The Public Health Case
A Crisis at the Clinic Door
On a humid morning in Nellmapius, Pretoria, Grace (not her real name) arrives at her local clinic carrying her nine-month-old daughter, burning with fever. At the triage desk, the nurse asks for a South African ID. Grace presents her Zimbabwean passport, its documentation expired. As a result, the nurse turns her away, citing policy.
What the clinic does not know is that Grace’s daughter has tuberculosis—an airborne disease that poses a serious public health risk. Consequently, the infection threatens everyone in that overcrowded waiting room, documented or not.
Scenes like this unfold daily across South African healthcare facilities. More importantly, they expose the fundamental tension at the heart of the National Health Insurance (NHI) Act, signed into law on 15 May 2024. Policymakers now face a critical question: how can South Africa reconcile universal health coverage with resource constraints while safeguarding public health?
What the NHI Act Says About Migrants
Section 4 of the NHI Act restricts access for asylum seekers and undocumented migrants. Under the Act, these groups may only receive emergency medical services and treatment for notifiable conditions of public health concern. At the same time, all children are entitled to basic healthcare services regardless of origin.
However, this framework contains a significant public health loophole. HIV is not classified as a notifiable disease in South Africa. Consequently, asylum seekers and undocumented migrants are excluded from life-saving antiretroviral treatment under current NHI provisions.
Understanding South Africa’s Migration Reality
The Numbers Tell a Different Story
Contrary to popular perception, cross-border migrants make up only 3–4% of South Africa’s population. By comparison, internal migrants—people moving between provinces—account for approximately 7%, nearly twice as many.
According to Statistics South Africa’s Migration Profile Report 2023, net migration stood at 1.84 per 1,000 persons. Meanwhile, continent-wide data indicate that approximately 43 million African migrants were documented in 2024, with around one million new migrants recorded that year.
Where Migrants Live and Seek Care
Migration is not evenly distributed across the country. Gauteng hosts the largest numbers of both internal and cross-border migrants, with Johannesburg serving as the primary destination for international migrants. In addition, Cape Town, Durban, and Limpopo’s Vhembe District—bordering Zimbabwe—also host significant migrant populations.
As a result, health system responses must be geographically targeted rather than uniform.
Who Migrates and Why
Recent studies reveal important patterns. At Johannesburg recruitment sites, migrants comprised nearly two-thirds of participants, with internal migrants outnumbering international migrants by a factor of two.
Notably, migrants with chronic conditions had only one-third the odds of consulting health services compared to non-migrants in the previous year. Consequently, forced migrants often struggle to access public healthcare despite being legally eligible. These populations account for roughly 9% of documented immigrants.
The Healthy Migrant Paradox
Research frequently describes a “healthy migrant effect.” Most migrants relocate for work, education, or safety—not healthcare. As a result, they often arrive relatively healthy, as long-distance migration requires physical resilience.
Over time, however, this advantage erodes. Overcrowded housing, hazardous working conditions, food insecurity, and limited healthcare access gradually undermine health outcomes.
The Inclusion Debate: Public Health at Stake
Why Comprehensive Coverage Protects Everyone
Universal health coverage (UHC) lies at the core of the NHI vision. Fundamentally, UHC holds that everyone should access quality health services without financial hardship, regardless of legal status.
In 2023, the United Nations reaffirmed this principle at its High-Level Meeting on UHC, emphasizing national responsibility to ensure inclusive coverage. Importantly, this commitment explicitly includes migrants.
The Infectious Disease Argument
Tuberculosis Shows Why Exclusion Fails
Tuberculosis illustrates the dangers of exclusionary policies. Southern Africa has the highest TB incidence globally—591 per 100,000 people, compared to a global average of 126.
Migration plays a key role in TB transmission. Movement introduces infection into new settings while increasing contact between infectious and susceptible individuals. Historically, cross-border labour migration has driven TB epidemics since the discovery of gold in 1886. Today, similar patterns persist in mining and informal labour sectors.
Therefore, TB control demands migration-aware responses that transcend documentation status.
HIV Treatment Gaps Create Systemic Risk
Equally concerning is the NHI Act’s exclusion of HIV treatment for undocumented migrants. Because HIV is not notifiable, these populations cannot access antiretroviral therapy under current provisions.
This restriction contradicts existing policy. Since 2007, Department of Health directives have guaranteed free ART to refugees and asylum seekers regardless of documentation. Moreover, evidence shows that migrants on ART achieve outcomes comparable to—or better than—citizens when access is uninterrupted.
Cost Arguments: Myths Versus Reality
Do Migrants Pay for Healthcare?
Opponents of inclusion often cite cost pressures. Yet evidence challenges this assumption. Non-South Africans pay for healthcare through the same means-tested hospital fee system as citizens. In fact, undocumented migrants from non-SADC countries pay the highest fees.
Furthermore, many migrants contribute positively to the fiscal balance through taxes, particularly in formal employment sectors.
Understanding Actual Healthcare Utilisation
Contrary to popular belief, migrants often use public healthcare less than non-migrants. While 97% of non-migrant rural residents rely on government facilities, many migrants turn to private care (31%) or traditional healers (25%).
As a result, migrants frequently avoid overburdening public services altogether.
Prevention Costs Less Than Crisis Care
From an economic perspective, exclusion is inefficient. Untreated TB spreads. Unmanaged HIV progresses to advanced disease requiring costly hospitalisation. In contrast, early treatment and prevention are far more cost-effective.
Simply put, emergency care costs more than routine clinic visits, and advanced disease costs more than prevention.
Evidence From the Ground: Three Case Studies
Case Study 1: Maria and the HIV Treatment Gap
Maria, a 34-year-old Mozambican domestic worker in Johannesburg, learned she was HIV-positive three years ago. Initially, she accessed ART at a public clinic. However, when her asylum permit expired due to Home Affairs backlogs, her access was curtailed.
Following the NHI Act’s passage, clinic staff informed her that new restrictions applied. Today, she relies on a faith-based organisation for intermittent medication. Her CD4 count has fallen, and she fears drug resistance.
Maria’s experience demonstrates how policy shifts can undermine both individual and public health.
Case Study 2: Joseph, Internal Migration, and TB
Joseph, a 42-year-old mine contractor from the Eastern Cape, works in Gauteng and returns home monthly. After developing a chronic cough, he struggled to maintain TB treatment due to frequent movement.
Research confirms that mobility disrupts TB treatment completion. In Joseph’s case, delayed diagnosis led to transmission across provinces. His story shows that mobility itself—not citizenship alone—poses a major health system challenge.
Case Study 3: Amina and Maternity Care
Amina, a Somali refugee in Cape Town, arrived pregnant with valid documentation. Despite a 2023 High Court ruling guaranteeing free maternity care regardless of nationality, she encountered language barriers, documentation demands, and xenophobic attitudes.
Only with NGO support did she receive care. Her case illustrates the persistent gap between legal rights and lived realities.
Policy Gaps and Implementation Challenges
Conflicting Legal Frameworks
South Africa’s Constitution guarantees healthcare access to everyone. The National Health Act provides free primary care without nationality restrictions, while the Refugees Act ensures parity with citizens.
Yet the Immigration Act requires reporting undocumented migrants, creating fear, confusion, and “medical xenophobia” within facilities.
Documentation Barriers
Home Affairs backlogs leave many migrants undocumented for years. Financial barriers exacerbate the problem, with passport and visa costs exceeding R3,500. As a result, administrative failure becomes a health barrier.
Provider Attitudes and Language Barriers
Studies in Gauteng reveal widespread discrimination, lack of training, and linguistic exclusion. Expecting migrants to speak local languages across provinces compounds inequity and undermines care quality.
Innovative Solutions That Work
Programs such as the Johannesburg Migrant Health Forum demonstrate what is possible. Through interpreter services and community partnerships, clinics serve over 11,000 migrants monthly without overwhelming resources.
Similarly, MSF’s Khayelitsha model shows how integrated, community-based HIV and TB care benefits diverse populations.
Cross-border TB screening initiatives further prove that regional cooperation saves lives and money.
Conclusion: A Public Health Imperative
South Africa’s NHI represents a historic opportunity. However, universal health coverage cannot be selective.
The evidence is unequivocal: diseases do not check documentation. Excluding migrants undermines public health, increases costs, and violates constitutional and international obligations.
Ultimately, the question is not whether South Africa can afford to include migrants in the NHI. The real question is whether it can afford not to.
Inclusive health policy is not charity. It is sound public health, economic sense, and constitutional duty.
Universal must mean universal. No one left behind.
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