Vol 26/2, 2024, pp. 87-90  PDF

SPECIAL SECTION: DISTRESS MIGRATION AND THE RIGHT TO HEALTH

VIEWPOINT

Rebecca Walker and Jo Vearey

Introduction

Since South Africa’s democratic transition in 1994, the country has been associated with a progressive Constitution and a rights-based legislative framework enshrining rights for all those within its borders.[1] For 30 years, the post-apartheid government’s commitment to building robust and accessible public services, such as health and education, has offered hope of an inclusive and equitable approach to socioeconomic development for all.

However, in recent years, South Africa’s legislative, political, and social erosion of its commitments to human rights and development has deepened inequalities and worsened development indicators.[2] The interplay of poor governance (characterized by corruption and political interference), resource constraints, and historical inequalities has negatively impacted all in South Africa and trapped many in cycles of poverty and unemployment.[3]

For distress migrants (asylum seekers, refugees, and undocumented migrants), these challenges are exacerbated by discriminatory policies and practices and institutional neglect.[4] Having left their countries of origin in search of safety, employment opportunities, and improved livelihoods, many distress migrants remain undocumented or in limbo for years in South Africa due to institutional inefficiencies and corruption.[5] Unable to regularize their status, distress migrants face barriers to accessing basic socioeconomic rights, including health care, secure housing, income-generation activities, and general safety.

Despite claims to the contrary, non-nationals (distress migrants and other migrant groups) compose only 3.9% of the overall population.[6] Yet distress migrants are targeted by the government’s deliberate and public strategy of scapegoating them for its failures to deliver on post-apartheid promises.[7] Experienced as negative determinants of health, these challenges not only increase inequity in South Africa but compromise the health and well-being of distress migrants by exposing them to neglect and (un)care in the very spaces where they seek support.[8]

A state of (un)care in health care

The state of (un)care is particularly evident in the poorly managed and inefficient public health system. While most South Africans relying on public health care (approximately 80%) face challenges accessing care, it is distress migrants who are disproportionately vulnerable to poor treatment, denial of medication, and limited access to health care facilities.[9]

South Africa’s Refugees Act guarantees asylum seekers and refugees the rights to work, study, access medical services and life-saving treatment, and enjoy freedom of movement.[10] Similarly, the National Health Act upholds the constitutional right to health by providing free primary health care access for all (with no mention of nationality or legal status).[11] The Uniform Fee Schedule confirms that refugees, asylum seekers, and undocumented migrants from the Southern African Development Community states are entitled to be treated in the same way as South African citizens in hospitals and to be means tested to determine their ability to pay for services.[12] Yet despite these legal protections, migrants frequently encounter discrimination, exclusion, and xenophobic attitudes from health care workers, negatively impacting their mental well-being (see Table 1).[13]

This neglect is also increasingly formalized through the deliberate exclusion of specific migrant groups in national policies, limiting the country’s likelihood of achieving global health targets and negatively affecting health outcomes for all in South Africa.[14] For example, in 2020 the Gauteng Province Department of Health (where Johannesburg is located) violated the National Health Act, the Constitution, and the Bill of Rights by restricting access to free health care for pregnant and lactating migrant women and children under six years of age on the basis of their nationality and documentation status. Despite a court order mandating the provincial department of health to amend the policy, discriminatory practices reportedly continue unchecked.[15]

Furthermore, national strategies for addressing both communicable and noncommunicable diseases lack migration awareness.[16] This is evident in the exclusion of migration and migrants from pandemic preparedness plans, including, most recently, the national COVID-19 vaccine program.[17] Additionally, the newly passed National Health Insurance Act, based on the principles of universal health coverage, is poised to restrict access to free basic health care for asylum seekers and undocumented migrants.[18] This not only undermines South Africa’s global health targets but contradicts the fundamental right to health enshrined in various global, continental, and regional governance frameworks the country has ratified (see Table 1).

Table 1 National laws and policies protecting the right to health for all in South Africa

Systemic neglect in the Department of Home Affairs

The state of (un)care is reflected by the Department of Home Affairs through its bureaucratic inefficiencies and corruption, which have led to massive backlogs in processing and adjudicating applications for asylum and other various visas and permits.[19] Instead of addressing the manifold structural challenges, the government has focused on an increasingly restrictive and securitized approach to immigration.[20] The recently revised White Paper on International Migration, for example, proposes relocating asylum processing to border areas, creating a dangerous de facto encampment policy while reducing access to basic services.[21] Additionally, the introduction of the Border Management Act, coupled with arbitrary arrests, detention, and deportation, all contribute to a climate of fear and vulnerabilities for distress migrants.[22]

Conclusion: Prioritizing punishment over protection

South Africa’s current migration and health agenda, characterized by xenophobia and a prioritization of punishment over protection, disproportionately undermines the health and well-being of distress migrants. To foster a more inclusive and equitable society, the government must adopt a fundamentally different approach. This involves implementing migrant-inclusive health policies, strengthening anti-discrimination laws, and addressing the complex interplay between governance and structural and systematic factors that contribute to health disparities among distress migrants. Providing migrants with opportunities to regularize their immigration status is also critical to addressing the structural determinants of poor health and well-being for all in South Africa. By effectively addressing the contradictory position taken by the government, South Africa can align its policies with the principles of universal health coverage and the numerous international human rights and health agreements it has ratified. Ultimately extending care and protection toward distress migrants will contribute to a more just and equitable society for all.

Rebecca Walker, PhD, is a senior researcher at the African Centre for Migration and Society at the University of the Witwatersrand, Johannesburg, South Africa.

Jo Vearey, PhD, is director of the African Centre for Migration and Society at the University of the Witwatersrand, Johannesburg, South Africa.

Please address correspondence to Rebecca Walker. Email: bexjwalker@gmail.com.

Competing interests: None declared.

Copyright © 2024 Walker and Vearey. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

[1] Constitution of the Republic of South Africa (1996).

[2] United Nations Development Programme, South Africa National Human Development Report 2022: Harnessing the Employability of South Africa’s Youth (New York: United Nations Development Programme, 2022).

[3] M. Matyana and X. Thusi, “Unemployment and Poverty in South Africa: Assessing the National Development Plan 2030 Predictions,” International Journal of Development and Sustainability 12/6 (2023); Oxfam South Africa, Reclaiming Power: Womxn’s Work and Income Inequality in South Africa (Johannesburg: Oxfam South Africa, 2020).

[4] G. Mthembu-Salter, R. Amit, L. B. Landau, and C. Gould, Counting the Cost of Securitising South Africa’s Immigration Regime (Migrating Out of Poverty Research Programme Consortium, University of Sussex, 2014).

[5] R. Amit and N. Kriger, “Making Migrants ‘Il-legible’: The Policies and Practices of Documentation in Post-Apartheid South Africa,” Kronos 1/40 (2014).

[6] L. B. Landau and R. Walker, “South Africa’s Immigration Proposals Are Based on False Claims and Poor Logic – Experts,” The Conversation (November 23 2023), http://theconversation.com/south-africas-immigration-proposals-are-based-on-false-claims-and-poor-logic-experts-217941; Statistics South Africa, Migration Profile Report for South Africa: A Country Profile 2023 (Statistics South Africa, 2024).

[7] R. Solomon, “Scapegoating Illegal African Immigrants as Criminals Adds Fuel to the Xenophobia Fire,” Daily Maverick (September 3, 2019), https://www.dailymaverick.co.za/article/2019-09-30-scapegoating-illegal-african-immigrants-as-criminals-adds-fuel-to-the-xenophobia-fire/.

[8] R. Walker and J. Vearey, “‘Let’s Manage the Stressor Today’: Exploring the Mental Health Response to Forced Migrants in Johannesburg, South Africa,” International Journal of Migration, Health and Social Care 19/1 (2023).

[9] Statistics South Africa, General Household Survey, 2018 (Statistics South Africa, 2020); T. Gordon, F. Booysen, and J. Mbonigaba, “Socio-Economic Inequalities in the Multiple Dimensions of Access to Healthcare: The Case of South Africa,” BMC Public Health 20/1 (2020).

[10] Department of Home Affairs, Refugees Act No. 130 of 1998 (1998).

[11] Gauteng Provincial Government, Uniform Patient Fee Schedule Tariffs 2024–25 (April 5, 2004), https://www.gauteng.gov.za/Publications/PublicationDetails/%7B30e7cff0-3657-4cab-94fd-14b08958bdaf%7D.

[12] Department of Health, National Health Act No. 61 of 2003 (2004).

[13] R. Walker, “Migration, Trauma and Well-being: Exploring the Impact of Violence within the Healthcare System on Refugee Women in South Africa,” in A. Sigfrid Gronseth and J. Skinner, Mobilities of Wellbeing: Migration, the State and Medical Knowledge (Carolina Academic Press, 2021).

[14] International Organization for Migration, Migrants’ Rights to Health: A Legislative and Policy Review for Southern Africa (International Organization for Migration Regional Office for Southern Africa, 2022).

[15] Section27, “Media Statement: Civil Society Organisations Condemn Gauteng Health Facilities’ Defiance of Laws and Recent Court Order on Free Access to Health Care for Pregnant Women” (July 4, 2023), https://section27.org.za/2023/07/media-statement-civil-society-organisations-condemn-gauteng-health-facilities-defiance-of-laws-and-recent-court-order-on-free-access-to-health-care-for-pregnant-women/.

[16] T. de Gruchy and J. Vearey, “Left Behind: Why Implementing Migration-Aware Responses to HIV for Migrant Farm Workers Is a Priority for South Africa,” African Journal of AIDS Research 19/1 (2020).

[17] F. C. Mukumbang, A. N. Ambe, and B. O. Adebiyi, “Unspoken Inequality: How COVID-19 Has Exacerbated Existing Vulnerabilities of Asylum-Seekers, Refugees, and Undocumented Migrants in South Africa,” International Journal for Equity in Health 19/1 (2020).

[18] Department of Health, National Health Insurance Act No. 20 of 2023 (2023).

[19] Amit and Kriger (see note 5).

[20] J. P. Misago and L. B. Landau, “‘Running Them Out of Time’: Xenophobia, Violence, and Co-authoring Spatiotemporal Exclusion in South Africa,” Geopolitics 28/4 (2023).

[21] Landau and Walker (see note 6).

[22] Department of Home Affairs, Border Management Act No. 2 of 2020 (2020).