1. www.migration.org.za
Exploring migration, mobility and health
in South Africa:
key public health imperatives
Jo Vearey, PhD
University of the Witwatersrand
jo.vearey@wits.ac.za
Brocher Foundation
25th
June 2013

2. www.migration.org.za
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
• Conduct research for government, civil
society and international organisations

3. Migration, mobility and health in South Africa:
4 key concerns
1. South(ern) Africa is associated with mixed migration flows:
internal > cross-border; livelihood seeking > forced migration; urban refugees;
marginalised and hidden migrant groups; spaces of vulnerability; negative assumptions
persist
2. Current public health responses do not engage with migration
and mobility: implications for communicable disease control (TB and HIV, malaria);
chronic treatment continuity; challenges in accessing the public system for non-nationals
3. The South African public health and social welfare systems are
overburdened and struggling: challenges are raised in a context of high
inequality where nationals are also struggling to access their basic rights (healthcare,
housing, water, sanitation)
4. South Africa is associated with anti-foreigner and xenophobic
attitudes: migration management is associated with increased securitisation; a lack
of regional responses; a restrictive immigration act; limited understanding of migration
dynamics; violence; fear

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

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

6. www.migration.org.za
Migration and health in South Africa
risk
vulnerability
healthy
migrant
effect
positive
selection
burden
HIV
developmentbenefits
dangerous
contagion
TB
exceptionalisation
trafficking
foreign
access to positivedeterminants of
health
Salmon effect
migration aware
v’s
migrant sensitive
improved
data
an informed
public health
response

7. www.migration.org.za
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.

8. www.migration.org.za
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.

9. www.migration.org.za
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.

10. www.migration.org.za
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.

11. www.migration.org.za
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).

12. www.migration.org.za
Livelihood seeking: spaces of vulnerability1
• Formal and informal
• Employed v’s self-employed
• Job seekers
• Mobility
 Cross-border traders
 Truck drivers
 Seafarers
 Miners
 Farm workers
 Sex workers
1
Crush et al (2002); IOM (2010)

13. www.migration.org.za

14. www.migration.org.za

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

16. www.migration.org.za
Census 2011
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

17. www.migration.org.za
Cross-border migrants as share of the
population
1990 2010
Namibia 7.9 6.3
Botswana 2.0 5.8
South Africa 3.3 3.7
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
3.3
2011

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

19. www.migration.org.za
Social Determinants of Health
http://www.who.int/social_determinants/en/

20. Overlapping vulnerabilities:
gender; food insecurity; lack of cash; living on the periphery;
struggle to meet basic needs
The social determinants of health:
socioeconomic and political context; structural determinants; intermediary determinants
livelihoodseeking
migrationand
mobility
Inequality
HIV TB
Governance (response):
healthy urban governance; intersectoral action; health in all policies;
developmental local government
Inequity
Access to positive determinants of health:
basic services; healthcare; housing; education;
secure livelihood activities; food security
spaces of vulnerability

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

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

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

24. www.migration.org.za
Migration, mobility and health in South Africa:
what is needed?
Migration and health is more than migration and HIV and/or TB.
• Psychosocial and mental health; sexual and reproductive health; social
determinants of health; spaces of vulnerability
Learn from and upscale simple interventions.
• Health passports; roadmaps for treatment access; referral letters; treatment
packs for planned movements; patient-held records
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

25. www.migration.org.za
Exploring migration, mobility and health
in South Africa:
key public health imperatives
Jo Vearey, PhD
University of the Witwatersrand
jo.vearey@wits.ac.za
Brocher Foundation
25th
June 2013