Policy Briefing: Migration and Universal Health Coverage in Southern Africa

Along with other partners, MHADRI participated in a high-level South African and regional policy roundtable held in Johannesburg, South Africa in July 2019. The following briefing outlines the key recommendations from the discussion.

Migration and universal health coverage roundtable


This policy briefing is based on a high-level South African and regional policy roundtable held on 31st July 2019 in Johannesburg, convened by the University of Witwatersrand, Chatham House, and the UCL-Lancet Commission on Migration and Health.  Thirty-five academics, policy makers and members of civil joined the roundtable which aimed to engage critical concerns regarding access to healthcare for internal and cross-border migrants as part of formulating an inclusive approach to the health of the South African population.

Key recommendations from the roundtable:

  • Migrant-inclusive universal health coverage policies need to be implemented by the South African government, including in the new National Health Insurance, to support wellbeing, livelihoods and sustainable development.
  • Cost effective early and preventative care for all migrant populations, regardless of legal status, is the most effective public health and development strategy.   Health goals including 90-90-90 targets and SDG goals cannot be met without inclusion of a largely mobile South African population and international migrants.
  • Regional and global partnerships should be built upon. Consideration of harmonisation and standardisation of policies, and action to realise interoperability of health policies,  systems and  programmes is encouraged.
  • There is a need to explore bilateral/tripartite solutions between countries.  There should be encouragement of sub regional entities such as SADC to have a greater role in supporting inclusion of migration and health.
  • An accountability framework  should be implemented  to support implementation of UHC and  encourage migration-aware planning and anti-xenophobic actions, this should include accountability to civil society.
  • Through inclusion of migrants in universal health coverage South Africa could be a leader in Africa in advancing the evolution of UHC and mobility.   

Migration and Health in South Africa

In 2019, the newly re-elected South African national government voiced its commitment to ensuring that quality health care be available to all citizens, with National Health Insurance (NHI) at the centre of policy development; strengthened by the constitution of South Africa (SA), which states: ‘Everyone has the right to have access to health care services’. NHI has great potential to address persisting health inequalities in SA, and in the process advance the UN and WHO goal of Universal Health Coverage (UHC).  However, as currently framed, the  NHI proposal means migrant and refugee communities will be left behind, with the rights of asylum seekers and undocumented migrants to access healthcare restricted. 

Labour migration has been central to the South African economy for decades. Today, around half of the national population is mobile (sometimes referred to as internal migrants), and failure to take account of such mobility and secure access to care has contributed to poorer health outcomes. An estimated 3-4% of the SA population – approximately 4 million people – are estimated to be cross-border (international) migrants, the majority of whom originate from elsewhere in the SADC region and include permanent residents, and those with work, study and spousal permits. International migrants have historically made, and continue to make, substantial contributions to the SA economy including the many branches of mining upon which national wealth was founded. UHC is dominating the global health agenda, particularly following the declaration at the high level meeting on UHC at the UN General Assembly in September 2019. SA is a focal point for discussing migration and health in the SADC region.  In order to effectively implement UHC, migrants must be explicitly included.

Universal Health Coverage and Migration in South Africa – Recommendations

The following policy recommendations were proposed during the roundtable in order to achieve Universal Health Coverage (UHC) in  South Africa (SA) which is inclusive of migrants:

1. Current practices in health service delivery and health policy

The current state of knowledge about migration is poor in South African policy and practice: migration has been framed as: a burden on healthcare resources, an affront to values, taking jobs from citizens, a challenge; rather than an opportunity.

Recommendations

R1. The multiple arguments supporting inclusion of migrants, including legal, public health, and  economic development should be highlighted, rather than relying solely on rights-based arguments.

R2. Recognition of the scale of internal mobility and the benefits is very important i.e. migrants are providers of healthcare services as well as consumers, therefore they are  integral  to the health system.

R3. There is a need for a national campaign on migration and the rights of migrants, including working with provinces and municipalities to support them in their mandate for health service planning for migrants.

R4. In order to integrate the goals of the constitution into health service delivery the values and ethics of health care provision need to be integral to health policy and part of health worker training.  To strengthen research and evaluation in migration health, training institutions should integrate the topic within their curriculum and training.

R5. Regional and global partnerships should be built upon. Consideration of harmonisation and standardisation of policies, and action to realise interoperability of migration health policies,  systems and  programmes is encouraged.

R6. There is a need to explore bilateral/tripartite solutions between countries in response to migration health challenges.  Good practice examples of regional responses exist and a renewed conversation is needed.

R7. Capturing population dynamics, particularly of internal mobility in SA,  should be a vital component of planning across all government departments, including local government , and can be supported by effective triangulation of data sources.

R8. There is a need for a multisectoral approach to gathering vital migration statistics, including cross-border referral systems. It is  critical that data is used to assist in planning and responding to both internal and cross-border migration; and  not used for surveillance.

2. Accountability and leadership to encourage inclusion of migrants in UHC

The SA state is taking an increasingly anti-immigrant position, with  a tension playing out between patriotism and pan-Africanism.  There  continues to be scapegoating of migrants for failures of state policy and the securitisation discourse portrays migrants as a threat to security.  Rising xenophobic rhetoric is rarely called out and therefore accountability structures fail.

Recommendations
R1. The UHC declaration on 23rd September 2019 at the UN General Assembly can help drive implementation towards UHC targets,  and inclusion of migrants, in SA.  Implementation of UHC within each regional context should be developed through strong collaboration between policy, academia and civil society.

R2. An accountability framework  should be implemented to support implementation of UHC and encourage migration-aware policy planning and anti-xenophobic action at all levels.  
R3. There should be more accountability to civil society and inclusion of varied sectors in discussions.  There is a need for political and societal champions to step forward with other key stakeholders and generate meaningful momentum to achieve truly universal health coverage in SA.  There should be encouragement of sub-regional entities such as SADC to have a greater role in supporting inclusion of migration and health.

3. Migration aware and mobility competent health care systems

In the region there is little detail or consensus on protocols for migration health; there is an urgent need for better cross-border coordination and interoperability of health services across the Southern African context.  Significant barriers to care and lack of information exist, even when there is a legal entitlement to access services. Likewise, there is daily  discrimination such as migrants being last in the row in a clinic or receiving verbal abuse.  Public health of migrants, and South Africans alike, requires that there be integration and access to care for all migrants.

Recommendations

R1. The development of migration aware and mobility competent systems is needed, including: addressing language barriers, providing translators, accessible information for both migrants and healthcare providers, ensuring health services respond to mobility of care both internally and across borders.

R2. There is a need to develop and implement effective strategies to support  providers in delivering their duty of care to all, including migrants.  This may include providing health services to mobile populations in transit points, or making use of outreach services. 

R3. Over half of South African citizens move internally, much of this work-related.  Recognition of this mobility needs to be integrated into the current health system and NHI reforms.  Inclusion of mobile and migrant groups into health care can lower public health costs, through opportunity for early intervention and increased immunisation rates. Available resources should support a NHI system that seeks to achieve inclusive UHC; however resource distribution is currently unequal.

R4. People should be able to access healthcare regardless of documentation to achieve health targets and to improve health for all populations. 

Policy briefing: Migration and Universal Health Coverage in SouthERN AfricaR5. There is a need to assess how best to use existing resources. Costing studies will help develop cost-sharing mechanisms and financing systems to enable effective regional responses to migration and health.

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