SAHARA

3rd December 2009

Jo Vearey

jovearey@gmail.com

http://migration.org.za/

Challenging common assumptions around

migration and health in South Africa

� 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.

� Patterns: � Linkages to “home”

� Health

� Determinants of movements.

� Place: � Urban and rural

origin/destination

� Urban - periphery and centre

� Border areas.

� Data: � Survey datasets

� In depth qualitative studies.

� Social determinants of health and migration: � Migration as a determinant of

health

� Health a determinant of migration

� Urban as a determinant of health

� Livelihoods and health systems.

� Socio-cultural dimensions of health:� Culture and religion

� Meanings and interpretations

� Illness experiences

� Strategies and health seeking behaviours.

� 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

� Asylum seekers (Section 22 permit);

� Refugees (Section 24 permit);

� Other: work permits, study permits; visitor permits; and

� Undocumented migrants.Immigration act makes it difficult for lower-

skilled workers to legalise their stay in South Africa.

Challenges at Home Affairs:

access to documentation is problematic.

Zimbabwean migrants struggle to access

passports and travel documents within Zimbabwe: presents challenges in crossing

the border

Special dispensation permits for

Zimbabweans have not been made available.

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).

� 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.

� 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.

� 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.

Migration is linked to seeking healthcare.

Provision of healthcare will result

in a ‘flood of migrants’.

Migrants are ‘unable to adhere to

ART’.

� 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).

Migrant Rights Monitoring Project

(MRMP):

National Public Service Access Survey

Forced Migration Studies Programme

Data collection period: 2007 – 2008

� Reporting period: 2007 – 2008

� 3,182 respondents;

� NGO service providers (59%) and

� Refugee Reception Offices (41%).

0

1020

30

40

5060

70

Asy

lum

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ker

(Sec

tion

22)

Ref

ugee

(Sec

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24)

Und

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ente

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Oth

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rary

Per

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Sou

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entit

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Reported documentation status

Rel

ativ

e fr

equ

ency

(%

)

n = 3,182

Under half of all respondents report ever

needing healthcare since their arrival in

South Africa:

� 45%; n = 1,403.

� 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.

� 30% (n = 396) report having experienced problems

when trying to access public health care.

0

20

40

60

80

100

120

Treated badlyby a nurse

Languageproblem

Deniedtreatment

because ofdocuments

Deniedtreatmentbecauseforeign

Treated badlyby clerk

Could notaccess

treatment dueto cost

Problems encountered

Fre

qu

ency

(n

um

ber

of

resp

on

ses)

n = 396; 542 responses (multi-answer)

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%).

RENEWAL household survey

Forced Migration Studies Programme

Data collection period: 2008

� 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

� 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.

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

� Individuals in need of ART do not generally migrate to South Africa in order to access treatment:

� Discovered their status in South Africa (80%);

� Mostly first tested for HIV in South Africa (76%);

� Tested when sick (like South Africans, p = 0.122);

� Came to South Africa for other reasons;

� Have been here for a period of time before discovering their status.

• Cross-sectional survey

• Four ART sites in inner-city

Johannesburg (2 government; 2

NGO)

• n = 449

� 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.

� 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.

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

� 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.

� 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.

Data does not support the assumption

that all migrants seek healthcare.

Migrants report that they would ‘return home’ if they were too sick to

work.

Migration is linked to seeking healthcare.

Provision of healthcare will result

in a ‘flood of migrants’.

Migrants are ‘unable to adhere to

ART’.Migrant health is more than access to

healthcare services.

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.

To implement the WHA Resolution on the Health of

Migrants:

• Consider health within the broader linked agenda of

migration and development;• To address the social determinants of migrant health;

• Strengthen the availability of data to inform

intersectoral, evidence-based, regional policies.

Develop regional frameworks to address migration and

health:

(draft) SADC framework on communicable diseases and

mobility

An urgent need to implement a public health

approach to the health of migrants.

Governments need to engage with – and

understand - migration and population

growth.

� All research participants

� FMSP/MRMP� Tara Polzer

� Tesfalem Araia

� Lorena Nunez

� Atlantic Philanthropies

� Lawyers for Human Rights & Ford Foundation

� RENEWAL & IDRC

� Partner organisations involved in the MRMP survey

� Nazareth House

� Dr. Kerrigan McCarthy (RHRU)

� Members of the Migrant Health Forum (RHRU, Johannesburg)

migration.org.za

SAHARA

3rd December 2009

Jo Vearey

jovearey@gmail.com

http://migration.org.za/

Challenging common assumptions around

migration and health in South Africa