li>How can the City of Johannesburg respond to migration and health? </li></ul><ul><ul><li>How can the City manage tensions between migrants and established residents in promoting access to health and social services for all? </li></ul></ul>
    3. 3. <ul><li>“ ......migration is not a random individual choice. People who migrate are highly organised and travel well-worn paths.” </li></ul><ul><li>(Harcourt, 2007: 3) </li></ul>Source: HDRO staff estimates based on University of Sussex (2007) database
    4. 4. <ul><li>Migration involves the movement of people; young, old, men, women, families. </li></ul><ul><li>People move for a range of reasons. </li></ul><ul><li>South African nationals </li></ul><ul><li>Rural to urban </li></ul><ul><li>Urban to urban </li></ul><ul><li>Within a municipality </li></ul><ul><li>Cross-border migrants </li></ul><ul><li>Forced migrants: asylum seekers; refugees </li></ul><ul><li>Other permits: work, visitor, study </li></ul><ul><li>Undocumented </li></ul>The overwhelming majority of migrants in Johannesburg move in order to seek improved livelihood opportunities . Migrants do not report moving to Johannesburg in order to access health care, ART or other services. On arrival in Johannesburg, migrants tend to be healthier than the host population. If they become too sick to work, migrants will return back home to seek care and support .
    5. 5. FMSP and UNOCHA, 2009
    6. 6. Percentage of international migrants living in urban settlement by District Municipality FMSP and UNOCHA, 2009
    7. 8. <ul><li>Urban growth </li></ul><ul><li>Estimated population of approximately 3.8 million ; </li></ul><ul><li>The City has grown by 20.5% since 2001 ; </li></ul><ul><li>Average growth rate of 4.16% per year ; </li></ul><ul><li>Estimated that the population will reach 6 – 8 million by 2040 . </li></ul>(City of Johannesburg, 2008; 2011) <ul><li>Migration </li></ul><ul><li>A ‘city of migrants ’: </li></ul><ul><ul><li>Rural to urban – internal; </li></ul></ul><ul><ul><li>Cross border – external. </li></ul></ul><ul><li>Informal housing </li></ul><ul><li>Almost 25% estimated to live informally. </li></ul>HIV
    8. 9. Internal AND cross-border migration
    9. 10. NDOH Financial Directive, 2007
    10. 11. <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; Windahl Pedersen 2010 ) </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><ul><li>Cross-border migrants have been found to experience better treatment outcomes on ART compared to South Africans. </li></ul><ul><li>(McCarthy et al., 2009) </li></ul>© Iketleng, 2010
    11. 12. <ul><li>Reasons for moving to Johannesburg: </li></ul><ul><ul><li>Both cross-border migrants and South African migrants report moving to Johannesburg for reasons other than health seeking. </li></ul></ul><ul><ul><li>Mostly: livelihood opportunities. </li></ul></ul><ul><ul><li>Some cross-border migrants fleeing persecution and </li></ul></ul><ul><ul><li>civil war. </li></ul></ul><ul><li>Documentation: </li></ul><ul><ul><li>Cross-border migrants experience challenges in accessing documentation. </li></ul></ul><ul><ul><li>(Landau, 2006; Vearey, 2008; Vearey et al., 2009; Vearey et al., 2010; Landau and Duponchel, 2010) </li></ul></ul>© Monica Mabasa, 2010
    12. 13. <ul><li>Urbanisation experiences : </li></ul><ul><ul><li>Cross-border migrants tend to have a better urbanisation experience than South Africans. </li></ul></ul><ul><ul><li>Previous urban experience. </li></ul></ul><ul><ul><li>Networks and linkages to the City. </li></ul></ul><ul><ul><li>Enter through the central-city and not the periphery. </li></ul></ul><ul><ul><li>Access to livelihood strategies and income-generating opportunities. </li></ul></ul><ul><ul><li>(Landau, 2006; Vearey, 2008; Vearey et al., 2009; Landau and Duponchel, 2010; Vearey et al ., 2010) </li></ul></ul>© Shorty, 2010
    13. 14. <ul><li>Social networks : </li></ul><ul><ul><li>Various studies have highlighted the strength of the social networks of cross-border migrants compared to host populations. </li></ul></ul><ul><ul><li>(Mitchell, 1974; McGaffey and Bazenguissa-Ganga, 2000; Stoller, 2002; Babou, 2002; Vearey, 2008; Landau and Duponchel, 2010; Vearey et al. 2010) </li></ul></ul><ul><ul><li>Knowing someone in the city. </li></ul></ul><ul><ul><li>(Landau, 2006; Landau and Duponchel, 2010; Vearey et al., 2010) </li></ul></ul><ul><ul><li>Non-citizens were more likely to be referred to the ART site by a friend or family member. </li></ul></ul><ul><ul><li>(Vearey, 2008) </li></ul></ul>© Mimi, 2010
    14. 15. <ul><li>Livelihood strategies: </li></ul><ul><ul><li>Cross-border migrants are more likely to be earning an income than South Africans. </li></ul></ul><ul><ul><li>The important role of the informal workplace. </li></ul></ul><ul><ul><li>(Vearey et al ., 2009; Landau and Duponchel, 2010; Vearey et al ., 2010) </li></ul></ul><ul><li>Dependents and the importance of home: </li></ul><ul><ul><li>More individuals are dependent on the income of a cross-border migrant than a South African. </li></ul></ul><ul><ul><li>Cross-border migrants are more likely to remit (money/food/goods/care) than South Africans. </li></ul></ul><ul><ul><li>(Vearey et al ., 2009; Landau and Duponchel, 2010; Vearey et al ., 2010; Nunez et al .,2010) </li></ul></ul>© Constance, 2010
    15. 16. <ul><li>Education levels : </li></ul><ul><ul><li>Cross-border migrants have been found to have higher education levels than South Africans. </li></ul></ul><ul><ul><li>(Landau, 2006; Vearey et al ., 2010; Landau and Dupochnel, 2010) </li></ul></ul><ul><li>Food security : </li></ul><ul><ul><li>Cross-border migrants have been found to have better food security and better nutritional status than South Africans (Dietary Diversity Score, DDS). </li></ul></ul><ul><ul><li>(CoRMSA, 2009; Vearey et al., 2009; Vearey et al ., 2010) </li></ul></ul>© Thembi, 2010
    16. 17. <ul><li>Cross-border migrants have the right to basic services, including healthcare, ART and psychosocial services. </li></ul><ul><li>Cross-border migrants experience challenges in accessing these services. </li></ul><ul><li>Cross-border migrants experience a range of “daily stressors” that are negatively effecting their well-being: </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><ul><li>Police harassment; fear </li></ul></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>
    17. 19. <ul><li>Ensure that all city officials understand migration and its implications for urban health </li></ul><ul><ul><li>Planning, budgeting, responding </li></ul></ul><ul><ul><li>“ Migration in all policies” </li></ul></ul><ul><ul><li>Seminars, workshops </li></ul></ul><ul><ul><li>Engagement with local leadership (ward councillors, street committees) </li></ul></ul><ul><ul><li>PHC restructuring </li></ul></ul><ul><ul><li>NHI </li></ul></ul><ul><ul><li>Urban health plan </li></ul></ul><ul><ul><li>Spatially sensitive approaches; linkages to other municipalities </li></ul></ul><ul><li>Improve data collection, analysis and use for planning </li></ul><ul><ul><li>Urbanisation; migration; settlements </li></ul></ul><ul><ul><li>Implement and monitor legislative frameworks </li></ul></ul>
    18. 20. <ul><li>Understand social determinants of urban health </li></ul><ul><ul><li>Migration, environment, housing </li></ul></ul><ul><li>Ongoing support to service providers </li></ul><ul><ul><li>City officials, managers, service providers </li></ul></ul><ul><ul><li>Seminars, workshops </li></ul></ul><ul><ul><li>Action plans </li></ul></ul><ul><ul><li>Expand language support to other social services </li></ul></ul><ul><ul><li>“ Health passports” </li></ul></ul><ul><li>Zimbabwean migrants </li></ul><ul><ul><li>Preparedness plans relating to the end of the moratorium on the deportation of undocumented Zimbabwean migrants </li></ul></ul><ul><ul><li>Ensure sensitive involvement of health officials to ensure health concerns address (including access to chronic medication) </li></ul></ul><ul><ul><li>Ensure communication with migration officials that allow people to collect possessions </li></ul></ul><ul><ul><li>Engagement with detention facilities </li></ul></ul>
    19. 21. 24 th August 2011 Migration and health in Johannesburg Implications for the GDS 2040 Jo Vearey, PhD [email_address]
    20. 22. <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
    21. 23. 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.”
    22. 24. <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
    23. 25. NDOH Financial Directive, 2007
    24. 26. <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
    25. 27. <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

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