What do we know about migration and health in South Africa and regionally? Why is there a concern?
Both internal and cross-border migrants play a crucial role in sustaining household livelihoods and bolstering the South African economy. The concern is two-fold. The first is to strengthen health systems to serve both host populations and internal migrants most effectively. The second is to ensure a public health system that is capable – despite resource constraints – of responding humanely and effectively to cross-border migrants.
But, in reality, we know far less than we should to design effective health systems. This is surprising since the South African mining economy – and to a degree, regional economies – rested for decades on a web of coercive labour legislation designed to ensure the supply of low-wage migrant workers. Levels of temporary (often labour) migration remain as high as they were before South Africa become a democracy in 1994.
The profile of internal labour migrants is changing. The majority are men. But growing numbers of younger women are migrating to join the labour force, many leaving young children in the care of family members.
As the commission report explains, health systems are generally structured around nation-states. This means that migration, especially mobility across national borders, can lead to challenges. For one thing, access is critical. Aspects of access include:
In South Africa, the lack of a common identity number to support care provision means that internal migrants – a substantial proportion of the adult population – tend to access episodic rather than continuous care. This has serious consequences for the clinical management of conditions like hypertension, diabetes or HIV/Aids.
Key competencies are also needed for care of special groups like adolescents and older people.
Altogether, this is a major challenge for South Africa’s health and medical training institutions. The upside is that, if addressed effectively, both host and migrant populations will benefit.
Good examples of migrant-inclusive health systems exist. But there’s no mechanism to systematically review practices and outcomes. This makes it difficult to compare country experiences and recommend models. The World Health Organisation and World Bank have implemented a global system to track progress in universal health coverage. But coverage for migrants, refugees and other mobile populations is not part of that process.
Countries that have ensured migrant health is high on the public health agenda include:
First, we expect the findings to focus attention – at national level, in the sustainable development community and among regional and international bodies such as the UN – on migration health as a public health priority, an issue as relevant to internal migrants as it is to cross-border migration.
Second, the commission documents clearly that those who migrate tend to be healthier than their resident counterparts and, in general, contribute meaningfully to local economic development, a priority for South Africa where jobs and employment are critical concerns.
Third, where cross-border or international migrants have experienced great hardship, an effective response by healthcare systems is called for. This will also benefit host communities, and may traverse the range of conditions from infections to mental health.
Fourth, a migrant-prepared health care system is likely to be more effective for all patients and conditions. This will boost public sector care for all users in South Africa. Quality of care will benefit from extending rather than restricting engagement with migrant communities.
Fifth, there are complexities and trade-offs given human resource, health system and funding constraints. But it’s better to have these foster concerted efforts by public sector leadership and stakeholders to optimise care in the spirit of universal health coverage, than to exclude communities with palpable needs.
Nyovani Madise, director of research and development policy at the African Institute for Development Policy, contributed to this article.
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