Non-citizen access to ART in Johannesburg: implications for the urban health agenda Jo Vearey  6 th  May 2009 [email_addre...
Overview of presentation <ul><li>An urban world; </li></ul><ul><li>Implications for urban health; </li></ul><ul><li>Johann...
World Urbanization Prospects (2005 Revision),  United Nations, Department of Economic and Social Affairs In 2009, over hal...
World Urbanization Prospects (2005 Revision),  United Nations, Department of Economic and Social Affairs By 2030, 50% or m...
What does this mean for the health of urban populations? <ul><li>It is increasingly important to  ensure and maintain the ...
Developing country urban environments:  specific complexities <ul><li>High rates of   migration ; </li></ul><ul><li>Increa...
<ul><li>Urban growth </li></ul><ul><li>Estimated population of nearly  3.9 million ; </li></ul><ul><li>The City has grown ...
Case study :  non-citizen access to ART in Johannesburg <ul><li>Non-citizen groups </li></ul><ul><li>Labour migrants: work...
Protective policy exists to ensure access to public health, including ART <ul><li>South African Constitution;  </li></ul><...
Data sources <ul><li>African Cities Survey (2006); </li></ul><ul><li>ART Access Study (2007); </li></ul><ul><li>Semi-struc...
Key findings <ul><li>The importance of the informal economy for international urban migrants; </li></ul><ul><li>The challe...
The importance of the informal economy for cross-border urban migrants <ul><li>Most report coming to JHB for economic oppo...
Non-citizens face challenges in accessing ART at government sites Government sites Non-governmental Government sites Non-g...
A dual healthcare system <ul><li>Non-citizens are  referred out of the public sector and into the NGO sector ; </li></ul><...
The linkages between upholding the right to access ART and maintaining a survivalist livelihood <ul><li>Importance of ART ...
A revised sustainable livelihoods framework for urban migrants
ASSETS (strengths) Resources Stresses Shocks financial physical human social hunger violence evictions unemployment sickne...
Key messages <ul><li>The context for taking action on improving the health of urban populations is complex; </li></ul><ul>...
Recommendations <ul><li>Policies must be implemented uniformly across the public health sector; </li></ul><ul><li>There is...
Acknowledgements <ul><li>Funding </li></ul><ul><li>Lawyers for Human  Rights </li></ul><ul><li>Ford Foundation </li></ul><...
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Non-citizen access to ART in Johannesburg: implications for the urban health agenda

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

    1. 1. 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
    2. 2. Overview of presentation <ul><li>An urban world; </li></ul><ul><li>Implications for urban health; </li></ul><ul><li>Johannesburg: </li></ul><ul><ul><li>Non-citizen access to ART; </li></ul></ul><ul><ul><li>Informal economy; </li></ul></ul><ul><ul><li>Policy and practice. </li></ul></ul><ul><li>Key messages. </li></ul>
    3. 3. 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
    4. 4. 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
    5. 5. What does this mean for the health of urban populations? <ul><li>It is increasingly important to ensure and maintain the public health of urban populations ; </li></ul><ul><li>Several frameworks exist that attempt to guide appropriate responses to urban health needs; </li></ul><ul><ul><li>Focus on developed countries in North America and Europe; </li></ul></ul><ul><ul><li>None are appropriate for the complexities of less developed country urban environments . </li></ul></ul>
    6. 6. Developing country urban environments: specific complexities <ul><li>High rates of migration ; </li></ul><ul><li>Increasing pressure on appropriate housing ; </li></ul><ul><li>High urban HIV prevalence rates – highest in urban informal areas; </li></ul><ul><li>Some residents with weak rights to the city; </li></ul><ul><li>Dependency on survivalist livelihoods located within the informal sector; </li></ul><ul><li>Increasing urban inequalities that impact ‘urban poor’ groups. </li></ul>
    7. 7. <ul><li>Urban growth </li></ul><ul><li>Estimated population of nearly 3.9 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 5.2 million by 2015 . </li></ul>Johannesburg: a complex urban context (City of Johannesburg, 2008) <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. 8. Case study : non-citizen access to ART in Johannesburg <ul><li>Non-citizen groups </li></ul><ul><li>Labour migrants: work permits; </li></ul><ul><li>Refugees and asylum seekers; </li></ul><ul><li>Other documented: </li></ul><ul><ul><li>study permits; visitor permits; and </li></ul></ul><ul><li>Undocumented migrants. </li></ul>
    9. 9. Protective policy exists to ensure access to public health, including ART <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>
    10. 10. Data sources <ul><li>African Cities Survey (2006); </li></ul><ul><li>ART Access Study (2007); </li></ul><ul><li>Semi-structured interviews with migrant ART clients engaged in the informal sector (2008); </li></ul><ul><li>RENEWAL Survey (2008). </li></ul>
    11. 11. Key findings <ul><li>The importance of the informal economy for international urban migrants; </li></ul><ul><li>The challenges non-citizens face in accessing ART in the public sector; and </li></ul><ul><li>The linkages between upholding the right to access ART and the ability to maintain a survivalist livelihood. </li></ul>
    12. 12. The importance of the informal economy for cross-border urban migrants <ul><li>Most report coming to JHB for economic opportunity (77%); </li></ul><ul><li>Over half of all respondents support others by sending money outside of Johannesburg; and </li></ul><ul><li>33% report having paid someone else since arriving in South Africa. </li></ul><ul><ul><li>(African Cities Survey, 2006 & RENEWAL, 2008) </li></ul></ul>
    13. 13. Non-citizens face challenges in accessing ART at government sites Government sites Non-governmental Government sites Non-governmental
    14. 14. A dual healthcare system <ul><li>Non-citizens are referred out of the public sector and into the NGO sector ; </li></ul><ul><li>A dual healthcare system exists for the delivery of ART: public and NGO: </li></ul><ul><ul><li>Presents a range of challenges. </li></ul></ul>
    15. 15. The linkages between upholding the right to access ART and maintaining a survivalist livelihood <ul><li>Importance of ART on maintaining or regaining livelihood strategies; and </li></ul><ul><li>The importance of starting ART early : the need for early testing. </li></ul>
    16. 16. A revised sustainable livelihoods framework for urban migrants
    17. 17. ASSETS (strengths) Resources Stresses Shocks financial physical human social hunger violence evictions unemployment sickness <ul><li>Urban migrants </li></ul><ul><ul><li>Refugees </li></ul></ul><ul><ul><li>Asylum seekers </li></ul></ul><ul><ul><li>Undocumented migrants </li></ul></ul><ul><ul><li>Labour migrants </li></ul></ul><ul><ul><li>Other: study/visitor permits </li></ul></ul>HIV provision of remittances ART Legislation Protective policy housing natural Outcome LIVELIHOOD STRATEGY
    18. 18. Key messages <ul><li>The context for taking action on improving the health of urban populations is complex; </li></ul><ul><li>HIV and migration are urban public health challenges that involve all dimensions of urban policy; </li></ul><ul><li>It is important to understand migrant livelihood strategies in order to improve interventions; </li></ul><ul><li>ART is an essential resource for all urban migrants. </li></ul>
    19. 19. Recommendations <ul><li>Policies must be implemented uniformly across the public health sector; </li></ul><ul><li>There is a need for cooperation between local and provincial health departments; </li></ul><ul><li>Developmental local government must be strengthened; </li></ul><ul><li>A return to public health advocacy. </li></ul>
    20. 20. Acknowledgements <ul><li>Funding </li></ul><ul><li>Lawyers for Human Rights </li></ul><ul><li>Ford Foundation </li></ul><ul><li>Atlantic Philanthropies </li></ul><ul><li>ARI PhD Bursary </li></ul><ul><li>Fieldwork and data entry </li></ul><ul><li>Xolani Tshabalala </li></ul><ul><li>Monica Kiwanuka </li></ul><ul><li>Lisa Kambala </li></ul><ul><li>Pascal Mbambi </li></ul><ul><li>All participants </li></ul><ul><li>ART clients </li></ul><ul><li>ART study site staff </li></ul>Ingrid Palmary Liz Thomas Forced Migration Studies Programme

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