This document summarizes challenges to common assumptions about migration and health in South Africa. It finds that migrants are often wrongly assumed to travel for healthcare and burden health systems. However, data shows that most migrants seek healthcare after living in South Africa for some time and for reasons other than health. While migrants face barriers to care, their health outcomes on treatment are similar to citizens. The document calls for implementing protective laws and considering health and migration together to address the social determinants of migrant health.

1. Challenging common assumptions around
migration and health in South Africa
SAHARA
3rd December 2009
Jo Vearey
jovearey@gmail.com
http://migration.org.za/

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. 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. 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. 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. 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. 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. 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.

10. 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.

11. Migration is linked to seeking healthcare.
Provision of healthcare will result
in a ‘flood of migrants’.
Migrants are ‘unable to adhere to
ART’.

12. 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).

13. Migrant Rights Monitoring Project
(MRMP):
National Public Service Access Survey
Forced Migration Studies Programme
Data collection period: 2007 – 2008

14. Reporting period: 2007 – 2008
3,182 respondents;
NGO service providers (59%) and
Refugee Reception Offices (41%).

15. 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

16. Under half of all respondents report ever
needing healthcare since their arrival in
South Africa:
45%; n = 1,403.

17. 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.

18. 30% (n = 396) report having experienced problems
when trying to access public health care.

19. 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)

20. 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%).

21. RENEWAL household survey
Forced Migration Studies Programme
Data collection period: 2008

22. 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

23. 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.

24. 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

25. 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.

26. 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.

27. 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.

28. 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

29. 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.

30. 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.

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33. 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.

34. 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

35. 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 migration.org.za
RENEWAL & IDRC
Partner organisations involved in
the MRMP survey

36. Challenging common assumptions around
migration and health in South Africa
SAHARA
3rd December 2009
Jo Vearey
jovearey@gmail.com
http://migration.org.za/