Ensuring migrant rights to health: lessons from a study assessing non-citiz...
Migrant friendly or migration aware? The challenges of a key populations approach to migration, HIV and TB
1. Migrant friendly or migration
aware?
The challenges of a key population
approach to migration, HIV and TB
Jo Vearey, PhD
jo.vearey@wits.ac.za
25th November 2012
3. 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)
Therefore, responses to HIV and TB must engage with
migration as a key social dynamic.
Source: HDRO staff estimates based on University of Sussex (2007) database
4. The 61st annual World Health Assembly
(WHA) adopted Resolution 61.17 on the
Empirical data: existing evidence on migration,
Health of Migrants in 2008.
health and HIV to inform responses
This Resolution calls on member states
Partnerships: governmental;to promote
(including South Africa) non-
governmental; civil society;to health promotion,
equitable access international
disease prevention and care for migrants.
organisations; academia
Four priority areas have been identified for
Programmesachieving the WHA resolution:
and interventions: good
practices – HIV interventions with migrant
1. Monitoring migrant health
2. Partnerships and networks
populations Migrant sensitive health systems
3.
4. Policy and legal frameworks
5. 1. South(ern) Africa is associated with
historical and contemporary population
movements.
8. 44% of 28.1% of
4.4% of the
Gauteng’s Western Cape’s
South African
population were population were
population were
born in a born in a
born outside of
different different
South Africa
province province
2,199,871 people
were born outside
of South Africa
Census 2011
10. 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
11. 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
13. 2. There are linkages between migration and health
in South(ern) Africa.
14. Migrants reflect health characteristics
of place of origin
AND
additional influences that result from
the process of migration
Gushulak & McPherson, 2006
15. 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;
• Duration of stay.
16. Protective policy
The right to health: internal and cross-border migrants
• South African Constitution and The Bill of Rights;
• Refugee Act (1998);
• National Strategic Plan for HIV, STIs and TB (2012 - 2016);
• National Department of Health (NDOH) Memo (2006);
• NDOH Directive (September 2007); and
• Gauteng DOH Letter (April 2008).
17.
18. 3. A “key populations” approach to migration, HIV
and TB has (unintended) negative consequences.
19. Challenges of a key population approach to
migration, HIV and TB.
• Migrant friendly approach:
• Individual focus (v’s population focus)
• Facility-level responses (v’s health system responses)
• Emphasis on language and translation; cultural competency
• Exceptionalise: focus on non-nationals
• “Right to health” focus
• Migrants perceived as sick, a burden on services, and in a larger number
than they are
• Limited (no) systems response
• Client mobility within the health system is not addressed
20. 4. There is a need for “migration aware” health
systems responses that embed migration as a key
social process in southern Africa.
21. Migrant friendly Migration aware
•“Right to health” •Mobility-sensitive
•Limited systems response •Heterogeneity of migrant
•Cross-border/non-national populations: considers internal
focus: an assumed movement
•Spaces of vulnerability
homogenous group •Systems response
•Exceptionalises •Spatially sensitive
•Individual level focus •“Health for all”
•Public health approach
•Regionally-aware
22. • Migration is a global reality (and a fact of life)
• Migration involves the movement of people within a country and, to a
lesser extent, the movement of people across borders.
• It is the conditions associated with migration that affect vulnerability to
HIV and TB, not being a migrant per se.
• Engaging with migration will strengthen health responses
• Healthcare planning
• Continuum of care and referrals
• Failure to do so will
• Create marginalised groups
• Infringe migrants rights
• Result in poor public practice
• Effectively implementing existing legislation relating to the right to
health for migrant groups will improve health for all.
Use of the map to emphasise that migration is a global reality and that southern Africa is mostly circular migration, most of which takes place within countries.
Key point: Global, regional, and national recognition of the importance of engaging with migration in health, including HIV, responses. Talk to slide as the various images appear Much evidence exists: research, programmatic evaluations, good practices These are based on partnerships, that already exist. So – a lot is known: we know that migration is a critical consideration for an effective HIV response.
A range of rights, including access to basic healthcare, are provided to non-nationals through the Refugee Act (1998) and the South African Constitution. The current HIV/AIDS and STI National Strategic Plan for South Africa (NSP) specifically includes non-nationals – international migrants, refugees and asylum seekers – and outlines their right to HIV prevention, treatment and support. In September 2007, the National Department of Health (NDOH) released a Revenue Directive [i] clarifying that refugees and asylum seekers – with or without a permit – shall be exempt from paying for antiretroviral treatment (ART) in the public sector. A key guiding principle to the successful implementation of the NSP is towards “ensuring equality and non-discrimination against marginalised groups”; refugees, asylum seekers and foreign migrants are specifically mentioned as having “a right to equal access to interventions for HIV prevention, treatment and support” [ii] . [i] Ref: BI 4/29 REFUG/ASYL 8 2007 [ii] Department of Health (2007) HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011. April 2007: Pretoria: Department of Health, p56
In September last year, the NDOH released a revenue directive clarifying that refugees and asylum seekers – with or without a permit – have to rhight to access basic health services and ART. They must be assessed according to the current means test, as applied to South African citizens, and must not be charged foreign category fees.
I suggest we state these up front. So that they’re clear from the start.