File: Doctors at Nelson Mandela Children's Hospital prepare to perform a heart procedure on 1 August 2019.
Reflecting global trends, most migration in South Africa is internal – people moving between the country’s different provinces. South Africa is also home to a much smaller population of foreign-born migrants, mostly from countries that are part of the South African Development Community, who make up about 4% of the total population.
Both internal migrants moving within the borders of the country and international migrants face daily stresses associated with the challenges of moving to a new area, seeking work, struggling to access safe housing and a secure livelihood, and – in some cases – feeling alone and without social support.
Both groups of migrants also face particular challenges when it comes to accessing healthcare. In the South African context this is exacerbated by historical disparities and a poorly functioning public healthcare system.
On top of this, the country is grappling with what’s known as the quadruple burden of disease – maternal, newborn and child health; HIV and tuberculosis (TB); non-communicable diseases; and violence and injury.
Population movements have implications for all four groups of disease meaning that migration needs to be considered in the development and implementation of all health system responses.
The problem is that the public health system isn’t engaging adequately with the movement of either internal South African migrants or foreign-born migrants. This affects everyone.
For example, efforts to control communicable diseases are undermined by the fact that the movement of people makes it hard for the health system – in its current form – to keep track of people’s medical records. Follow-up appointments are easily missed, and drug regimens may not be completed. The result is that the whole population is placed at an increased risk of acquiring a communicable disease.
One major challenge is that South Africa’s healthcare facilities are unable to access health records of people moving within the country.
The result is that clerks and healthcare providers are forced to spend time trying to trace client records. Very often they can’t, and have to open a new file and begin the process again. Not only does this take up time, but it also means that the needs of all who migrate are compromised.
This has implications for accessing testing and treatment. Migrants struggle to continue treatment and care because health facilities in different locations are not linked, and – for those moving into and out of South Africa – treatment regimens across the region differ.
In the case of TB and HIV, long treatment regimens are needed and there’s a risk of treatment being disrupted due to migration. This has implications for resistance and – in the case of HIV – increasing the risk of onward transmission.
The consequences are dire for patients, as well as the broader population.
Tied to this is the fact that migrants may find themselves living and working in environments in which they are at higher risk of acquiring HIV than the general population. These include commercial farms, mining communities and urban informal settlements. In the context of migrant labour, many people work in dangerous and exploitative conditions, that are associated with occupational health risks including injuries linked to working in the mining and agricultural sectors.
Another challenge relates to antenatal care and childbirth. Many South African women living in urban areas choose to return to their rural homes to deliver their babies. This can lead to a chain of events that affect both the mother and the child. For example, women may miss antenatal care visits because they’ve moved away from the first clinic they visited. Then after the baby is born, it can mean that their babies aren’t entered into the vaccination system when they return to the city.
The movement of people also makes it hard for the country’s health system to respond to non-communicable diseases like heart disease and diabetes. These too require long-term, chronic treatment and support.
Added to this is the fact that migrants face multiple forms of violence. For foreign nationals, various forms of structural, physical, and verbal xenophobic violence are persistent.
Some international migrants may be undocumented and experience further stress due to fear of arrest, detention and deportation. This is further coupled with xenophobic violence – and the fear of violence – which negatively affects migrants’ mental and psychosocial well being.
People seeking asylum based on sexual orientation or gender identity are also likely to experience violence in South Africa.
The next steps
South Africa’s health system needs to engage with migration. Developing a migration-aware health system will support the improvement of health for all in South Africa.
A migration-aware health system must have population movement embedded as a central concern in the design of policies and interventions.
South Africa could learn from the experiences of Sri Lanka. In 2010, the government of Sri Lanka commissioned a study to explore health impacts of inbound, outbound, and internal migrant flows. The study included the families left behind by migrants and contributed to the formulation of a National Migration Health Policy and national action plan.
Such an approach requires input from all sectors of society including government, academia and civil society. Sri Lanka developed a national migration and health research commission and provided opportunities for engagement between researchers, communities and policy makers. This led to evidence-informed interventions to support the health of different migrant groups.
By establishing a national migration and health task team, South Africa could develop a similar approach that engages with internal and international migration.
Sasha Frade, Sasha Frade is a PhD student, as well as an Associate Lecturer, in the Demography and Population Studies, University of the Witwatersrand; Jo Vearey, Associate Professor, University of the Witwatersrand, and Stephen Tollman, Director: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand