A review of migration and health – seven key findings for SA [SAHR 2017]

TOWARDS MIGRATION-AWARE RESPONSES TO HEALTH IN SOUTH AFRICA:  AN OPPORTUNITY TO ADDRESS INEQUITY IN HEALTH?

[in press] South African Health Review 2017 – supplementary files

Jo Vearey1, Moeketsi Modisenyane2,3 and Jo Hunter-Adams4

1 African Centre for Migration & Society (ACMS), University of the Witwatersrand

2 National Department of Health, Directorate: International Health Development and Support

3 School of Health Systems and Public Health, University of Pretoria

4 Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town

Corresponding author: jovearey@gmail.com

 

A review of migration and health – seven key findings for SA

 

Key finding Overview
1.  The movement of SA nationals present greater governance, health systems, and health equity challenges than the movement of cross-border migrants. ·   In spite of prevailing assumptions to the contrary, there is a larger population of internal SA migrants than cross-border migrants (1–5).

·   Public healthcare users in SA are mobile for reasons other than healthcare-seeking and evidence does not support the suggestion that people move long distances in order to access healthcare (6,7).  However, local mobility in order to access a facility of choice has been demonstrated (6). Border areas present specific challenges whereby individuals may cross a national border in order to access their geographically closest healthcare facility (6).

2.  Responding to migration and health is a global, regional and national priority. ·     Migration and health recognised as a priority area globally (8–12); regionally (SADC) (13–15); and, nationally (16).
3.  Migration is associated with inequity in health and is a social determinant of health. ·     Migration is increasingly recognised as a determinant of health (in)equity (12,17–20).
4.  Migration impacts the public healthcare system in SA, but not in ways often assumed.

 

·     Evidence suggests a healthy migrant effect in SA, with positively selected healthy working-age individuals who move to seek improved livelihood opportunities in urban and peri-urban areas (21,22).  An urban health penalty appears to be present whereby migrants struggle to access the benefits of city living/positive determinants of health (23).  This results in individuals losing their health benefit and returning home when they are too sick to work, presenting a burden on (predominantly rural) sending households and healthcare systems (21,24–27).

·     Access to public healthcare is problematic for non-nationals (7,20,28–30) and internal migrants living on the urban periphery (23).

5.  Strategic opportunities exist for developing a migration-aware health system in SA, and regionally. ·     Various policy processes are influencing and/or have the opportunity to influence the development of a migration-aware health system in SA and regionally

·     Globally: the February 2017 Global Consultation on Migration and Health, and associated re-formulation of the WHA Resolution on the Health of Migrants (12)

·     Regionally (SADC): implementation of the 2012 SADC TB in the Mines Declaration (14), E8 Malaria Elimination (31), SADC HIV Cross border Initiative (32); towards malaria elimination in the MOSASWA (Mozambique, South Africa and Swaziland) region (MOSASWA) Initiative (33); SA as incoming Chair of SADC in August 2017; draft Financing of Mobile Populations in SADC – Situational Analysis of Financing Mobile Populations and the associated Financing Mechanisms (34–36)

·     Nationally: Development of unique HIS identifiers (37,38); NHI (39); Green paper on International migration (40); PHC re-engineering (41); Universal Health Care (UHC) (37)

6.  Improved data is needed to develop and implement migration-aware health systems responses in SA. ·     Costing data is needed for the finalisation of a regional (SADC) financing model for migration and health (35).

·     Improved data is needed for the development of migration-aware health system responses, including better data on the mobility of healthcare users (6).

7.  Good practice examples identified through our review: opportunities for scaling-up ·     Regionally: TB in the mines (strengthened partnerships to tackle tuberculosis in miners, ex-miners, local mining communities and labour supply areas in Southern Africa; access to occupational health services in a selected labour sending area) (42); malaria and HIV/AIDS and STI through the establishment of border health posts (31,32); development of referral policies across borders (43); surveillance and epidemic preparedness (44); and, the harmonization of policies across some of SADC countries (45)

·     Nationally: inter-sectoral partnerships to tackle migration and health including establishment of a national migration and health forum (46)

·     Locally: establishment of local-level Migrant Health Forums (MHFs) (47); IOM domestic work and farm workers initiatives (48,49); MSF referral protocol  and provision of ART through mobile clinics to migrant farm workers – Hlokomela (48)and the Musina Model of Care (50)

Table 3: An overview of policy processes influencing or with the opportunity to influence the development of a migration-aware health system in SA and regionally

 

 

Policy process Summary of engagement with migration and health
INTERNATIONAL
WHA Resolution on the Health of Migrants (2008) (8) The Resolution calls on member states – including SA – to improve their responses to health and migration through an operational framework based on four key components:  monitoring of migrants’ health; policy and legal frameworks; migrant-sensitive health systems; and, partnerships, networks and multi-country frameworks
2nd Global Consultation on Migration and Health, February 2017 – ‘Resetting the Agenda’ (12) This second global consultation plans to “take stock” of action to date in addressing the 2008 WHA Resolution and will use existing evidence to reset the agenda of the Resolution.
African Union Executive Council. 2006. African Common Position on Migration and Development (51) Provides the continental body’s most detailed and expansive guidance on how African states should regulate migration. They also address policies governing how member states regulate migrant access to their territories, and the treatment of immigrants within their lands.
African Union Executive Council. 2006. The Migration Policy Framework for Africa. (52)

 

Calls on member states to enact policies protecting and promoting migrants’ human rights, including guidelines for combatting discrimination and xenophobia through, for example, civic education and awareness-raising. It also calls on member states to, ‘harmonise national legislation with international convention’ to ensure the protection of the rights of migrants, including ensuring access to courts, and promoting
REGIONAL (SADC)
SADC HIV Cross Border Initiative (32) Aims to improve the coherence and effectiveness of the regional response to HIV and AIDS with regard to mobile populations in order to reduce HIV infections in the SADC region and mitigate the impacts of HIV and AIDS on mobile populations and affected communities across member states.
E8 Elimination (53) The regional grant aims “To accelerate zero local transmission in the four frontline countries by 2020 through the provision of a mechanism for collaboration and joint strategic programming.”
Mozambique, South Africa and Swaziland (MOSASWA) (33) To build solidarity and jointly work collaboratively as public and private sector to accelerate and intensify from control to pre-elimination in southern Mozambique and accelerate the transition from pre-elimination to elimination  of malaria in Swaziland and South-Africa, and accelerate from control to pre-elimination in southern Mozambique, so as to achieve zero local transmission in Swaziland, South Africa and Maputo province by 2018 and achieve pre-elimination (API <1 per 1000 &TPR<5%) status in southern Mozambique by 2020
TB in the Mines (TIMS) (42) and SADC TB in the mines (14) To contribute towards the reduction of the TB burden in the mining sector in Southern Africa countries
draft 2009 declaration on population mobility and communicable diseases and associated financing model (SADC) (13,35,36) The framework provides guidance on a) the  protection  of  the  health  of cross-border mobile  people  in  the  face  of communicable diseases, including source, transit and destination communities; and b) the control of communicable diseases in the face of  movement of people across borders in the region.
NATIONAL
The Constitution Contains a wide range of rights that are relevant to the protection, promotion and realisation of the right to health. Where a direct link to the right of health is not found, then the alternative is to relay on a progressive interpretation of other related provisions of the Constitution. The right to life and the equality and non-discrimination provisions enshrines in SA Constitution, may indirectly provide the basis for migrants’ protection of the right to health.

 

The National Health Act of 2003 seeks to “protect, respect, promote and fulfill the rights of the people of South Africa to the progressive realisation of the constitutional right to access to health care services, including reproductive health care. The Act ensures the rights of patients, which includes the right not to be refused emergency medical treatment.
The White paper on National Health Insurance (NHI) (39) The NHI intends to ‘promote equity and efficiency so as to ensure that all South Africans (including refugees and asylum seekers) have access to affordable, quality healthcare services regardless of their socioeconomic status’. The core guiding principles of the NHI are social solidarity, right to access, equality and affordability. The NHI proposes that direct payments or co-payments will be for those populations who will not be covered under the NHI package, such as tourists, foreign students.
National Strategic Plan for HIV, STIs and TB 2012 – 2016 (54) and 2017 – 2022 (55) Various NSP for HIV/AIDS and STIs seeks to ensure non-discrimination in accessing HIV prevention, treatment and support by marginalized groups including sex workers, refugees and undocumented migrants and immigrants.

 

The National Malaria Policy (56) and associated Malaria Elimination Strategy (57) This identifies population mobility and labour migration as one of the drivers of the spread of malaria and recognizes the vulnerability of mobile populations to malaria.

 

The TB Strategic Plan for South Africa (2007-2011) (58) This emphasises that the TB programme respond to migrant and mobile populations.

 

Strategic Plan for Maternal, Neonatal, Child and Women’s Health (MNCWH) and Nutrition in South Africa (2009-2014) (59) One of the key priority interventions of the is on addressing inequity and social determinants of health and this will be implemented through scaling up and improving the quality of priority MNCWH & Nutrition interventions in the under-served districts and sub-districts. Although the draft Plan does not talk specifically about cross-border mobile population, its guiding principles include a commitment to realizing the human rights of women, newborns and children in general.

 

Initiative to regularise neighbouring nationals (Special Dispensation Permits) (60)

 

South Africa has established initiatives to allow regularization of nationals from neighboring countries, granting the right to live and work in the country.

 

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