EDITORIAL

 

Understanding healthcare and population mobility in southern Africa: The case of South Africa

 

 

Correspondence

 

 

The impact of global increases in human mobility on health systems is a little understood but highly political issue in recipient countries.^[1] South Africa (SA) is greatest recipient of migrants from the Southern African Development Community (SADC), a region with high levels of migration, a high communicable disease burden and struggling public healthcare systems.^[2] There is a policy of free primary healthcare for all in SA, as outlined in the Constitution and the National Health Act, but its interpretation is less inclusive within implementation guidelines and practice. As a result, non-nationals face access challenges, and healthcare responses have engaged with migration to a limited extent only. Migration provides opportunities for health and economic benefits, and has the potential to positively and negatively affect health systems. To maximise positive impact and mitigate against potential negative consequences requires attention and engagement of policy-makers from health and other sectors, including public health researchers and health workers. We outline our current research and existing responses to migration and health in southern Africa.

Despite clear evidence of considerable migration within and into SA,^[3] its impact on the healthcare system is unclear and controversial, with assumptions and popular rhetoric often driving responses in lieu of data and evidence.^[4]

The basic human right of access to health services is incorporated in the SA Constitution, with an acknowledgment of the progressive realisation of this right given limited resources.^[5] This is in line with the 2008 World Health Assembly resolution on the issue of migrants, which calls upon member states to promote equitable access to health promotion, disease prevention and care for migrants.^[6,7] The Constitution is interpreted within the National Health Act (2004) ^[8] to include provisions relating to access to public healthcare services for all in SA, with no mention of nationality or legal status. This involves free healthcare services for all pregnant and lactating women and for children under 6 years of age, free primary healthcare for all, and free emergency care at the point of use for all. The Act also states that these rights to access are subject to any provisions prescribed by the Minister. The Uniform Patient Fee Schedule (Appendix H) of the National Health Act provides a fee schedule where a sliding scale of income-dependent co-payments for users of public healthcare services beyond primary healthcare level (e.g. hospitals and specialised services) are outlined; it is this document that outlines differential access to healthcare through user fees being dependent on nationality and documentation status. The result is a complicated system that can lead to confusion for providers and users. Problems are compounded by the politicisation of migration in wider society^[9,10] - a challenge in SA and elsewhere in recent years.^[9,11-13]

Estimates of cross-border migration in SA vary widely, but national census data from 2011 suggest that there are approximately 1.7 million migrants in the country,^[3] which at 3.3% of the population reflects global norms.^'21 Available data suggest that the numbers of international migrants in SA requiring healthcare, including antiretroviral therapy, are relatively low.^[4]

Migrants are often (at least initially) more healthy than non-migrant populations in their host countries, known as the 'healthy migrant effect'.^[14] However, while human mobility is not inherently risky,^[15] some migrant groups face challenges to their health, often associated with living and working conditions in their destinations, which include unsafe, overcrowded living spaces, poor food security, limited livelihood opportunities and (fear of) violence.^[16] These challenges are exacerbated by the social exclusion and socioeconomic hardships resulting from xenophobia and barriers to accessing social services, including healthcare. Maintaining the good health of migrants has been shown to bring economic benefits to the socioeconomic development of both countries of origin and destination.^[17] However, these wider societal benefits of migration and health are often overlooked, particularly in the context of a resource-constrained health system.^[4] Discussions and research on migration and health have often focused on the issue of migrants' health and associated costs. Less attention has been paid to the health systems and economic impact of patient mobility, which would enable a more holistic understanding of migration and health.

Governance of migration and health in southern Africa, whether migration with the explicit purpose of medical travel or through general population mobility, should be evidence-informed and based on robust data and their interpretation, including on the cost-effectiveness of healthcare provision for migrants. Such analysis requires better measurement of the numbers of migrants in countries, and of those accessing healthcare services, and will assist the SADC and national, regional and local government policy-makers to ensure that appropriate resources for health and migration are budgeted and planned for.

Responses to addressing migration and health in southern Africa, including current research responses, are worth outlining.

 

Responding to migration and health in the SADC region

Addressing migration and health in the SADC is an issue gaining momentum, albeit slowly. Just as in many other regions, there is increasing recognition from regional and national policy-makers and practitioners that, in order to address communicable diseases in the region effectively, prevention and treatment responses must engage with migration.^[2] This has resulted in considerable policy activity,^[18-19] including the SADC Declaration on Tuberculosis in the Mining Sector, ratified in 2012,^[19] and the 2009 SADC Draft Policy Framework on Population Mobility and Communicable Diseases in the SADC Region, which is currently being revitalised with the finalisation of a regional needs assessment and the development of proposed regional financing mechanisms (not yet online). Furthermore, health ministers from SA and a range of SADC member states have signed bilateral agreements that aim to address collaboration on a range of health issues, including the treatment of patients, between countries.^[20]

 

Current research responses

Research on population mobility and health is increasing in the southern Africa region. However, there remain considerable knowledge gaps, including a better understanding of the user, provider and policy-maker experiences of policy (development and) implementation, and the impacts of migration and patient mobility - including by type of migrant status - on health systems. Such understanding would guide the development and implementation of practical responses within health systems.

Our current research is examining whether and how patient mobility affects the SA public healthcare system, with a focus on maternal and child health (MCH). This includes exploring the impact of non-nationals living and working in SA on the public healthcare system, and their experiences, and understanding the impact and experience of patients who move with the explicit intention of accessing public healthcare (patient mobility). MCH, a pressing public health issue in SA, serves as an indicator for assessing the health impact of patient mobility, MCH services being an indicator of health system functioning.^[21] This research is the first of its kind in the SADC region. The work is being undertaken collaboratively by an international group of researchers based at the African Centre for Migration and Society at the University of the Witwatersrand, Johannesburg, the Aurum Institute, Johannesburg, and the London School of Hygiene and Tropical Medicine. An advisory group involving a range of key players has been established to guide the research process.

More specifically, this research will compare health outcomes and patient and health worker experiences in facilities situated in areas where non-national populations are known to be located. This 'place-based' research approach will help to inform understanding of the local context in which diverse migrant groups access healthcare. It will examine whether patients are travelling to SA with the intention of accessing the public healthcare system, and if they are, the extent to which this affects perceived and actual quality of public services, or may lead to 'crowding out' of domestic patients, including those accessing the private sector. Equally, the research will examine the potential positive contribution of migrants to the health system. The perspectives on these issues of policy-makers, academics and representatives of key non-governmental organisations will also be explored, with the aim of improving understanding of the governance arrangements regarding health, migration and patient mobility between SA and neighbouring countries. Additionally, we will establish what data are routinely collected and available to monitor health systems impact with regard to MCH, and analyse these data alongside the qualitative data obtained. Importantly, the research will inform the development of a larger comparative research project, which will further explore health system impacts of patient mobility.

 

Conclusion

SA's migration policy needs further development in relation to documented and undocumented migrants. Current health system responses do not adequately engage with and address patient mobility and migration.^[2] While SA's Constitution includes the human right of access to health services for all, its interpretation into policy emphasises differential rights on the basis of nationality and documentation status. This leads to administrative confusion. As a result, some non-nationals face challenges in accessing healthcare. Until migration is better considered in health systems planning, the health of people in southern Africa and developmental benefits associated with the movement of people will be compromised.

Accurate and consistent policy implementation, and an improved consideration of migration in health systems policy and its application, are needed at SADC, national, provincial and local government levels, including within healthcare facilities. Improved data collection and research on these issues will greatly assist with the enactment of evidence- based responses to migration and health in the southern African region. We urge public health practitioners and researchers to embed migration as a central consideration in their work, and, along with policy-makers from health and other sectors, to advocate for improved responses to the movement of people and health in southern Africa.

Acknowledgements. This work is supported by a grant from the Health Systems Research Initiative (MR/M002160/1), jointly supported by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and Wellcome Trust.

 

Helen L Walls

Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK, Leverhulme Centre for Integrative Research on Agriculture and Health, London, UK, and African Centre for Migration and Society, University of the Witwatersrand, Johannesburg, South Africa

Jo Vearey

African Centre for Migration and Society, University of the Witwatersrand, Johannesburg, South Africa

Moeketsi Modisenyane

School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, South Africa

Candice M Chetty-Makkan, Salome Charalambous

Research Department, The Aurum Institute, Johannesburg, South Africa

Richard D Smith

Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK, and Leverhulme Centre for Integrative Research on Agriculture and Health, London, UK

Johanna Hanefeld

Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK, and African Centre for Migration and Society, University of the Witwatersrand, Johannesburg, South Africa

 

REFERENCES

1. Hanefeld J, Smith D, Lunt N, Horsfall D. What do we know about medical tourism - a review of the literature with discussion of its implications for the UK NHS as an example of a public health care system. J Travel Med 2014;21(6):410-417. [http://dx.doi.org/10.1111/jtm.12147]        [ Links ]

2. Vearey J. Healthy migration: A public health and development imperative for south(ern) Africa. S Afr Med J 2014;104(10):603-604. [http://dx.doi.org/10.7196/SAMJ.8569]        [ Links ]

3. Statistics South Africa. Census 2011: Census in Brief. Pretoria: Statistics South Africa, 2012. http://www.statssa.gov.za/census/census_2011/census_products/Census_2011_Census_in_brief. pdf (accessed 10 November 2015).         [ Links ]

4. Vearey J. Learning from HIV: Exploring migration and health in South Africa. Glob Public Health 2012;7(1):58-70. [http://dx.doi.org/10.1080/17441692.2010.549494]        [ Links ]

5. Republic of South Africa. The Constitution of the Republic of South Africa - No. 108 of 1996. 1996. http://www.gov.za/sites/www.gov.za/files/images/a108-96.pdf (accessed 10 November 2015).         [ Links ]

6. Ghent A. Overcoming migrants' barriers to health. Bull World Health Organ 2008;86(8):583-584. [http://dx.doi.org/10.2471/BLT.08.020808]        [ Links ]

7. World Health Assembly. Resolution 61.17 'Health of Migrants. A61/VR/8 Sixty-first World Health Assembly. Geneva: WHA, 2008. http://apps.who.int/gb/ebwha/pdf_files/A61/A61_R17-en.pdf (accessed 10 November 2015).         [ Links ]

8. Republic of South Africa. National Health Act - Act No. 61. Government Gazette 2004;469(23): No. 26595. http://www.chr.up.ac.za/undp/domestic/docs/legislation_55.pdf (accessed 10 November 2015).         [ Links ]

9. Crush J, Tawodzera G. Medical xenophobia and Zimbabwean migrant access to public health services in South Africa. J Ethn Migr Stud 2014;40(4):655-670. [http://dx.doi.org/10.1080/1369183X.2013.830504]        [ Links ]

10. Zihindula G, Meyer-Weitz A, Akintola O. Access to healthcare services by refugees in southern Africa: A review of literature. S Afr J Demogr 2015;16(1):7-35.         [ Links ]

11. Delamothe T. Migrant healthcare: Public health versus politics. BMJ 2012;344:e924. [http://dx.doi.org/10.1136/bmj.e924]        [ Links ]

12. Kirshner J. We are Gauteng people': Challenging the politics of xenophobia in Khutsong, South Africa. Antipode 2012;44(4):1307-1328. [http://dx.doi.org/10.1111/j.1467-8330.2011.00953.x]        [ Links ]

13. Frankel A. The intersection of gender, race and ethnicity in South Africa: How xenophobia affects immigrant and refugee women in Cape Town. 2014. Spring 2014. Paper 143. http://openscholarship.wustledu/cgi/viewcontent.cgi?artide=1142&context=wushta_spr2014 (accessed 10 November 2015).         [ Links ]

14. Malmusi D, Borrell C, Benach J. Migration-related health inequalities: Showing the complex interactions between gender, social class and place of origin. Soc Sci Med 2010;71(9):1610-1619. [http://dx.doi.org/10.1016/j.socscimed.2010.07.043]        [ Links ]

15. Zimmerman C, Kiss L, Hossain M. Migration and health: A framework for 21st century policy- making. PLoS Med 2011;8(5):e1001034. [http://dx.doi.org/10.1371/journal.pmed.1001034]        [ Links ]

16. International Organization for Migration. Migration and Health in South Africa: A Review of the Current Situation and Recommendations for Achieving the World Health Assembly Resolution on the Health of Migrants. Pretoria: IOM Regional Office for Southern Africa, 2010. http://southafrica.iom.int/publication/migration-and-health-in-south-africa/ (accessed 10 November 2015).         [ Links ]

17. Landau L, Kabwe-Segatti A. Human development impacts of migration: South Africa case study. United Nations Development Programme, 2009. (http://core.ac.uk/download/pdf/6569650.pdf (accessed 10 November 2015).         [ Links ]

18. Southern African Development Community Directorate for Social and Human Development and Special Programs. Policy Framework for Population Mobility and Communicable Diseases in the SADC Region: Final Draft. Gaborone, Botswana: SADC Secretariat, April 2009. http://www.arasa.info/files/6613/7574/3254/SADC_Policy_Framework_FINAL.pdf (accessed 10 November 2015).         [ Links ]

19. Southern African Development Community. SADC Declaration on Tuberculosis in the Mining Sector. Gaborone: Botswana: SADC, 2012. http://www.stoptb.org/assets/documents/news/Declaration%20on%20Tubercuosis%20in%20the%20Mining%20Sector2012English.pdf (accessed 10 November 2015).         [ Links ]

20. Crush J, Chikanda A. South-South medical tourism and the quest for health in southern Africa. Soc Sci Med 2015;124(Jan):313-320. [http://dx.doi.org/10.1016/j.socscimed.2014.06.025]        [ Links ]

21. UN Millennium Project. Who's Got the Power? Transforming Health Systems for Women and Children. Task Force on Child Health and Maternal Health. 2005. http://www.unmillenniumproject.org/documents/maternalchild-complete.pdf (accessed 10 November 2015).         [ Links ]

 

 

Correspondence:
H Walls
helen.walls@lshtm.ac.uk