Stephen Tollman, University of the Witwatersrand; Davide Mosca, UCL, and Miriam Orcutt, UCL

A global commission on health and migration has released its report on how health care systems fail migrants. The aim is to provide the basis for evidence-based approaches to policy. The report calls on civil society, academics, and policy makers to maximise the benefits and reduce the costs of migration on health. Ina Skosana asked three of the commissioners to explain what the report found on the challenges facing countries in southern Africa.

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.

Are health systems prepared to deal with the movement of people within and across borders?

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:

• Patient engagement. This covers the social and cultural preparedness of public health systems to serve migrants and families, whether internal or cross-border. Practitioners’ sensitivity to the beliefs and practices of others shouldn’t be assumed. It can be learned. Patient engagement is thus closely tied to:

• Clinical competence. Clinicians are trained to provide care to all patients, irrespective of background, who present to their clinic, ward or surgery. But cross-cultural awareness is vital to effective history taking and clinical examination. This is true whether care is provided by a nurse, doctor or allied professional. Similarly, treatment prescription, adherence to medication and suggesting changes in behaviour to lower personal risk depend on quality communication between practitioner and patient.

• System preparedness. A major challenge to health systems is continuity of care. This holds for both mobile and settled populations especially when – as increasingly happens – patients present with chronic or long-term conditions. Examples include those affecting the vascular system (like strokes), the metabolic system (notably diabetes), infections (TB) or mental ill-health (such as depression).

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.

Are there countries that are worse or better off? And why?

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:

• Italy. Despite the profoundly divisive political debate underway, the right to health for migrants is enshrined in Italy’s Constitution. Irregular migrants can access essential health services anonymously and free of charge. They are also entitled to preventive care, including maternity and chronic conditions. Health promotion campaigns, interpreters and cultural mediators are widely used to overcome barriers.

• Sri Lanka. The country launched an inclusive National Migration Health Policy in 2013. Restrictions that might limit access by non-citizens have been removed. Community health services that are provided free to Sri Lankans are also available to migrants and refugees, including immunisations, antenatal and emergency care. Sri Lanka has promoted the migration and health agenda regionally, globally and at the highest political level.

• Thailand. Undocumented migrants can buy low-cost subsidised health insurance once they’re registered with government under the One Stop Service Policy. Using the Health Insurance Card Scheme, migrants can access free care in public hospitals; similarly, the uninsured can access services but at a cost.

How will the Commission’s findings contribute to the improvement of the situation faced by migrants?

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 health care 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.

Stephen Tollman, Director: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand; Davide Mosca, Honorary Associate Professor, UCL, and Miriam Orcutt, Migration and Health Research Associate, UCL

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