A dangerous prognosis: vulnerable migrants can no longer access essential health services


In Eshowe, in South Africa’s KwaZulu-Natal province, MSF has helped the health department set up help desks outside clinics – triage points where everyone who wants to enter is screened using a screening tool, and possible COVID-19 patients are then referred to a separate service. tent for testing.


Tuesday, September 6, 2022 — In South Africa, reports of xenophobic incidents are a daily reality, but migrants’ use of the country’s strained public health system is now a hot topic as impartial access to healthcare has become very politicized in recent days. .

By Dr. Tasanya Chinsamy, Head of Medical Activities of the Doctors Without Borders (MSF) Tshwane Migrant Health Access Project and Claire Waterhouse, Head of MSF’s Operational Support Unit in Southern Africa

To achieve a political goal, Operation Dudula anti-migrant protesters targeted the sick and vulnerable outside Kalafong Hospital in Tshwane where they profiled patients, allegedly by skin color and the tongue, pushing back all those who did not succeed in the gathering. Protesters also targeted Hillbrow Community Health Center where they intimidated migrants accessing healthcare. Days before, at a hospital in Limpopo, MEC for Health Dr Phophi Ramathuba was filmed berating a Zimbabwean patient, saying migrants are “killing my health system”. In a television interview, a prominent politician, Gayton McKenzie, said he would cut off a foreign national’s oxygen to save a South African.

After days of silence, the The South African government finally publicly condemned the xenophobic demonstrations of Operation Dudula, emphasizing that “the right to access basic health services is a fundamental human right guaranteed by the Constitution…which provides that everyone in the country, regardless of nationality or status of papers, can access health care. ”

This statement is welcome, but is it a sincere position when, in the province of Gauteng, the guardians of the public health system have undermined this right of access to care for certain groups of migrants?

Unlike anti-migrant protesters outside hospitals and clinics, who use physical intimidation to turn migrants away, some hospitals in Gauteng are using policies that directly contradict South Africa’s national health law,[i] which stipulates free health care for pregnant women and children under the age of six.

Working on HIV and TB care in South Africa since 2000, Médecins Sans Frontières (MSF) began in 2018 to provide basic primary health and psychosocial services to vulnerable communities around Tshwane CBD and outlying areas. where migrants live. We have witnessed a marked increase in cases where migrants or asylum seekers who do not have formal refugee status are excluded from the tertiary level due to the imposition of fees.

In some of Tshwane’s major tertiary hospitals, non-South African pregnant and nursing women and children under six regularly face difficulties accessing care if they do not have the proper documentation and are not able to afford the higher fees for the essential services they need. At the root of these rejections is a document known as “Circular 27 of 2020”, issued by the Gauteng Department of Health (DoH), which contains ambiguous wording around the “scheduling of fees for hospital service”.

Although the circular itself states that all pregnant women and children under the age of six “irrespective of any other classification” can be exempted from paying fees if they cannot afford to pay, these are mainly South African patients with identity documents and documented refugees whose ability to pay is assessed. Some senior hospital officials view this circular as an instruction from the Gauteng DoH to deny free (or lower-cost) resource testing and services to pregnant and nursing women and children if they are asylum seekers, people without papers or people affected by statelessness – unless they need emergency services. This contradicts the National Health Act.

Many countries, including South Africa, have adopted progressive national policies of not charging pregnant women and children, but the reversal of Gauteng’s health system down this path must be confronted to protect impartial medical care. that save and protect all lives.

This is why MSF is supporting the lawsuit against the Gauteng DoH in the Johannesburg High Court by SECTION27 with three patients who were denied treatment. Together, we call on the Gauteng DoH to clarify its ambiguous payment policies that have been used to impede access to care. We call on the Court to reaffirm access to free health care for all pregnant and breastfeeding women and children under six – including asylum seekers, undocumented people and people affected by statelessness. We hope the court will declare Gauteng’s obstructive regulations an illegal breach of national health law.

Until then, the status quo remains deeply distressing for patients.

Eldred Kaseke*, a 33-year-old asylum seeker, is one of at least 13 users of MSF services who have experienced the negative effects of Gauteng’s regulations in the past 12 months. At 29 weeks pregnant and having already suffered a miscarriage and the death of another child shortly after birth, she was found to have high blood sugar during a clinic visit for her current pregnancy. Hers is considered a ‘high-risk pregnancy’, meaning potential complications could affect mother, baby or both. Eldred was duly referred to a secondary level hospital who deemed her case too complex for them and referred her to a tertiary hospital in Gauteng for specialist examination.

After a visit to the tertiary hospital, Eldred was told that due to her status as an asylum seeker she would have to pay 848 rand for the initial consultation and follow-up visit – and that she would have to pay more for any medication and other consultations. throughout her pregnancy. Eldred is unemployed and poorly supported and simply cannot afford these fees. Rejected and increasingly worried about the risks to herself and her unborn child, Eldred decided to leave Gauteng and seek help in the Eastern Cape, where she had previously been seen in a tertiary hospital.

Gauteng’s public health system failed Eldred by forcing her to pay high fees for essential antenatal healthcare to which she is fully entitled under national health law and which was not available at the level primary health clinics. Gauteng health authorities have also imposed costs and health risks on her by leaving her no choice but to travel to the Eastern Cape in the hope of getting the treatment she needs.

Today, Eldred is 4 weeks away from full term pregnancy. The uncertainty of where she can safely give birth weighs on her.

The effective denial of access to child and maternal health services for people like Eldred in Gauteng has many serious and negative health consequences. Impeding access to timely, quality health services increases the risk of preventable maternal illness and death. Preventing women from routinely accessing the appropriate level of prenatal care during pregnancy is a surefire way to miss early opportunities to identify and minimize pregnancy-related health risks. More fundamentally, Gauteng’s healthcare system betrays medical ethics by endangering life rather than protecting and saving life, obstructing care with high fees. This is ultimately counterproductive to the healthcare system, as it is much more cost-effective to provide routine prenatal care and planned delivery for complex cases than to let vulnerable patients deteriorate until they die. ‘they need resource-intensive emergency care and need to be hospitalized, because no hospital can deny them urgent care.

Demanding payment for curative care in public hospitals, especially in an atmosphere of xenophobic intimidation, deters vulnerable people from seeking preventive services because they will avoid health facilities and the risk of confrontation. This has major implications for antenatal care coverage for pregnant women or those who have access to contraceptive and family planning services. It also has adverse effects on immunization rates and access to other essential health services for young children.

This politicization of health care must stop. The Gauteng DoH must urgently provide clarity to hospital managers on the implementation of ‘Circular 27 of 2020’, while affirming a commitment to universal access to essential care, regardless of nationality or status of immigrants. The department must find lasting solutions in the form of properly managed and resourced facilities and end the obstruction of care for people like Eldred by ensuring equitable access to health care for all people living in South Africa. South. Otherwise, darker days are coming.

*Name changed to protect his identity

[i] On July 1, 1994, under National Health Act 63 of 1977, the Minister of Health published Notice 657 of 1994 in the Government Gazette. The notice states that from June 1, 1994, free health services shall be provided to the following persons: a) pregnant women (from confirmation of pregnancy until 42 days after termination or if a complication occurs until it is Section 27 of the Constitution of South Africa.

Images and text provided by MSF Southern Africa.

The opinions expressed are those of the author and do not reflect the official policy or position of The Daily Vox.

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