Undocumented Migrants and Health Access in Gauteng: A Public Health Analysis

Opening: Human Stories and Stark Statistics

In a crowded public clinic in Soweto, a pregnant Congolese woman, undocumented, waited for hours. She was turned away by vigilante group members demanding identification. Consequently, she had to seek care at a private hospital, which she could not afford. Unfortunately, her story is not unique. Anti-migrant groups, such as Operation Dudula, have blocked foreigners from accessing clinics across Gauteng Province, threatening both health and human rights.

Statistics highlight the problem. A recent study found that 5.5% of in-migrant youths in Gauteng reported medical exclusion, compared to 4.2% of immigrant youths. These figures indicate systemic barriers rather than isolated incidents. Therefore, undocumented migrants face significant challenges that affect both public health and social justice.

Legal and Policy Framework

Constitutional Protections

South Africa’s Constitution, Section 27, guarantees the right to health care for everyone, regardless of nationality or documentation. In particular, Section 27(3) mandates that emergency medical treatment cannot be denied to anyone. Consequently, all migrants, including the undocumented, should receive urgent care.

National Health Act and NHI Policies

The National Health Act reinforces the provision of primary care services to all. However, the National Health Insurance (NHI) Act, 2023, restricts some “illegal foreigners” to emergency and communicable disease services, narrowing access compared to previous norms. This restriction has already created confusion among health facilities and staff.

Court Rulings and Civil Society Advocacy

In 2023, a High Court ruling declared unlawful a 2020 policy that denied free public health care to pregnant and lactating migrant women and children under six, regardless of documentation. The court ordered public facilities to display notices informing patients of these rights. Civil society organizations swiftly supported the ruling, emphasizing that health exclusion based on nationality violates constitutional and human rights principles.

Empirical Evidence and Intersectional Perspectives

Medical Xenophobia and Health Service Exclusion

Research confirms that medical xenophobia remains pervasive. For instance, a 2023 PLOS ONE study found that migrant youths reported discrimination, denial of services, and low satisfaction with care. Similarly, a Southern Africa working paper documented that undocumented migrants often avoid hospitals due to fear of being turned away or reported.

Intersectional Factors

Gender: Zimbabwean migrant women in Johannesburg face higher barriers to antenatal care, verbal abuse, and denial of services.
Age: Young migrants experience stigma and social phobia, reducing their willingness to seek care.
Nationality and Documentation: Undocumented Zimbabweans in Tshwane face financial barriers and documentation demands that limit access.
Children: Children under six are constitutionally protected, yet families often avoid care due to fear of being questioned.

Public Health Implications

Denying care increases risks for communicable diseases such as TB and HIV. Moreover, vigilante blockades, including by Operation Dudula, pose broader public health hazards, as sick individuals are prevented from receiving timely treatment.

Anonymized Case Studies

Case 1: “Amina”

A 28-year-old Congolese woman, undocumented and pregnant, tried to access antenatal care in Johannesburg. Operation Dudula members demanded her ID at the clinic entrance. Consequently, she delayed care until an emergency in her third trimester.

Case 2: “Joseph”

A 19-year-old Zimbabwean migrant with chronic asthma avoided regular clinic visits after staff demanded proof of residence or payment. This reluctance increased his risk for severe exacerbations.

Case 3: “Maria”

A 3-year-old child, born in South Africa to undocumented parents, occasionally missed well-child visits. Although legally entitled to care, the family feared discrimination. Eventually, the child accessed care, but the experience caused significant stress.

Root Causes and Barriers

Medical Xenophobia

Discriminatory attitudes and practices of health workers discourage migrants from seeking care. For instance, some staff demand identification or payment upfront, violating constitutional rights.

Policy Ambiguity and Restrictive Regulations

The NHI Act’s restrictive language limits services for certain categories of undocumented migrants. Additionally, administrative discretion causes inconsistent application across clinics.

Weak Enforcement and Vigilante Interference

Although the 2023 High Court ruling protects vulnerable groups, not all clinics display mandated notices. Meanwhile, Operation Dudula actively blocks migrants, undermining human rights and public health.

Financial and Data Gaps

Health departments cannot reclaim treatment costs from migrants’ countries of origin. Furthermore, lack of disaggregated data on nationality and documentation status hampers planning and monitoring.

Fear and Structural Vulnerability

Undocumented migrants often avoid formal health systems due to fear of detention or deportation. Bureaucratic delays in residency or asylum status further erode trust in public care.

Innovative Responses

Civil Society Legal Advocacy

Organizations like SECTION27 successfully challenged exclusionary policies in court, restoring rights for pregnant women, lactating mothers, and children under six.

Community Accountability

The South African Human Rights Commission (SAHRC) condemns vigilante actions and calls for police protection at clinics.

Research and Monitoring

Studies by Harerimana et al., Walker & Vearey, and Akokuwebe provide data on medical exclusion and xenophobia, informing policy reforms.

Grassroots Health Initiatives

NGOs like the Scalabrini Centre provide paralegal support and health navigation services, helping undocumented migrants understand and assert their rights.

Recommendations

Stakeholder	Recommendations	Timeline
National Government	Clarify NHI provisions for undocumented migrants; develop cost-recovery framework; mandate data collection on nationality/status; issue directive reinforcing court ruling.	0–12 months
Gauteng Provincial Health	Display court-ordered posters; train health workers in non-discriminatory care; establish grievance mechanisms; partner with NGOs for outreach.	3–9 months
Law Enforcement / Human Rights Bodies	Monitor and prevent vigilante clinic blockades; enforce legal protections for migrants and staff.	3–12 months
Civil Society / NGOs	Scale up paralegal and health navigation programs; conduct awareness campaigns; engage in strategic litigation; monitor and report violations.	Ongoing
Academic / Research Institutions	Conduct evaluations of NHI inclusion; study intersectional outcomes; co-produce research with migrant communities.	12–36 months

Ethical Considerations and Limitations

Dignity and confidentiality: Any intervention must respect migrants’ rights and privacy.
Sustainability: Long-term solutions must be state-led, not solely reliant on NGOs or donor funding.
Research gaps: Limited data exists on older undocumented adults and migrants with chronic diseases. Future studies should address these gaps.

Call to Action

Policy Makers: Reinforce and update laws to ensure true universal health care.
Health Practitioners: Uphold ethical duty to treat all patients, regardless of status.
Civil Society: Advocate, monitor, and empower migrants to claim their rights.
Researchers: Conduct rigorous, ethical studies amplifying migrants’ voices.

Conclusion

Undocumented African migrants in Gauteng face systemic barriers to health care, including medical xenophobia, policy ambiguity, vigilante interference, and data gaps. While legal frameworks provide protections, implementation is uneven. Coordinated action by government, civil society, researchers, and health practitioners is essential to ensure health care access, protect human rights, and strengthen public health outcomes.

Harerimana, A., Pillay, J. D., & Mchunu, G. Medical xenophobia and healthcare exclusion of refugees and migrants in Africa: A scoping review. Journal of Migration & Health, 12, 100343 (2025). DOI: 10.1016/j.jmh.2025.100343. JCU Research Online+1
Walker, R. & Vearey, J. “Closing the gap in the wrong direction”: migration, health policy, and the exclusion of asylum seekers, refugees and undocumented migrants from healthcare access in South Africa. BMC Public Health 25, 3877 (2025). DOI: 10.1186/s12889-025-24751-4. BioMed Central+1
Akokuwebe, M. E., Osuafor, G. N., Likoko, S., & Idemudia, E. S. Health services satisfaction and medical exclusion among migrant youths in Gauteng Province of South Africa: A cross‑sectional analysis of the GCRO survey (2017–2018). PLOS ONE 18 (11): e0293958 (2023). DOI: 10.1371/journal.pone.0293958. PMC+1
Walker, R., Vearey, J., Said Bile, A., & Lolimo, G. L. Upholding the Right to Health in Contexts of Displacement: A Whole-of-Route Policy Analysis in South Africa, Kenya, Somalia, and the Democratic Republic of Congo. International Journal of Environmental Research and Public Health 22, 1042 (2025). DOI: 10.3390/ijerph22071042. MDPI
Akokuwebe, M. E., Likoko, S., & Osuafor, G. N., et al. Determinants of life satisfaction among migrants in South Africa: an analysis of the GCRO’s quality of life survey (2009–2021). BMC Public Health 23, 2030 (2023). DOI: 10.1186/s12889-023-16868-1. BioMed Central
Health‑e News, Pushback Against Foreign Nationals Using Public Health Facilities (2025). Available at: Health‑e News article. health-e.org.za

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