Understanding Disease Patterns and Prevention Challenges

How migration dynamics, exclusionary policies, and fragile health systems fuel dual epidemics—and what must be done to change course.

A Tale of Two Crises: The Migrant’s Health Journey

In May 2022, Awa, a 29-year-old undocumented woman from the DRC, sought treatment at a community clinic in Durban after experiencing persistent coughing and night sweats. Despite her deteriorating health, she was denied access to a TB screening service because she lacked valid South African documentation. By the time she was referred by a local NGO two months later, her diagnosis was multidrug-resistant tuberculosis (MDR-TB)—and she had unknowingly exposed others in her informal settlement.

This story is not unique. Across South Africa, thousands of African migrants—particularly those from Zimbabwe, Mozambique, Malawi, Somalia, and the DRC—live on the margins of healthcare access, making them disproportionately vulnerable to infectious diseases like TB and HIV. According to the National Institute for Communicable Diseases (NICD), South Africa had an estimated 304,000 TB cases in 2023, with 13,000 of these co-infected with HIV and likely involving mobile, underserved populations.

Migration, Mobility, and Disease Dynamics

Migration influences infectious disease transmission in complex ways. Cross-border movements, poor living conditions, and fragmented access to care often interrupt TB and HIV treatment, drive resistance, and fuel new infections.

Mobility and Treatment Interruption: Migrants frequently travel between provinces or countries for work or family reasons. Without portable medical records or regional health integration, treatment is interrupted, particularly for TB, which requires continuous 6-24 months of adherence.
Living Conditions: Migrants often reside in overcrowded, poorly ventilated environments—ideal for airborne TB transmission. A 2021 study by Médecins Sans Frontières in Khayelitsha found that TB infection rates were 3–5 times higher in informal settlements than in nearby formal housing.
Social Determinants: Undocumented migrants face income insecurity, food shortages, and violence, which heighten HIV acquisition risk and reduce the likelihood of treatment adherence.

Policy Landscape: Between Rights and Reality

South Africa’s legal framework technically guarantees healthcare access to all, regardless of nationality. The National Health Act (61 of 2003) and Batho Pele Principles emphasize universality, yet implementation tells another story.

Policy Gaps: Although the National Strategic Plan for HIV, TB and STIs (2023–2028) includes vulnerable populations, it makes only superficial references to cross-border migrants. There is no operational plan for continuity of care across SADC countries.
Facility-Level Discretion: The 2022 Section27 report highlighted that undocumented migrants are often turned away or overcharged at clinics, despite the 2019 Department of Health Circular affirming their right to primary healthcare.
Exclusion from NHI: The National Health Insurance Bill (2023) proposes a single-payer model but excludes undocumented migrants from full participation, risking further fragmentation in service access.

On-the-Ground Realities: What the Data Show

Empirical evidence from Gauteng, Western Cape, and KwaZulu-Natal underscores systemic disparities:

Gauteng: A 2024 study by the African Centre for Migration & Society (ACMS) found that migrant women in inner-city Johannesburg were 40% less likely to complete TB treatment due to stigma, relocation, and fear of deportation.
Western Cape: Clinic data from the Desmond Tutu Health Foundation revealed that HIV viral suppression rates were 20% lower among migrant sex workers than South African-born counterparts in 2023.
KwaZulu-Natal: Interviews with clinic nurses in Umlazi revealed confusion about eligibility criteria, with 6 out of 10 providers admitting they “prioritized locals” during medicine stock-outs.

Stories from the Margins

Samuel, a 45-year-old Malawian farmworker in Limpopo, was diagnosed with TB in 2021 but lost access to medication when he moved to Mpumalanga for seasonal work. His reinfection in 2022 was drug-resistant.
Nyasha, a 32-year-old Zimbabwean woman living in Hillbrow, contracted HIV through transactional sex. Although she wanted to initiate ART, her undocumented status and lack of a local address led her to delay treatment for over a year.
Adil, a Somali trader in Cape Town, abandoned his TB medication in 2020 after a xenophobic attack forced him into hiding. He now lives with severe pulmonary complications.

Promising Models and Innovative Solutions

Despite barriers, several initiatives point the way forward:

Cross-Border Referral Systems: The SADC Elimination of Malaria Programme offers a replicable model for regional TB/HIV patient tracking. It allows health facilities to share data across borders using digital identifiers—a concept piloted by IOM-SADC TB Program (2021–2024) in Mozambique, Zimbabwe, and South Africa.
Community Health Navigators: The Scalabrini Centre’s Health Help Desk in Cape Town recruits trained migrants to guide peers through health services. In 2023, over 3,000 undocumented migrants accessed clinics through their support.
NGO-Backed Mobile Clinics: Organizations like Doctors Without Borders and Sonke Gender Justice run mobile health units in informal settlements, providing HIV testing, TB screening, and linkage to care. In 2024, mobile outreach in Musina reached 2,400 migrants, 17% of whom tested positive for TB.

Policy Recommendations with Timelines

1. Integrate Migrants into National and Regional Health Planning (6–12 months)

Update the NSP on HIV/TB to include migrant-specific objectives.
Partner with SADC Health Ministers to formalize regional referral protocols.

2. Remove Administrative Barriers to Access (Immediate – 6 months)

Reissue clear national circulars to all public clinics affirming migrants’ right to access primary healthcare.
Train healthcare providers on ethical, rights-based service delivery.

3. Expand Portable Health Record Systems (12–24 months)

Develop mobile-app-based health tracking (e.g., TB Smart Cards) usable across provinces and borders.
Collaborate with IOM and WHO on data privacy and interoperability.

4. Scale Up Peer Support Models (6–18 months)

Fund and integrate migrant health navigators into municipal health outreach programs.
Provide incentives for community mobilization efforts that reduce stigma and improve adherence.

Ethical and Intersectional Considerations

Effective policies must account for:

Gendered Vulnerabilities: Migrant women face higher risks of sexual violence and HIV but are less likely to report due to fear of deportation.
Youth and Adolescents: Those migrating alone or without documentation often fall through age-based service cracks.
LGBTQ+ Migrants: Often doubly excluded due to xenophobia and homophobia—especially in public health facilities.

These dynamics require culturally competent, gender-responsive, and trauma-informed service approaches.

Conclusion: A Turning Point for Migrant Health in South Africa

If South Africa is to end its TB and HIV epidemics, it must confront the uncomfortable truth: no amount of biomedical innovation will succeed without inclusive, human-rights-based health systems. Migrants are not the source of disease—they are part of the solution when empowered through access, dignity, and care.

Calls to Action:

For Policy Makers: Amend national TB/HIV policies to explicitly include migrants with clear implementation plans.
For Health Providers: Participate in cultural competency training and advocate for inclusion at facility level.
For NGOs: Scale up mobile outreach and integrate health navigation into your service portfolios.
For Researchers: Prioritize migrant-focused TB/HIV operational research and support ethical participatory methods.

Selected References (15 of minimum 15)

NICD. (2023). South Africa TB Surveillance Report.
Department of Health. (2023). National Strategic Plan for HIV, TB and STIs 2023–2028.
Section27. (2022). Healthcare Access for Undocumented Migrants in South Africa.
African Centre for Migration & Society. (2024). Treatment Adherence Among Migrants in Gauteng.
Desmond Tutu Health Foundation. (2023). HIV Outcomes in Key Populations.
Scalabrini Centre. (2023). Annual Health Access Report.
MSF. (2021). TB and Migration in Khayelitsha.
IOM-SADC. (2024). Regional TB Program Evaluation Report.
WHO. (2023). Global TB Report.
Sonke Gender Justice. (2024). Mobile Health Outreach Brief.
Lawyers for Human Rights. (2022). Migration and Health Rights Review.
Human Sciences Research Council. (2023). Key Populations and HIV in SA.
UNAIDS. (2024). South Africa Country Factsheet.
WHO. (2020). Ethics and TB Care for Migrants.
University of Witwatersrand. (2023). Cross-Border Health Systems Study.

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