Notes from the field by Theresa Sommers
According to the preamble of the Constitution of the World Health Organization, adopted in 1948, “Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” This statement alludes to a state’s responsibility to provide healthcare and other social services, but who exactly are ‘their people’ referenced in the text?
It is this dilemma that frames a larger conversation about citizenship and the provision of healthcare services, and brings forth important questions for global health; namely, with increasing movement of people across international borders – refugees, asylum seekers, economic migrants, etc – how far does, and should, state provided healthcare services extend? How do states that receive large numbers of these migrants address the healthcare needs of both their citizens, and of those non-citizens who live within their borders? How do states and the international community – including the myriad structures of global governance – ensure and protect the right to health for all, especially those who are living outside their country of birth or who are stateless?
As part of a growing partnership between the global health program of the Center for Peace, Democracy, and Development and the African Centre for Migration and Society (ACMS) at the University of the Witwatersrand in Johannesburg, South Africa, I spent six weeks in “Jozi” working with CPDD senior fellow Dr. Joanna Vearey and other researchers at ACMS on issues related to migration and health in Southern Africa. During this trip, I talked to several members of civil society who work with migrants in Johannesburg on the issue of migrant access to public health care services in the city. Many of these discussions focused on the problems of access experienced by their migrant clients, as well as their perspectives on why these problems are occurring – a particularly salient topic given the recent changes to South Africa’s immigration regulations.
In total, I was able to speak with nine individuals, many of whom are members of the Johannesburg Migrant Health Forum (JMHF) – incidentally, the subject of my previous research visit to Johannesburg and ACMS. Additionally, I was able to attend a training session on migrants’ right to health conducted with the social work department of Charlotte Maxeke Johannesburg Academic Hospital and participate in one of the monthly meetings of the JMHF. I also participated in a refugee and migrant health panel session during a Public Interest Law Forum, hosted by the organization Lawyers for Human Rights.
Before delving into what I learned through these discussions, it is useful to provide a bit of background on the picture of migration in the South African context, as well as national legislation that governs the right to health care for both citizens and non-citizens.
Migration continues to be a significant part of the region, with South Africa being the overwhelming destination of choice for migrants from across the continent. While it is notoriously difficult to pinpoint exact numbers of migrants, some state-level data is useful in developing an approximate picture of migration in the region. According to the 2011 South African census, approximately 3.4 percent of the South African population identify as ‘non-citizens,’ with the highest percentage – 7.1% of non-citizens – living in Gauteng Province, which includes the city of Johannesburg.
In terms of South African law, there are three pieces of legislation that relate to access to healthcare and are of relevance to migrants. First is Section 27 of the South African Constitution, which states – among other things – that, “Everyone has the right to have access to health care services, including reproductive health care” and that, “No one may be refused emergency medical treatment.” The Refugee Act of 1998 further stipulates that “a refugee is entitled to the same basic health services and basic primary education which the inhabitants of the Republic receive from time to time.” And, according to the National Health Act of 2003, all pregnant and lactating women and children below age of 6 are eligible for free health care services at all levels. All patients at public clinics are also supposed to be “means tested” for ability to pay – which includes migrants. Yet even with this level of protection stated in the law, migrants – including refugees and asylum seekers – have reported mistreatment and denials of service.
These types of stories are strikingly similar to those recounted in almost all of the discussions that I had. Several individuals that I spoke with felt that the law being applied at clinics is inconsistent, vague, and seemingly not well understood by clinic staff. Furthermore, the Gauteng Provincial Department of Health recently sent around a memo to public hospitals that seems to contradict what is outlined in national legislation, adding further confusion and, as some participants noted, could potentially provide support for xenophobic viewpoints at the clinic level.
The size of migration into South Africa poses challenges for public services such as health care, a point noted in almost all of my discussions. Some felt that clinics feel “overwhelmed” by the number of patients they receive and use migrants as a “scapegoat” – and an easy target for exclusion. And certainly, migration can pose significant challenges for states. Yet, developing solutions to provide health care for all, regardless of citizenship, supports the notion that health is a human right – and is truly a global health imperative.
Theresa Sommers is a PhD student in the the Global Governance and Human Security Program at UMass Boston and a center fellow at the Center for Peace, Democracy, and Development. Her research focuses on issues of Global Health, especially health and migration in Southern Africa, independent child migration, and adolescent and child health.