Non-citizen access to ART in Johannesburg:implications for the urban health agenda

Non-citizen access to ART in Johannesburg: implications for the urban health agenda Jo Vearey 6 th May 2009 [email_address] University of the Witwatersrand Forced Migration Studies Programme Health and Migration Initiative

Overview of presentation
An urban world;
Implications for urban health;
Johannesburg:
Non-citizen access to ART;
Informal economy;
Policy and practice.
Key messages.

World Urbanization Prospects (2005 Revision), United Nations, Department of Economic and Social Affairs In 2009, over half of the world’s population is now urban An urban world

World Urbanization Prospects (2005 Revision), United Nations, Department of Economic and Social Affairs By 2030, 50% or more of the African population will be living in a city

What does this mean for the health of urban populations?
It is increasingly important to ensure and maintain the public health of urban populations ;
Several frameworks exist that attempt to guide appropriate responses to urban health needs;
Focus on developed countries in North America and Europe;
None are appropriate for the complexities of less developed country urban environments .

Developing country urban environments: specific complexities
High rates of migration ;
Increasing pressure on appropriate housing ;
High urban HIV prevalence rates – highest in urban informal areas;
Some residents with weak rights to the city;
Dependency on survivalist livelihoods located within the informal sector;
Increasing urban inequalities that impact ‘urban poor’ groups.

Urban growth
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 .
Johannesburg: a complex urban context (City of Johannesburg, 2008)
Migration
A ‘city of migrants ’:
Rural to urban – internal;
Cross border – external.
Informal housing
Almost 25% estimated to live informally.
HIV

Case study : non-citizen access to ART in Johannesburg
Non-citizen groups
Labour migrants: work permits;
Refugees and asylum seekers;
Other documented:
study permits; visitor permits; and
Undocumented migrants.

Protective policy exists to ensure access to public 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 (2006);
NDOH Directive (September 2007); and
Gauteng DOH Letter (April 2008).

Data sources
African Cities Survey (2006);
ART Access Study (2007);
Semi-structured interviews with migrant ART clients engaged in the informal sector (2008);
RENEWAL Survey (2008).

Key findings
The importance of the informal economy for international urban migrants;
The challenges non-citizens 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.

The importance of the informal economy for cross-border urban migrants
Most report coming to JHB for economic opportunity (77%);
Over half of all respondents support others by sending money outside of Johannesburg; and
33% report having paid someone else since arriving in South Africa.
(African Cities Survey, 2006 & RENEWAL, 2008)

Non-citizens face challenges in accessing ART at government sites Government sites Non-governmental Government sites Non-governmental

A dual healthcare system
Non-citizens are referred out of the public sector and into the NGO sector ;
A dual healthcare system exists for the delivery of ART: public and NGO:
Presents a range of challenges.

The linkages between upholding the right to access ART and maintaining a survivalist livelihood
Importance of ART on maintaining or regaining livelihood strategies; and
The importance of starting ART early : the need for early testing.

A revised sustainable livelihoods framework for urban migrants

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 natural Outcome LIVELIHOOD STRATEGY

Key messages
The context for taking action on improving the health of urban populations is complex;
HIV and migration are urban public health challenges that involve all dimensions of urban policy;
It is important to understand migrant livelihood strategies in order to improve interventions;
ART is an essential resource for all urban migrants.

Recommendations
Policies must be implemented uniformly across the public health sector;
There is a need for cooperation between local and provincial health departments;
Developmental local government must be strengthened;
A return to public health advocacy.

Acknowledgements
Funding
Lawyers for Human Rights
Ford Foundation
Atlantic Philanthropies
ARI PhD Bursary
Fieldwork and data entry
Xolani Tshabalala
Monica Kiwanuka
Lisa Kambala
Pascal Mbambi
All participants
ART clients
ART study site staff
Ingrid Palmary Liz Thomas Forced Migration Studies Programme

Non-citizen access to ART in Johannesburg:implications for the urban health agenda

by Jo Vearey

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