Policy exclusion or confusion? Perspectives on universal health coverage for migrants and refugees in South Africa

Abstract

Notwithstanding the promise of the inclusivity of universal health coverage (UHC), the integration of migrants and refugees into host countries’ health systems remains elusive and contested. In South Africa, there is insufficient scholarly attention on UHC, migrants and refugees, given the country’s strategic importance in Africa and the envisaged implementation of the National Health Insurance (NHI) system. In this paper, a social exclusion conceptual framework is used to explore whether South African legislation, health policies and perspectives or actions of health policy actors facilitate UHC for migrants and refugees or exacerbate their exclusion. We combined a review of legislation and policies since 1994, with semi-structured interviews with 18 key informants from government, academia, civil society organizations and a United Nations organization. We used thematic analysis to identify themes and sub-themes from the qualitative data. The South African Constitution and the National Health Act facilitate UHC, while the Immigration Act and the 2019 NHI Bill make the legal status of migrants the most significant determinant of healthcare access. This legislative disjuncture is exacerbated by variations in content, interpretation and/or implementation of policies at the provincial level. Resource constraints in the public health sector contribute to the perceived dysfunctionality of the public healthcare system, which affects the financial classification, quality of care and access for all public sector patients. However, migrants and refugees bear the brunt of the reported dysfunctionality, in addition to experiences of medical xenophobia. These issues need to be addressed to ensure that South Africa’s quest for UHC expressed through the NHI system is realized.

The impact of COVID-19 on a cohort of origin residents and internal migrants from South Africa's rural northeast

“…South Africa's urban environments, while offering better-resourced and serviced health facilities than those located in rural areas ( van Rensburg, 2014 ), may still present difficulties of access among migrant groups. Internal migrants experience fewer challenges of exclusion than have been reported among international migrants ( White & Rispel, 2021 ). Nevertheless, internal migrants may experience barriers impacting on health service use, in particular in relation to public facilities ( Vearey et al, 2017 ).…”

A discourse and content analysis of representation in the mainstream media of the South African National Health Insurance policy from 2011 to 2019

“…Public participation has been described as necessary to implement real change away from neoliberal ideology [ 65 ], but has been limited in the context of the SA NHI policy. Public awareness of the NHI is low [ 46 , 121 ], with exclusion of vulnerable groups such as migrants and youth in the policy process [ 122 , 123 ].…”

Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review

“…To be more focused, conceptual and historical developments toward UHC have been presented from the available literature. We fixed the article's content in light of policy and program confusions in various countries ( 15 ), the multiple foundations of UHC ( 16 ), gaps in healthcare equity and excess during historical paradigm shifts ( 17 ), and the current and future challenges on the path of UHC ( 18 ). The future challenges for UHC presented in this article were articulated on the basis of epidemiological, demographic, existing policy discrepancies, and lifestyle factors associated with healthcare ( 11 , 19 ).…”