Healthy migration: A public health and development imperative for south(ern) Africa
Jo Vearey, PhD, is a senior researcher with the African Centre for Migration & Society, School of Social Sciences, University of the Witwatersrand, Johannesburg, South Africa. With a commitment to social justice and the development of pro-poor policy responses, Jo’s current research explores international, regional, national and local responses to migration, health, and urban vulnerabilities.
South Africa (SA), like the rest of the Southern African Development Community, has a high prevalence of communicable diseases, an increasing non-communicable disease burden, and diverse internal and cross-border population movements. Healthy migration is good for development, but current prevention, testing and treatment responses within public health systems – particularly for chronic conditions – fail to engage with migration. Understanding of migration is poor within sectors responsible for developing appropriate responses; negative, unsupported assumptions relating to the prevalence of cross-border migration, the spread of disease, and the burden on receiving health systems prevail. In SA, public health responses fail to address internal and cross-border mobilities, and non-nationals face challenges in accessing healthcare. Of particular concern is the lack of nationally and regionally co-ordinated strategies to ensure treatment continuity for chronic conditions. Co-ordinated, evidence-informed responses to migration, mobility and health are urgently needed. These will have developmental and public health benefits for all.
S Afr Med J 2014;104(10):663-664.
Healthy migration is good for development, but migration is
rarely managed in a healthy way.1
2 Migration and mobility are
recognised globally to be central determinants of health and as
key concerns for public health programming, yet appropriate
responses to population movements and health are lacking in the
Southern African Development Community (SADC) region.3-5 Given
the historical and contemporary importance of population
movements in the SADC, the high communicable disease – and
increasing non-communicable disease (NCD) – burden in the
region, and the knowledge that healthy migration is good for
development, it is surprising that health responses do not
sufficiently engage with, and respond to, migration and
mobility. A large body of evidence acknowledges that the
relationship between migration, mobility and health in the
region is complex: while the migrant labour system was clearly
implicated in the early transmission and spread of syphilis,
tuberculosis (TB) and HIV (especially in relation to the ongoing
systems of labour migration associated with the mines in South
Africa (SA)), these dynamics have changed over time, and the
association between movement and the spread of communicable
diseases is less clear cut today.4 However, prevention, testing
and treatment programmes for common communicable diseases and
NCDs in the SADC must be continuously available for those who
move, both within countries and across borders. Key concerns in
2014 relate to the (lack of) effective management of chronic
conditions for those who move. This has negative implications
not only on the morbidity and mortality of a highly mobile
population, but also on the healthcare systems and family
structures that are forced to manage the costs associated with
delayed healthcare seeking.
The diversity of movement
While the majority of people who move within the SADC do so within the borders of their country of birth, a smaller – yet important – number move across national borders. Globally, just over 3% of the world’s population are estimated to be cross-border migrants; this is also observed in SA, where – despite popular assumptions to the contrary – 3.3% of the country’s population are non-citizens.6 Migration and movement are not homogeneous processes, and those who move form heterogeneous groups; it is exactly this complexity that public health responses in the SADC must engage with and respond to. Owing to the ways in which people move and the spaces they transit or at which they arrive, migrants may reside in – or pass through – spaces of vulnerability,1 , 7 , 8 spaces that contain a combination of social, economic and physical conditions that may increase the likelihood of exposure to, and acquisition of, a communicable disease, or of developing an NCD. The daily stressors that may be experienced in these spaces are increasingly acknowledged to affect emotional wellbeing and mental health.9
Within the SADC region (as is often the case globally), health-seeking is an assumed reason for movement – yet evidence suggests otherwise; the majority move in search of improved livelihood opportunities, and to do so they need to be in good health.5 An important phenomenon, the ‘healthy migrant effect’, is the common observation that recent arrivals are in better health than the local population, reflecting the positive selection of migrants – to move, an individual needs to be healthy.10 However, this health benefit is seen to deteriorate, sometimes rapidly, as a result of the conditions in which migrants live and work. This is particularly the case in cities, and is mostly associated with the inability of migrants – both internal and cross-border – to access positive determinants of health in the city, a phenomenon known as the urban health penalty.11
Responding to migration and health
When considering the development of appropriate responses to
population movements and health in the SADC, it is essential
that discussions do not get twisted (as they often do) into
debates that focus solely on cross-border migrants. As indicated
above, the majority who move are internal migrants (i.e.
national citizens of member states), and internal mobility is
recognised as placing the greatest developmental challenges on
national and local governments.2 Despite this, the notion of
‘migration’ within the SADC region – including in SA – is often
quickly (re)interpreted to refer exclusively to cross-border
migration, leading to discussions of immigration management and
border securitisation. When health is added to the equation,
with unsupported assumptions relating to the health burden
presumed to be presented by cross-border migrants and the
communicable diseases they are assumed to spread, questions
relating to whether non-citizens deserve public healthcare, and
the rationing of healthcare services, prevail. As a result,
population movement remains excluded from the development of
improved health system responses to communicable and
non-communicable diseases in the SADC, with negative public
The policy context
In 2008, the World Health Assembly passed a Resolution on the
Health of Migrants.1 This resolution calls on
member states (including SA) to improve responses to the health
of migrants. Meanwhile, in 2009, a Framework for the Control of
Population Mobility and Communicable Diseases was drafted in the
SADC. This calls for the development of a co-ordinated regional
response to migration and health, including cross-border
referral systems and financing mechanisms. However, SA is still
to approve and ratify the framework. At the same time, the SADC
HIV and AIDS Strategic Framework, 2009 - 2015, was finalised,
highlighting the need to ensure that migrant and mobile
populations are considered in regional responses to HIV. The
year 2012 saw the ratification of the SADC Declaration on
Tuberculosis in the Mining Sector, which clearly outlines the
need for improved, co-ordinated regional responses to the
migrant labour systems associated with SA mines, and HIV and TB.
In SA, responses have mostly been restricted to discussions related to key populations (viewing migrants, particularly cross-border migrants, as such a group) and the country’s HIV response. Additionally, a Migrant Health Forum (MHF) in Johannesburg (established in 2008) brings together various researchers and civil society representatives, including non-governmental, community-based and international organisations, working on migration and health in the city. Different iterations of the MHF have, with the support of the International Organization for Migration and the Office of the Premier in Limpopo Province, been established in several districts in Limpopo.
Despite official recognition of the public health
importance of ensuring timely access to health for all
within legislative frameworks, non-nationals continue to
face multiple, intersecting challenges when attempting to
access public healthcare in SA.1
Key challenges exist in how frontline staff – including
security guards, receptionists and data clerks – engage with
and treat non-nationals. In 2014, these challenges have
worsened (particularly in Gauteng Province), with increasing
reports of incorrect fee classification for higher levels of
care being made, and upfront payment being demanded for
emergency care. This appears to be in response to guidelines
and posters circulated by the provincial Department of
Health which demand up-front payment for all treatment and
imply the need for frontline staff to act as immigration
officials. These actions are unhelpful – not only in terms
of the misapplication of policy and the associated
extralegal implications of denying access to care, but in
the negative public health consequences for all in SA and
the additional costs and burdens associated with delayed
What is needed?
A growing body of evidence provided by researchers, civil society and international organisations emphasises the following:
• Training on migration, mobility, health and development for all levels of staff in the Department of Health, including frontline staff, healthcare providers, facility managers, district and provincial health co-ordinators, and within the national department.
• Recognition of the importance of internal mobility within SA and other countries in the SADC region, and the development of migration-aware health systems.
• SA should lead the development of a co-ordinated regional response to migration, mobility and health.
• Effective implementation of current protective and progressive legislation relating to the right to health for non-nationals in SA.
• Correct classification of non-nationals when being means tested for co-payment for healthcare.
• Implementation of national monitoring of the correct implementation of existing legislation within health facilities.
• Health passports or regionally recognised ‘road-to-health’ cards for all (a form of patient-held records).
• Referral letters for internal AND cross-border migrants.
• The establishment of local migrant health forums.
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8. International Organization for Migration. Migration and Health in SADC: A Review of the Literature. Pretoria: IOM, 2011.
9. Vearey J, Nunez L, Lakika D. Exploring the Psychosocial & Health Rights of Forced Migrants in Johannesburg: The Impact of ‘Daily Stressors’ on the Emotional Wellbeing of Forced Migrants. Johannesburg: Centre for the Study of Violence and Reconciliation and African Centre for Migration & Society, University of the Witwatersrand, 2011.
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11. Vearey J. Migration, urban health and inequality in Johannesburg. In: Bastia T, ed. Migration and Inequality. London: Routledge, 2013:121-144.
12. Vearey J. Migration, access to ART, and survivalist livelihood strategies in Johannesburg. Afr J AIDS Res 2008;7(3):361-374. [http://dx.doi.org/10.2989/AJAR.2008.7.3.13.660]
Accepted 3 July 2014.
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