The Public Health Crisis We’re Creating: Why Excluding Migrants from Healthcare Threatens Us All
Picture this screnario on Migrants Healthcare in South Africa: A Zimbabwean construction worker in Johannesburg develops a persistent cough. He knows it could be tuberculosis—TB is endemic in his home region—but he’s terrified to seek treatment. He’s heard the stories from other migrants: turned away at clinics, demanded payments they can’t afford, or worse, reported to authorities. So he continues working, coughing, hoping it will pass. Meanwhile, he shares cramped accommodation with twelve other people and takes crowded taxis to construction sites across the city.
This scenario plays out thousands of times across South Africa, creating what researchers are calling a “public health paradox”—where policies designed to protect citizens’ health actually make everyone less safe.
The Numbers Don’t Lie
South Africa hosts approximately 2.9 million international migrants, making it the largest destination for migrants in the Southern African Development Community region. Yet recent research reveals a troubling pattern: migrants with chronic conditions had 0.33 times the odds of non-migrants to have consulted a health service in the preceding year. This means migrants are three times less likely to access healthcare when they need it most.
The timing couldn’t be worse. HIV prevalence varies dramatically across South Africa, ranging from 8% in the Western Cape Province to 22% in KwaZulu-Natal Province, with nearly twice as high prevalence among women (20%) compared to men (12%). Meanwhile, South Africa contributes to an astounding 50% of HIV/TB co-infection cases in Africa, the region with the highest burden globally.
The Legal Contradiction
Here’s where things get particularly complicated. South Africa’s Constitution enshrines the right to health for all, and the National Health Insurance Bill commits the public health system to universal health coverage, including for migrants. On paper, refugees and asylum-seekers should have the same healthcare access as South African citizens.
But reality tells a different story. A comprehensive study of healthcare providers in Gauteng Province found that healthcare provider attitudes and behavior could either advance or impede universal health coverage for migrants. The gap between policy intention and frontline implementation creates what researchers call “policy exclusion or confusion” in the system.
When Healthcare Exclusion Becomes Everyone’s Problem
The mathematics of infectious disease are unforgiving. TB doesn’t check immigration status before it spreads through shared air. HIV doesn’t discriminate based on citizenship when transmitted between sexual partners. When we exclude nearly 3 million people from systematic healthcare, we’re not protecting the remaining population—we’re creating ideal conditions for disease transmission and drug resistance.
Consider the construction worker from our opening scenario. If he has drug-susceptible TB and receives proper treatment, he becomes non-infectious within weeks. If he remains untreated, he could infect 10-15 people annually. If he develops drug-resistant TB from incomplete treatment, those numbers multiply, and the cost of treating drug-resistant cases can be 50-100 times higher than treating drug-susceptible TB.
The Economics of Exclusion
The economic argument for exclusion often centers on resource protection—the idea that limiting healthcare access preserves services for citizens. But this logic falls apart under scrutiny. Emergency treatment for advanced diseases costs exponentially more than preventive care. A single drug-resistant TB case can cost over R100,000 to treat, while standard TB treatment costs under R1,000.
When we add the costs of outbreak investigations, contact tracing, and community-wide treatment programs that become necessary when diseases spread unchecked, the economic case for inclusion becomes overwhelming. Recent data shows 1.3 million people in South Africa are using PrEP for HIV prevention, but these prevention efforts are undermined when excluded populations serve as ongoing transmission sources.
What Healthcare Workers Are Seeing
Research conducted in Gauteng public health facilities reveals the frontline reality of this exclusion. Healthcare providers find themselves caught between professional obligations to provide care and institutional pressures to limit access. This creates what researchers term “social exclusion” within healthcare settings, where the perspectives of healthcare providers on delivering health services to migrants become critical to understanding system functioning.
The psychological toll on healthcare workers shouldn’t be underestimated. Trained to treat illness regardless of a patient’s background, many providers report moral distress when forced to turn away sick individuals due to documentation requirements or payment demands.
Regional Implications
South Africa’s migration patterns reflect broader regional dynamics. While African irregular migration off-continent dropped dramatically in 2024 to 146,000 interceptions compared to 282,000 in 2023, intra-African migration continues at high levels. This means health exclusion policies don’t just affect South Africa—they have implications for the entire Southern African region.
When migrants return home with untreated infections, or when diseases spread back and forth across borders through migrant networks, national health security becomes regional health insecurity.
The Path Forward
The solution isn’t complex in theory, though implementation requires political will. Global health community initiatives have called on governments to provide universal health coverage to all people, regardless of their migratory and/or legal status. This isn’t just humanitarian advocacy—it’s evidence-based public health practice.
Successful models exist. Countries that have implemented migrant-inclusive healthcare policies report better population health outcomes and lower long-term costs than exclusionary systems. The key is shifting from a citizenship-based approach to a residence-based approach, where anyone living in the country has access to essential health services.
What This Means for All of Us
The public health paradox of migrant exclusion reveals a fundamental truth: in an interconnected world, everyone’s health security depends on everyone having access to healthcare. When we exclude nearly 3 million residents from systematic healthcare, we don’t create a protected enclave for citizens—we create conditions that threaten the entire population.
This isn’t about being generous to migrants. It’s about being smart about public health. The viruses and bacteria don’t care about documentation status, and neither should our health policies. Until we recognize that migrant health is public health, we’ll continue creating the very problems our exclusionary policies claim to solve.
The choice is stark: we can continue the current approach and accept the ongoing costs of outbreak management, drug-resistant diseases, and regional health instability. Or we can embrace the evidence-based approach of inclusive healthcare and create genuine health security for everyone living in South Africa.
The construction worker with the cough is still out there, still working, still hoping his symptoms will disappear. But hope isn’t a public health strategy, and exclusion isn’t protection. It’s time our policies reflected that reality.
References
Crush, J. & Tawodzera, G. (2014). Medical xenophobia and Zimbabwean migrant access to public health services in South Africa. Journal of Ethnic and Migration Studies, 40(4), 655-670.
Hanefeld, J., Vearey, J., Lunt, N., Bell, S., Blanchet, K., Duclos, D., … & Pocock, N. (2021). Policy exclusion or confusion? Perspectives on universal health coverage for migrants and refugees in South Africa. Health Policy and Planning, 36(8), 1292-1302.
Human Sciences Research Council. (2023, November 28). New HIV Survey Highlights Progress and Ongoing Disparities in South Africa’s HIV Epidemic. Retrieved from https://hsrc.ac.za/press-releases/hsc/new-hiv-survey-highlights-progress-and-ongoing-disparities-in-south-africas-hiv-epidemic/
Migration Data Portal. (2024). Migration Data in the Southern African Development Community (SADC). Retrieved from https://www.migrationdataportal.org/regional-data-overview/southern-africa
Sonke Gender Justice. (2021, December 10). What does the law say about migrants and refugees accessing healthcare in South Africa? Retrieved from https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/what-does-the-law-say-about-migrants-and-refugees-accessing-healthcare-in-south-africa/
Vearey, J., Hui, C., & Hills, L. (2021). An analysis of migration and implications for health in government policy of South Africa. International Journal for Equity in Health, 20(1), 1-14.
Wabiri, N., Chersich, M., Zuma, K., Blaauw, D., Goudge, J., & Dwane, N. (2021). Internal migration and health in South Africa: determinants of healthcare utilisation in a young adult cohort. BMC Public Health, 21(1), 1-12.
Wahlberg, A., Wambi, R., Berhane, N., Noor, R. A., & Wafula, S. T. (2021). Social exclusion and the perspectives of health care providers on migrants in Gauteng public health facilities, South Africa. PLOS One, 16(12), e0244080.
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