1) The document discusses migration and health issues in Southern Africa. It notes that the region experiences complex migration flows and public health responses have not adequately addressed migration and mobility. 2) Healthcare systems in the region are overburdened and migrants often struggle to access healthcare. South Africa also experiences xenophobic attitudes which negatively impact migration management and health. 3) The document calls for developing migration-sensitive approaches to public health that consider both cross-border and internal migration in order to achieve equitable access to healthcare for all people in the region.

1. Migration and health in South(ern) Africa
Jo Vearey, PhD
Associate Professor, Wits University
22nd November 2016
jovearey@gmail.com

2. Through a series of unique research and public engagement projects, maHp aims
to generate and communicate knowledge in order to improve responses to
migration, health and wellbeing in the southern African region.
www.mahpsa.org
jovearey@gmail.com

3. • 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.

4. Migration and health in South(ern) Africa
1. South(ern) Africa is associated with mixed migration flows:
internal > cross-border; livelihood seeking > forced migration; urban refugees; marginalised and hidden
migrant groups; spaces of vulnerability; negative assumptions persist
2. Current public health responses do not engage with,
migration and mobility: implications for communicable disease control (TB and HIV,
malaria); chronic treatment continuity; challenges in accessing the public system for non-nationals
3. The South(ern) African public health and social welfare
systems are overburdened and struggling: challenges are raised in a
context of high inequality where nationals are also struggling to access their basic rights
4. South Africa is associated with anti-foreigner and
xenophobic attitudes: migration management is associated with increased
securitisation; a lack of regional responses; a restrictive immigration act; limited understanding of
migration dynamics; violence; fear; securitisation of health

6. Net internal migration by district,
South Africa 2001-2011

7. International immigrants, 2001-2011, by
district of enumeration in the 2011 census

8. 44% of
Gauteng’s
population were
born in a
different
province
Census 2011
8.1% of
Limpop’s
population were
born in a
different
province
4.4% of the
South African
population were
born outside of
South Africa
2,199,871 people
were born
outside of South
Africa

9. Census 2011
7,4% of
Gauteng’s
population are
non-citizens
3.3% ofWestern
Cape’s
population are
non-citizens
3.3% of the
South African
population are
non-citizens

10. Making sense of migration:
exploring attitudes and responses of primary healthcare workers in South Africa

11. Interviews with 77 healthcare providers at 6 clinics
1. Migration is understood to mean foreign nationals/cross-border
migrants and the (internal) mobility of South African nationals is
not considered by most healthcare workers
2. Healthcare workers are internal migrants / have migration
histories
3. Lack of guidance/support from National/Provincial/Local levels
re. how to respond to migration and mobility
4. [some] Healthcare workers develop innovative responses to deal
with migration
5. Healthcare workers as street level bureaucrats: as innovators AND
as gatekeepers [NB v little evidence of gatekeeping]

12. Migration is understood to mean foreign nationals
• HCWs almost exclusively associate migration / migrants
with cross-border mobility
– very few HCWs mention internal mobility; after prompting,
some agree that internal movement is a form of migration
• Migrants are identified by language, accent, ways of
dressing, documentation
• HCWs report that:
– most migrants have moved for reasons other than healthcare
seeking
– some migrants move for ANC/delivery or to access chronic
medication

13. Healthcare workers are internal migrants / have migration
histories
• Migration trajectories of HCWs
– daily / weekly commute
– movement for training and work
– languages

14. Lack of guidance/support from
National/Provincial/Local levels re. how to respond to
migration and mobility
• Innovative responses
• Making sense of migration: exploring attitudes and
responses of primary healthcare workers in South Africa

15. Healthcare workers develop innovative responses to
deal with migration
• Peak periods/high demand for chronic medications
– Ordering additional medications, contrary to head count
data
• Language and translation support
• Identification number: use DOB
• Road-to-health cards/vaccination cards
Healthcare workers as street level bureaucrats: as innovators
AND as gatekeepers

16. Migration and access to PHC clinics:
exploring the migration and mobility profiles of PHC users

17. Here they treat patients nicely
The services are fast you came
around 12 by 2pm you are done
Used to use this clinic before 2007, then she went back home to
Eastern Cape. She now comes back here if her clinic date falls at
a time when she's up here visiting her husband. She does not get
a file here, as she travels with her cards. She's never had
problems receiving health care here.
Why come to
this clinic?

18. What is needed?

19. 1. Do 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

20. 2. Support SANAC to ensure migration
and mobility acknowledged in HIV
responses.
• Provincial Strategic Plans
• Local Strategic Plans
• NSP to guide/inform IDPs and District Health Plans

21. 3. Advocate for a migration-aware approach.
3.• Migrant friendly approach:
• Individual focus (v’s population focus)
• Facility-level responses (v’s health system
responses)
• Emphasis on language and translation; cultural
competency
• Exceptionalise: focus on non-nationals
• “Right to health” focus
• Migrants perceived as sick, a burden on services, and
in a larger number than they are
• Limited (no) systems response
• Client mobility within the health system is not
addressed
There is a need for “migration aware” responses to HIV that embed migration
as a key social process in southern Africa.

22. Migrant friendly v’s migration aware
Migrant friendly
•“Right to health”
•Limited systems response
•Cross-border/non-national
focus: an assumed
homogenous group
•Exceptionalises
•Individual level focus
Migration aware
•Mobility-sensitive
•Heterogeneity of migrant
populations: considers internal
movement
•Spaces of vulnerability
•Systems response
•Spatially sensitive
•“Health for all”
•Public health approach
•Regionally-aware

23. 4. Mobilise a renewed – and
revised - regional conversation
for developing a coordinated
response to health and
migration.

24. 5. Learn from and upscale simple interventions.
• Translation and interpretation services in Johannesburg
• Health passports; roadmaps for treatment access; referral letters; treatment packs
for planned movements; patient-held records

25. 1. How can we use a focus on migration and mobility to support achieving ‘health
for all’?
1. What is needed to support the development of regional migration-aware
responses to migration, mobility and health in southern Africa?
2. How can a migration-aware approach be integrated into the NHI and beyond?
3. What resources are (not) available?

26. The way forward….

27. Thank you
• Many thanks to Limpopo Provincial Health,
Vhembe District Health, Musina sub-district
• The staff of Nancefield and Makhukule Clinics
• Sister Winnie Mokoki