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 & AIDS and STI Strategic Plan for South Africa, 2007 – 2011. April 2007: Pretoria: Department of Health, p56
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.
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.
Policy dialogue: towards pro-poor policy responses to migration and urban vulnerabilities in Johannesburg
Policy Dialogue on Urban Health, HIV and Migration in Johannesburg: developing pro-poor policy responses to urban vulnerabilities 22nd November 2012
1. To bring policy makers, implementers, researchers and civil society together to discuss the current health challenges faced by migrants in Johannesburg.2. To share current responses in the City of Johannesburg that are addressing the needs of urban migrants.3. To develop recommendations for action that will lead to the development and implementation of strengthened responses to address the urban vulnerabilities experienced by migrants in Johannesburg.
Migration involves the movement of The overwhelming majority ofpeople; young, old, men, women, migrants in Johannesburg move infamilies. order to seek improved livelihood opportunities.People move for a range of reasons. Migrants do not report moving toSouth African nationals Johannesburg in order to access health•Rural to urban care, ART or other services.•Urban to urban•Within a municipality On arrival in Johannesburg, migrants tend to be healthier than the hostCross-border migrants population.•Forced migrants: asylum seekers;refugees If they become too sick to work,•Other permits: work, visitor, study migrants will return back home to•Undocumented seek care and support.
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Protective policyThe right to health: internal and cross-border migrants• South African Constitution and The Bill of Rights;• Refugee Act (1998);• National Strategic Plan for HIV, STIs and TB (2012 - 2016);• National Department of Health (NDOH) Memo (2006);• NDOH Directive (September 2007); and• Gauteng DOH Letter (April 2008).
• The 61st annual World Health Assembly (WHA) adopted Resolution 61.17 on the Health of Migrants.• This Resolution calls on member states to promote equitable access to health promotion, disease prevention and care for migrants.• Four priority areas have been identified for achieving the WHA resolution: 1. Monitoring migrant health; 2. Partnerships and networks; 3. Migrant sensitive health systems; and 4. Policy and legal frameworks.
The social determinants of health (SDH) The SDH are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. http://www.who.int/social_determinants/en/
WHO Commission on the Social Determinants of Health (2008)
“local government committed to working with citizens and groups within the community to find sustainable ways to meet their social, economic and material needs and improve the quality of their lives” (RSA, 1998: 23)
Migration and health e rous angccess t c healt hy d a o ponita migra os tivei n determin g on ect effec t ants of Sa lmon eff t r abi l i t y he alth for an in formed positivev ulne ri s eig ic health k n publde selection spvense re o lopm migration aware ben e efit nt HIV ng s v’ s trafficki impro grBnt sensitive ved mi T a data exceptionalisatio burden n
Migrants reflect health characteristics of place of origin ANDadditional influences that result from the process of migration Gushulak & McPherson, 2006
Figure 1: Factors that can affect the well being of migrants during the migrationprocess (IOM, 2008) Pre-migration phase Movement Phase • Pre-migratory events and trauma • Travel conditions and mode (war, human rights violations, (perilous, lack of basic health torture), especially for forced necessities), especially for irregular migration flows; migration flows; • Epidemiological profile and how it • Duration of journey; compares to the profile at • Traumatic events, such as abuse; destination; • Single or Mass movement. • Linguistic, cultural, and geographic proximity to destination. Cross cutting aspects: Gender, age; socio- Migrant economic status; genetic s’ well- factors being Return phase Arrival and Integration phase • Level of home community services • Migration policies; (possibly destroyed), especially after • Social exclusion; discrimination; crisis situation: • Exploitation; • Remaining community ties; • Legal status and access to service; • Duration of absence; • Language and cultural values; • Behavioural and health profile as • Linguistically and culturally adjusted acquired in host community. services; • Separation from family/partner; • Duration of stay.
Gini coefficient in selected SouthAfrican cities (Figure adapted from UN-HABITAT, 2008: 72)
Desk review•Urban migrants, urban vulnerabilities, HIV•Legislation, policy, good practicesFieldwork (ongoing)•Identification of key urban migrant groups•Mapping of key organisations; interviews with representativesof key organisations•Interviews with representatives of different migrant groups
Legislation exists to uphold the right of cross-border migrants toaccess basic healthcare – including ART – in South Africa.(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)Despite this, cross-border migrants face challenges in accessingpublic health services, including ART.(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) • Cross-border and internal migrants are affected by poor access to healthcare services – as are those who have always resided in JHB. • Being a cross-border migrant presents additional access challenges: documentation; “being foreign”; language barriers.
Urban HIV in urban vulnerabilities informal settlements ViolenceHIV in Structural Migration Directurban Urban Access toareas growth services Natural population Livelihood Urban growth activities health
Internal Cross-borderMigrants living Migrants living with HIV with disabilities Migrant sex workers Migrants with mental health LGBTI migrants Migrants living and psychosocial on the streets needs Migrants living in informal housing
UNHCR Urban “These rights include, but are not limited to, the right to life; the right not to be subjected to cruel Policy, 2009 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.” “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: • 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; UNHCR, 2009: 18
Key concerns (1)Communicable diseases Mental health and•Transmission psychosocial concerns•Predominantly move from •Traumalower to higher HIV/TB •Daily stressorsprevalence •Violence: direct and•Treatment continuity structural•Referrals•Harmonisation of protocolshome/pre-departure transit/journey interception destination return
Key concerns (2)Sexual and reproductive Spaces of vulnerabilityhealth •Urban areas•Family planning/contraception •Informal settlements•Testing, treatment for STIs •Dense inner-city(including HIV) •Detention centres•Safe termination of pregnancy •Informal workplaces•Antenatal care•Delivery choices•PMTCT home/pre-departure transit/journey interception destination return
Key concerns (3)The health system as a Healthy urbancentral determinant of governancehealth •Developmental local•Accessibility: government • Availability •Joined-up government • Acceptability •Intersectoral action • Affordability •Health in all policies •IDPs & District Health Planshome/pre-departure transit/journey interception destination return
Some questions and concerns….•How to bridge the internal – cross-border migration divide?•What can or should be done to promote domestic political interests/advocacyon migration and health issues?•What is the most effective strategy for linking migration and developmental /planning concerns? • Integrated development plans, district health plans, growth and development strategies•Are regional coordinated responses to communicable diseases and mobilityfeasible? (e.g. harmonisation of treatment protocols)
Recommendations for action (1)Migration and health is more than migration and HIV and/or TB. • Psychosocial and mental health; sexual and reproductive health; determinants of healthApply a social determinants of health lens. • Engage with spaces of vulnerabilityImproved data on migration and health is needed. • Numbers of migrants; numbers of HIV and TB clients who are mobile; strategies employed by mobile clients; referral systemsAdvocate for a migration-aware public health response. • Work with multiple levels/spheres of governance: regional, national, local; involve state and non-state actors; the urban-rural continuumDo not exceptionalise cross-border migrants. • Internal migrants are greater in number and a larger development challenge, and are often worse off than cross-border migrants
Recommendations for action (2)Mobilise a renewed – and revised - regional conversation for developing a coordinatedresponse to health and migration. • SADC Consultancy on Regional Financing Mechanisms; social rights portability: state and non-state actors; internal and cross-border mobilityWork with the Southern African HIV Clinicians Society. • Update of guidelines on ART for displaced populationsEngage with SANAC to ensure migration and mobility acknowledged in HIV responses. • Beyond migrants as a ‘key population’; work towards a migration-aware response • Provincial Strategic Plans • Local Strategic Plans • NSP to guide/inform IDPs and District Health PlansLearn from and upscale simple interventions.•Translation and interpretation services in Johannesburg•Health passports; roadmaps for treatment access; referral letters; treatment packs forplanned movements; patient-held records
AcknowledgementsSex work and migration Local government and urban health•Marlise Richter •Liz Thomas•Elsa Oliveira •Pinky Mahlangu•Greta Schuler •Michelle Peens•Sisonke sex worker movement Disability and migrationMigration and health •Matthew Wilhelm-Solomon•Lorena Nunez•Roseline Hwati LGBTI and migration•Adrien Bazolakio •Nadya HusakouskayaJohannesburg Migrant Health Forum IHRE interns •Patricia Ndhlovu •Ng’andwe Chibuye Lenore Longwe and Sharon Olago for all their support in organising today!
Urban vulnerabilities andmigration in Johannesburg: setting the scene Jo Vearey, PhD firstname.lastname@example.org 22nd November 2012
Group discussionsGiven the developmental mandate of local government, howcould the City of Johannesburg strengthen responses tomigration, urban vulnerabilities and HIV? Evidence Problem statement What has been done? What is missing? What are the possible solutions?
• Ongoing engagement with the City through dialogues in 2013 • Developing joint research agendas • Communicating research • Support to IDP and District Health Plan processes• Meeting report, research paper and policy brief to be finalised and distributed to participants • Share with Migrant Health Forum• Strengthen City engagement with the Migrant Health Forum • Participation in meetings
An integrative asylum policy South Africa has an integrative asylum policy: Refugees and asylum seekers are encouraged to self-settle and integrate. A range of rights are afforded: Policies exist that assure the right to health – including ART – for refugees, asylum seekers and other cross-border migrants. Key challenges to the effective implementation of these policies: Restrictive Immigration Policy; Backlog at Department of Home Affairs; and Lack of awareness of rights: health facilities.