1. Policy Dialogue on Urban Health, HIV and
Migration in Johannesburg:
developing pro-poor policy responses to
urban vulnerabilities
22nd November 2012

2. 1. To bring policy makers, implementers, researchers
and civil society together to discuss the current health
challenges faced by migrants in Johannesburg.
2. To share current responses in the City of Johannesburg
that are addressing the needs of urban migrants.
3. To develop recommendations for action that will
lead to the development and implementation of
strengthened responses to address the urban
vulnerabilities experienced by migrants in Johannesburg.

3. Migration involves the movement of The overwhelming majority of
people; young, old, men, women, migrants in Johannesburg move in
families. order to seek improved livelihood
opportunities.
People move for a range of reasons.
Migrants do not report moving to
South African nationals Johannesburg in order to access health
•Rural to urban care, ART or other services.
•Urban to urban
•Within a municipality On arrival in Johannesburg, migrants
tend to be healthier than the host
Cross-border migrants population.
•Forced migrants: asylum seekers;
refugees If they become too sick to work,
•Other permits: work, visitor, study
migrants will return back home to
•Undocumented
seek care and support.

4. Health is a state of complete physical, mental
and social well-being and not merely the
absence of disease or infirmity.

5. 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).

6. • The 61st annual World Health Assembly (WHA) adopted
Resolution 61.17 on the Health of Migrants.
• This Resolution calls on member states 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.

7. The social determinants of health (SDH)
 The SDH are the conditions in
which people are born, grow,
live, work and age, including
the health system.
 These circumstances are
shaped by the distribution of
money, power and resources
at global, national and local
levels, which are themselves
influenced by policy choices.
 The social determinants of
health are mostly responsible
for health inequities - the
unfair and avoidable
differences in health status
seen within and between
countries. http://www.who.int/social_determinants/en/

8. WHO Commission on the Social
Determinants of Health (2008)

9. “local government committed to working with citizens
and groups within the community to find
sustainable ways to meet their social,
economic and material needs and improve
the quality of their lives”
(RSA, 1998: 23)

10. Source: INCA CBF MRC DPLG Handbook

11. Evidence
Problem statement
Today
What has been done?
What is missing?
What are the possible solutions?
Develop a policy brief to use to advocate
for change.

12. 1. What do you think are the key messages?
2. Who needs to hear them?

13. Policy Dialogue on Urban Health, HIV and
Migration in Johannesburg:
developing pro-poor policy responses to
urban vulnerabilities
22nd November 2012

14. Urban vulnerabilities and
migration in Johannesburg:
setting the scene
Jo Vearey, PhD
jo.vearey@wits.ac.za
22nd November 2012

15. Migration
Approximately 214 million cross-border migrants (around 3% of the world’s
population) and 740 million internal migrants globally.
Africa:
•17 million cross-border migrants (18% estimated to be refugees).
•Less than 2% of the total African population.
Southern Africa:
•Home to 9% of continent’s cross-border migrant population.
•Approximately 3% of region estimated to be cross-border migrants.
South Africa
•Between 3 and 4% of the total population are cross-border migrants (around 2 million
people).
•Internal and cross-border migration: different forms of migration and different reasons
for migration are found to determine urbanisation experiences; impacts on health.
UNDP, 2009; UNOCHA & FMSP, 2009; Zlotnick, 2006; Population Division of the Dept. of Economic and Social Affairs of the UN Secretariat, 2005
© Monica Mabasa, 2010

18. 44% of
Gauteng’s
population were
born in a
different
province
Census 2011

19. Percentage of international
migrants living in urban
settlement by District
Municipality

20. Census 2011

21. Census 2011

22. 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

23. Cross-border migrants in South
Africa
1990 1995 2000 2005 2010
International migrants 1 224 368 1 097 790 1 022 376 1 248 732 1 862 889
Refugees 0 96 651 14 801 28 699 35 911
Population (thousands) 36 745 41 375 44 872 48 073 50 492
International migrants as a 3.3 2.7 2.3 2.6 3.7
% of population
Female migrants as % of 37.3 38.9 40.1 41.4 42.7
int. migrants
Refugees as a % of int. 0.0 8.8 1.4 2.3 1
migrants
Source: http://esa.un.org/migration/p2k0data.asp

24. Cross-border
migration
• Asylum seekers (Section 22 • Formal and informal
permit) • Employed v’s self-employed
• Refugees (Section 24 • Job seekers
permit)
• Other documents: work • Cross-border traders
permits, study permits; • Truck drivers
visitor permits • Sex workers
• Undocumented migrants • Waste pickers
• Street traders
© Constance, 2010

25. Migration and health
e rous
angccess t c
healt
hy
d a o ponita migra
os tivei n
determin g on ect effec t
ants of Sa lmon eff t
r abi l i t
y he
alth for an in formed positive
v ulne ri s eig ic health
k n publde selection
spvense
re o lopm
migration aware ben e
efit nt
HIV ng s
v’ s trafficki impro
grBnt sensitive ved
mi T a data
exceptionalisatio
burden n

26. Migrants reflect health characteristics
of place of origin
AND
additional influences that result from
the process of migration
Gushulak & McPherson, 2006

27. 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.

28. Gini coefficient in selected South
African cities
(Figure adapted from UN-HABITAT, 2008: 72)

29. Desk review
•Urban migrants, urban vulnerabilities, HIV
•Legislation, policy, good practices
Fieldwork (ongoing)
•Identification of key urban migrant groups
•Mapping of key organisations; interviews with representatives
of key organisations
•Interviews with representatives of different migrant groups

30. Legislation exists to uphold the right of cross-border migrants to
access basic healthcare – including ART – in South Africa.
(The Constitution, 1996; Refugee Act, 1998; National Health Act, 2004; NDOH Memo, 1996; NDOH Revunue Directive,
2007; Gauteng DOH Memo, 2008; Vearey & Richter, 2008; Vearey, 2008; CoRMSA, 2011; Moyo, 2010; Vearey, 2010;
Vearey 2011)
Despite this, cross-border migrants face challenges in accessing
public health services, including ART.
(Amon & Todrys, 2009; CoRMSA, 2011; Human Rights Watch, 2009a, 2009b; IOM, 2008; Landau, 2006; Moyo, 2010;
MSF, 2009; Pursell, 2004; Vearey, 2008; Vearey, 2010; Vearey 2011)
• Cross-border and internal migrants are affected by poor access to healthcare
services – as are those who have always resided in JHB.
• Being a cross-border migrant presents additional access challenges:
documentation; “being foreign”; language barriers.

31. Urban
HIV in urban
vulnerabilities
informal
settlements Violence
HIV in Structural
Migration Direct
urban Urban Access to
areas growth services
Natural
population Livelihood
Urban growth activities
health

32. Internal Cross-border
Migrants living Migrants living
with HIV with disabilities Migrant sex
workers
Migrants with
mental health LGBTI migrants Migrants living
and psychosocial on the streets
needs
Migrants living in
informal housing

33. UNHCR Urban “These rights include, but are not limited to, the
right to life; the right not to be subjected to cruel
Policy, 2009 or degrading treatment or punishment; the right
not to be tortured or arbitrarily detained; the
right to family unity; the right to adequate
food, shelter, health and education, as well as
livelihoods opportunities.”
“Given the need to prioritize its efforts and
allocation of resources, UNHCR will focus on the
provision of services to those refugees and
asylum seekers whose needs are most acute.
While these priorities will vary from city to city,
they will usually include:
• providing care and counselling to people with
specific needs, especially people with disabilities,
those who are traumatized or mentally ill,
victims of torture and SGBV, as well as those
with complex diseases requiring specialized
care;
UNHCR, 2009: 18

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

35. Key concerns (2)
Sexual and reproductive Spaces of vulnerability
health •Urban areas
•Family planning/contraception •Informal settlements
•Testing, treatment for STIs •Dense inner-city
(including HIV) •Detention centres
•Safe termination of pregnancy •Informal workplaces
•Antenatal care
•Delivery choices
•PMTCT
home/pre-departure  transit/journey  interception  destination  return

36. DIEPSLOOT EXT. 1: 2000 - 2009
36

37. Key concerns (3)
The health system as a Healthy urban
central determinant of governance
health •Developmental local
•Accessibility: government
• Availability •Joined-up government
• Acceptability •Intersectoral action
• Affordability •Health in all policies
•IDPs & District Health
Plans
home/pre-departure  transit/journey  interception  destination  return

38. Some questions and concerns….
•How to bridge the internal – cross-border migration divide?
•What can or should be done to promote domestic political interests/advocacy
on migration and health issues?
•What is the most effective strategy for linking migration and developmental /
planning concerns?
• Integrated development plans, district health plans, growth and
development strategies
•Are regional coordinated responses to communicable diseases and mobility
feasible? (e.g. harmonisation of treatment protocols)

39. Recommendations for action (1)
Migration and health is more than migration and HIV and/or TB.
• Psychosocial and mental health; sexual and reproductive health; determinants of
health
Apply a social determinants of health lens.
• Engage with spaces of vulnerability
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.
• 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

40. Recommendations for action (2)
Mobilise a renewed – and revised - regional conversation for developing a coordinated
response to health and migration.
• SADC Consultancy on Regional Financing Mechanisms; social rights portability:
state and non-state actors; internal and cross-border mobility
Work with the Southern African HIV Clinicians Society.
• Update of guidelines on ART for displaced populations
Engage with SANAC to ensure migration and mobility acknowledged in HIV responses.
• Beyond migrants as a ‘key population’; work towards a migration-aware response
• Provincial Strategic Plans
• Local Strategic Plans
• NSP to guide/inform IDPs and District Health Plans
Learn from and upscale simple interventions.
•Translation and interpretation services in Johannesburg
•Health passports; roadmaps for treatment access; referral letters; treatment packs for
planned movements; patient-held records

41. Acknowledgements
Sex work and migration Local government and urban health
•Marlise Richter •Liz Thomas
•Elsa Oliveira •Pinky Mahlangu
•Greta Schuler •Michelle Peens
•Sisonke sex worker movement
Disability and migration
Migration and health •Matthew Wilhelm-Solomon
•Lorena Nunez
•Roseline Hwati LGBTI and migration
•Adrien Bazolakio •Nadya Husakouskaya
Johannesburg Migrant Health Forum IHRE interns
•Patricia Ndhlovu
•Ng’andwe Chibuye
Lenore Longwe and Sharon Olago for all their support in organising today!

42. Urban vulnerabilities and
migration in Johannesburg:
setting the scene
Jo Vearey, PhD
jo.vearey@wits.ac.za
22nd November 2012

43. Group discussions
Given the developmental mandate of local government, how
could the City of Johannesburg strengthen responses to
migration, urban vulnerabilities and HIV?
Evidence
Problem statement
What has been done?
What is missing?
What are the possible solutions?

44. • Ongoing engagement with the City through dialogues in
2013
• Developing joint research agendas
• Communicating research
• Support to IDP and District Health Plan processes
• Meeting report, research paper and policy brief to be
finalised and distributed to participants
• Share with Migrant Health Forum
• Strengthen City engagement with the Migrant Health
Forum
• Participation in meetings

45. An integrative asylum policy
 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.
 Key challenges to the effective implementation of these
policies:
 Restrictive Immigration Policy;
 Backlog at Department of Home Affairs; and
 Lack of awareness of rights: health facilities.

46. NDOH Financial Directive, 2007

47. NDOH memo,
2006
 Clarifies that
possession of a South
African identity
booklet is NOT a
prerequisite for
eligibility for ART;
 Important for South
African citizens as
well as non-citizens.

48. Letter from
Gauteng DOH,
2008
 April 2008;
 Additional clarification
that South African
identity documents are
not required for health
care, including ART.