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01 Vearey Sahara Iom Session 3 Dec 2009


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01 Vearey Sahara Iom Session 3 Dec 2009

  1. 1. Challenging common assumptions around migration and health in South Africa SAHARA 3rd December 2009 Jo Vearey
  2. 2. Cross-border migrants and healthcare provision: a global challenge; Assumptions linking migration, health and health- seeking; Some data on migrant health in Southern Africa: this includes (but is not limited to) migrant access to public healthcare services; Recommendations to policy makers and practitioners.
  3. 3. Patterns: Social determinants of Linkages to “home” health and migration: Health Migration as a determinant of health Determinants of movements. Health a determinant of migration Urban as a determinant of health Place: Livelihoods and health systems. Urban and rural origin/destination Urban - periphery and centre Socio-cultural dimensions Border areas. of health: Culture and religion Meanings and interpretations Data: Illness experiences Survey datasets Strategies and health seeking In depth qualitative studies. behaviours.
  4. 4. Internal and cross-border migration: Different forms of migration and different reasons for migration are found to determine migration experiences; impacts on health. The need for a regional lens: Essential to view migration as a connecting process. Recognising migration as a livelihood strategy that connects the (urban) migrant with another household “back home” Sickness negatively affects this interlinked livelhood system. Zimbabwean “humanitarian migration”: FMSP Report (Nov 2009): Zimbabwean humanitarian migration into South Africa: Inadequate regional responses
  5. 5. Zimbabwean migrants struggle to access Asylum seekers (Section 22 permit); passports and travel documents within Zimbabwe: presents challenges in crossing Refugees (Section 24 permit); the border Special dispensation permits for Other: Zimbabweans havestudy permits; visitor work permits, not been made permits; and available. Challenges at Home Affairs: Undocumented migrants. problematic. access to documentation is Immigration act makes it difficult for lower- skilled workers to legalise their stay in South Africa.
  6. 6. 1. South African Constitution; 2. Refugee Act (1998); 3. HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011 (NSP); 4. National Department of Health (NDOH) Memo (2006); 5. NDOH Directive (September 2007); and 6. Gauteng DOH Letter (April 2008).
  7. 7. 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.
  8. 8. An historical perspective; Discourse of risk and blame: ‘Plague’; ‘Invasion’; context of HIV; Globally, ‘foreigners’ are often blamed by governments for introducing and spreading disease: ‘disease carriers’. Geographic/national boundaries historically a first line of defence against disease.
  9. 9. 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.
  10. 10. Migration is linked to seeking healthcare. Provision of healthcare will result in a ‘flood of migrants’. Migrants are ‘unable to adhere to ART’.
  11. 11. 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).
  12. 12. Migrant Rights Monitoring Project (MRMP): National Public Service Access Survey Forced Migration Studies Programme Data collection period: 2007 – 2008
  13. 13. Reporting period: 2007 – 2008 3,182 respondents; NGO service providers (59%) and Refugee Reception Offices (41%).
  14. 14. Relative frequency (%) 0 10 20 30 40 50 60 70 Asylum seeker (Section 22) Refugee (Section 24) Undocumented Other temporary Reported documentation status Permanent residence South African identity n = 3,182
  15. 15. Under half of all respondents report ever needing healthcare since their arrival in South Africa: 45%; n = 1,403.
  16. 16. 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.
  17. 17. 30% (n = 396) report having experienced problems when trying to access public health care.
  18. 18. Frequency (number of responses) 120 100 80 60 40 20 0 Treated badly Language Denied Denied Treated badly Could not by a nurse problem treatment treatment by clerk access because of because treatment due documents foreign to cost Problems encountered n = 396; 542 responses (multi-answer)
  19. 19. Documentation status is related to the likelihood of experiencing a problem: 1. Undocumented migrants (38%); 2. Asylum seekers – Section 22 (31%); 3. Other documented migrants (28%); 4. Refugees – Section 24 (24%).
  20. 20. RENEWAL household survey Forced Migration Studies Programme Data collection period: 2008
  21. 21. 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
  22. 22. 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.
  23. 23. Non-citizen access to ART in inner-city Johannesburg Vearey, J. (2008) Migration, Access to ART, and Survivalist Livelihood Strategies in Johannesburg. African Journal of AIDS Research 7 (3), pp. 361 – 374 Data collection: 2007
  24. 24. Individuals in need of ART do not generally migrate to South Africa in order to access treatment: • Cross-sectional survey Discovered their status in South Africa (80%); • Four ART sites in inner-city MostlyJohannesburgin South Africa (76%); 2 first tested for HIV (2 government; NGO) Tested when sick (like South Africans, p = 0.122); • n = 449 Came to South Africa for other reasons; Have been here for a period of time before discovering their status.
  25. 25. 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.
  26. 26. 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.
  27. 27. Successful outcomes amongst foreigners receiving antiretroviral therapy in Johannesburg, South Africa K McCarthy, M F Chersich, J Vearey , G Meyer-Rath, A Jaffer, S Simpwalo and W D F Venter (2009) International Journal of STD & AIDS 20 858-862 Data collection period: March 2004 – Feb 2007
  28. 28. 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.
  29. 29. 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.
  30. 30. lthc are. hea king Data does not support the assumption see that all migrants seeko ink ed t healthcare. sult n is l ill re ratio are w nts’. lthc gra Mig f hea they Migrants report thatof miwould o on if they d ‘return visi a ‘floo were too sick to Pro home’ in work. dhe re to a e to u nabl are ‘ ART’. ants Migr Migrant health is more than access to healthcare services.
  31. 31. 1. Whilst the numbers of international migrants in need of healthcare and ART are small, they are significant; 2. Existing protective legislation is not applied uniformly across public institutions; 3. The objectives outlined within the National Strategic Plan for STIs and HIV&AIDS need to be implemented; 4. Upholding the right to health for all within South Africa will have a population-level benefit; 5. There is a need to better understand linked livelihood systems and sickness that cross borders in the context of migration and HIV.
  32. 32. To implement the WHA Resolution on the Health of Governments need to engage with – and Migrants: understand - migration and population • Consider health within the broader linked agenda of growth. migration and development; • To address the social determinants of migrant health; • Strengthen the availability of dataato inform An urgent need to implement public health intersectoral, evidence-based, regional policies. approach to the health of migrants. Develop regional frameworks to address migration and health: (draft) SADC framework on communicable diseases and mobility
  33. 33. All research participants Nazareth House FMSP/MRMP Tara Polzer Dr. Kerrigan McCarthy (RHRU) Tesfalem Araia Lorena Nunez Members of the Migrant Health Forum (RHRU, Johannesburg) Atlantic Philanthropies Lawyers for Human Rights & Ford Foundation RENEWAL & IDRC Partner organisations involved in the MRMP survey
  34. 34. Challenging common assumptions around migration and health in South Africa SAHARA 3rd December 2009 Jo Vearey