This document discusses migration and health in South Africa. It provides background on migration patterns and health concerns for migrants in South Africa and the Southern African region. Key points include: 1) South Africa experiences significant internal and cross-border migration that impacts health. Migrants face challenges accessing care despite some protective legislation. 2) Migration is a social determinant of health. Migrants are vulnerable to communicable diseases, mental health issues, and face barriers to sexual/reproductive healthcare. 3) Emerging issues include the need for cross-border collaboration, addressing rights around sexuality and migration, and involving multiple levels of governance and private sector in migrant health responses.

1. Migration and health in South Africa
Jo Vearey, PhD
University of the Witwatersrand
jo.vearey@wits.ac.za
National Migrant Health Consultation
Pretoria, 23rd April 2013
www.migration.org.za

2. The African Centre for Migration & Society
.
• Independent, academic research and
teaching unit based at Wits University
• Policy-relevant research in 11 African
countries
• Partnerships in Africa, Asia, Europe and
the Americas
• Post-graduate training
• Contract research for government, civil
society and international organisations
-
www.migration.org.za

3. Today
1. Migration and mobility in South Africa
• Mixed migration; diverse contexts
2. Migration and health in South Africa
• Social determinants of health; spaces of vulnerability
2. Legislative frameworks
• Policy frameworks and opportunities
2. Emerging issues
www.migration.org.za

4. Approximately 214 million cross-border migrants
(around 3% of the world’s population) and
740 million internal migrants globally.
“......migration is not a random individual
choice. People who migrate are highly
organised and travel well-worn paths.”
(Harcourt, 2007: 3)
www.migration.org.za
Source: HDRO staff estimates based on University of Sussex (2007) database

5. Increasing recognition of migration as a
determinant of health
The 61st annual World Health Assembly
(WHA) adopted Resolution 61.17 on the
Health of Migrants in 2008.
Empirical data: existing evidence on
migration, health and HIV to inform responses
This Resolution calls on member states
(including South Africa) to promote equitable
Partnerships: governmental; non-
access to health promotion, disease
prevention and care for migrants.
governmental; civil society; international
organisations; academia identified for
Four priority areas have been
achieving the WHA resolution:
Programmes and interventions: good
1. Monitoring migrant health;
2. Partnerships and networks;
practices – HIV interventions sensitivemigrant and
3. Migrant with health systems;
populations and legal frameworks.
4. Policy
www.migration.org.za

6. Migration and health in SADC (1)
1. SADC is a region of historical and continuing,
varied migratory flows.
2. Linkages between urban and rural areas
through circular migration processes have been
identified as critical to the comprehension of
health concerns within SADC.
3. Cross-border migrants face challenges in
accessing public-health services despite the
presence of protective legislation.
4. There is a strong bias present, with most
published research focussing on migration
within and into South Africa.
www.migration.org.za

7. Migration and health in SADC (2)
5. The relationship between HIV and migration has
emerged as the most researched and published.
6. There is a lack of published research that (1)
documents and (2) evaluates interventions
addressing migration and health in SADC.
7. Migration is a central developmental issue for
the SADC region.
8. Despite the international recognition of the
importance of good governance in managing both
migration and health, there is very little literature
available that considers the governance of health
and migration within the SADC region.
www.migration.org.za

8. Migration is a determinant of health
migration  health
migration can determine health
migration  health
health can determine migration
www.migration.org.za

9. Migration and health
e rous
angccess t c
healt
hy
d a o ponita migra
os ive
gio nt
determin
ants of n Sa lmon eff
e ct effect
bility health for an in formed positive
era eig
vuln ris n publdic health selection
k sevense
re po lopm
migration aware ben ent
HIV g
efits
v’ s t raffickin impro
grBnt sensitive ved
mi T a data
exceptionalisation
burden
www.migration.org.za

10. Migrants reflect health characteristics
of place of origin
AND
additional influences that result from
the process of migration
Gushulak & McPherson, 2006
www.migration.org.za

11. Figure 1: Factors that can affect the well being of migrants during the migration
process (IOM, 2008)
Pre-migration phase Movement Phase
• Pre-migratory events and trauma • Travel conditions and mode
(war, human rights violations, (perilous, lack of basic health
torture), especially for forced necessities), especially for irregular
migration flows; migration flows;
• Epidemiological profile and how it • Duration of journey;
compares to the profile at • Traumatic events, such as abuse;
destination; • Single or Mass movement.
• Linguistic, cultural, and geographic
proximity to destination.
Cross cutting aspects:
Gender, age; socio- Migrant
economic status; genetic s’ well-
factors being
Return phase Arrival and Integration phase
• Level of home community services • Migration policies;
(possibly destroyed), especially after • Social exclusion; discrimination;
crisis situation: • Exploitation;
• Remaining community ties; • Legal status and access to service;
• Duration of absence; • Language and cultural values;
• Behavioural and health profile as • Linguistically and culturally adjusted
acquired in host community. services;
• Separation from family/partner;
• www.migration.org.za
Duration of stay.

12. Mixed migration and mobility in South Africa
• Internal migration > cross-border migration
• The majority of movement in SADC is associated with livelihood
seeking
• Temporary migration v’s transit v’s permanent migration
• (Lack of) Access to documentation
Forced migration Young people
Arrest,
• Refugees
• Asylum seekers detention Students
• Returnees and Women
• Undocumented
deportation Families
www.migration.org.za

13. Livelihood seeking
• Formal and informal
• Employed v’s self-employed
• Job seekers
• Mobility
• Cross-border traders
• Truck drivers
• Seafarers
• Miners
• Farm workers – seasonality
• Sex workers
www.migration.org.za

14. www.migration.org.za

15. 44% of Gauteng’s 28.1% of Western 4.4% of the South
population were Cape’s population African population
born in a different were born in a were born outside of
province different province South Africa
2,199,871
people were
born outside of
South Africa
Census 2011 www.migration.org.za

16. Percentage of international
migrants living in urban
settlement by District
Municipality
www.migration.org.za

17. 7,4% of
Gauteng’s
population are
non-citizens
3.3% of
Western
Cape’s
population are
non-citizens
3.3% of the
South African
population are
non-citizens
Census 2011
www.migration.org.za

18. Cross-border migrants as share of the
population
1990 2010 2011
Namibia 7.9 6.3
Botswana 2.0 5.8
South Africa 3.3 3.7 3.3
Swaziland 8.3 3.4
Mozambique 0.9 1.9
Malawi 12.2 1.8
Zambia 3.5 1.8
DR Congo 2.0 0.7
Lesotho 0.5 0.3
Source: http://esa.un.org/migration/p2k0data.asp www.migration.org.za

19. Key migration and health concerns (1)
Communicable diseases Mental health and
•Transmission psychosocial concerns
•Predominantly move from •Trauma
lower to higher HIV/TB •Daily stressors
prevalence •Violence: direct and
•Treatment continuity structural
•Referrals
•Harmonisation of protocols
home/pre-departure  transit/journey  interception  destination  return
www.migration.org.za

20. Key migration and health concerns (2)
Sexual and reproductive Spaces of vulnerability
health •Urban areas
•Family planning/contraception •Informal settlements
•Testing, treatment for STIs •Dense inner-city
(including HIV) •Farms
•Safe termination of pregnancy •Detention centres
•Antenatal care •Informal workplaces
•Delivery choices •Refugee camps
•PMTCT •RROs
•Border spaces
home/pre-departure  transit/journey  interception  destination  return
www.migration.org.za

21. The social determinants of health (SDH)
 The SDH are the conditions in which people are born, grow,
live, work and age, including the health system.
 These circumstances are shaped by the distribution of
money, power and resources at global, national and local
levels, which are themselves influenced by policy choices.
 The social determinants of
health are mostly responsible
for health inequities - the unfair
and avoidable differences in
health status seen within and
between countries.
http://www.who.int/social_determinants/en/
www.migration.org.za

22. Social Determinants of Health
www.migration.org.za

23. Governing migration in South Africa
www.migration.org.za

24. The Immigration Act
• Governs immigration into South Africa
• Restrictive
• Recent amendments
Republic of South Africa (RSA) (2002) Immigration Act — Act 13 of
2002. Pretoria, South Africa, Government Printers.
Republic of South Africa (RSA) (2004) Immigration
Amendment Act — Act 19 of 2004. Pretoria, South Africa,
Government Printers.
www.migration.org.za

25. The Refugee Act
• South Africa has an integrative asylum policy:
• Refugees and asylum seekers are encouraged to self-
settle and integrate.
• A range of rights are afforded:
• Policies exist that assure the right to health – including
ART – for refugees, asylum seekers and other cross-border
migrants.
• However, recent amendments may affect this.
Republic of South Africa (RSA) (1998) Refugees Act — Act 130 of
1998. Pretoria, South Africa, Government Printers.
www.migration.org.za

26. Cross-border migration into South Africa
 Asylum seekers (Section 22 permit);
 Refugees (Section 24 permit);
 Other:work permits, study permits; visitor
permits;
 Undocumented migrants; and
 Unaccompanied minors.
www.migration.org.za

27. South African legislation
•Cross-border migrant access to healthcare
www.migration.org.za

28. Protective legislation:
the right to health, including ART
1. South African Constitution;
2. Refugee Act (1998);
3. National Department of Health (NDOH) Memo (2006);
4. NDOH Directive (September 2007);
5. Gauteng DOH Letter (April 2008); and
6. HIV & AIDS, STI and TB National Strategic Plan for South
Africa, 2012 - 2016 (NSP).
www.migration.org.za

29. National Strategic Plan (NSP) for HIV & AIDS, STIs
and TB 2012 - 2016
Recognition of:
• Migration – internal and cross-border.
• Migrants recognised as a key population.
• Indicators for key populations include migrants
(e.g. early initiation of ART and TB treatment).
However:
• No framework or guideline for how to
implement responses to HIV and migration.
www.migration.org.za

30. Developmental local government
“local government committed to working with citizens
and groups within the community to find
sustainable ways to meet their social,
economic and material needs and improve
the quality of their lives”
(RSA, 1998: 23)
www.migration.org.za

31. The role of local government
Source: INCA CBF MRC DPLG Handbook
www.migration.org.za

32. Policy opportunities?
www.migration.org.za

33. Emerging issues
• Cross border collaborations
• Human rights, migration and sexuality (including LGBTI asylum)
• TB/HIV in the mines: role of the private sector
• Malaria and mobility
• Sex work and migration
• Work, informal work, migration and health
• Local responses: migrant health forums
• New legislation: NHI; PHC Re-engineering www.migration.org.za

34. Recommendations for action (1)
Migration and health is more than migration and HIV and/or TB.
• Psychosocial and mental health; sexual and reproductive health; determinants of
health
Apply a social determinants of health lens.
• Engage with the informal workplace as a space of vulnerability
Improved data on migration and health is needed.
• Numbers of migrants; numbers of HIV and TB clients who are mobile; strategies
employed by mobile clients; referral systems
Advocate for a migration-aware public health response in RSA and regionally.
• Work with multiple levels/spheres of governance: regional, national, local;
involve state and non-state actors; the urban-rural continuum
Do not exceptionalise cross-border migrants.
• Internal migrants are greater in number and a larger development challenge, and
are often worse off than cross-border migrants
www.migration.org.za

35. Recommendations for action (2)
Mobilise a renewed – and revised - regional conversation for developing a
coordinated response to health and migration.
• SADC Consultancy on Regional Financing Mechanisms; social rights portability:
state and non-state actors; internal and cross-border mobility
Learn from the SADC Declaration on TB in the mining sector.
• Political leadership; private sector; naming and shaming
Migration as a key developmental issue
• The role of developmental local government
Engage with national AIDS councils to ensure migration and mobility
acknowledged in NSPs.
• Beyond migrants as a ‘key population’; work towards a migration-aware response
Learn from and upscale simple interventions.
• Health passports; roadmaps for treatment access; referral letters; treatment
packs for planned movements; patient-held records
www.migration.org.za

36. Migration and health in South Africa
Jo Vearey, PhD
University of the Witwatersrand
jo.vearey@wits.ac.za
National Migrant Health Consultation
Pretoria, 23rd April 2013
www.migration.org.za