When Chronic Illness Meets Barriers: Migrants Struggling to Access Medication in South Africa

A human story, and why it matters

In early 2025, a 34‑year-old Zimbabwean woman — we’ll call her “Amina” — living in Johannesburg was diagnosed with hypertension. After losing her job, she could no longer afford private care. At her local public clinic, staff turned her away twice because she lacked South African identity documentation. Consequently, she skipped doses for weeks, and her blood pressure spiked. Eventually, she suffered a hypertensive crisis and was hospitalized with a stroke. After a prolonged stay, she survived but now depends on others to manage her medication and cannot return to work.

Amina’s story reflects a broader crisis. Across Gauteng, KwaZulu‑Natal, Tshwane, and other urban centers, migrants — including asylum seekers, refugees, and undocumented persons — frequently face denial of medication for chronic diseases. Such disruptions carry serious individual, public health, and social consequences. This post explores what happens when migrants with chronic diseases cannot access affordable medication, including risks of self-medication, disease progression, and community health consequences. It also examines policy gaps, highlights real anonymized examples, and offers evidence-based solutions.

Policy and legal context: rights in theory, barriers in practice

Formal rights and legal guarantees

The National Health Act and constitutional provisions (Section 27) guarantee healthcare for everyone, regardless of nationality or documentation status. Moreover, a 2022 IOM Southern Africa review confirmed that migrants without South African identity documents should not be prohibited from accessing essential treatment, including antiretroviral therapy (ART) and other chronic care. Additionally, free basic care is guaranteed for pregnant and lactating women, as well as children under six.

Despite these protections, migrants face persistent obstacles. Administrative discretion, unclear facility-level guidelines, and misinterpretation of policies often prevent access. Furthermore, anti-immigrant groups sometimes block clinic entrances, creating social and legal barriers simultaneously.

Reality on the ground: denial, discrimination, and out-of-pocket costs

A 2024 qualitative study among 13 undocumented Zimbabwean migrants in Pretoria revealed that participants were often refused subsidized public care. They described experiences of medical xenophobia, humiliation, and denial of treatment due to missing documentation. As a result, many turned to self-medication or shared leftover medicines within social networks. Despite legal guarantees, undocumented migrants often cannot access quality care comparable to South Africans.

Consequences of disrupted medication: individual and public health risks

Self-medication and under-dosage

When migrants cannot rely on formal health services or medicine supply, self-medication often becomes the default. Some consult pharmacists without prescriptions, while others borrow leftover medication from friends. Such practices carry serious risks. For instance, incorrect dosing may fail to control chronic disease, cause drug interactions, or, in cases of HIV or TB, promote resistance. Additionally, fear of stigma or deportation can delay care-seeking further, worsening outcomes.

Disease progression and preventable complications

Interruptions in treatment can quickly escalate into serious health outcomes. Uncontrolled hypertension may result in stroke or kidney damage. Poorly managed diabetes increases the risk of neuropathy, renal failure, and amputations. Disrupted ART can lead to viral rebound and opportunistic infections. Additionally, interrupted TB treatment increases the risk of multidrug resistance and community transmission.

These scenarios highlight that exclusion harms not only individuals but also public health. For infectious diseases, treatment discontinuity can undermine decades of progress in prevention and care.

Public health and health system costs

Untreated or poorly managed chronic disease increases demand for emergency and tertiary care, which is more expensive and resource-intensive. For example, hypertensive crises or advanced HIV complications require hospitalization. Moreover, interrupted treatment for HIV and TB elevates the risk of outbreaks and drug resistance. Finally, exclusion impedes disease surveillance: when migrants avoid or are turned away from clinics, health systems lose critical data, undermining epidemic control.

Anonymized examples from migrants and practitioners

Example 1: “J.” — living with HIV in Tshwane

“J.” is a 28-year-old male asylum seeker from the Democratic Republic of Congo. He had been on ART for two years. After his permit expired, he lost access to his clinic. Local xenophobic protests blocked entrances, and he missed ART for three weeks. Unable to buy ARVs privately, he borrowed leftover pills from a friend. Consequently, his viral load increased, and he developed recurrent opportunistic infections.

Example 2: “L.” — diabetic and undocumented in Johannesburg

“L.” is a 45-year-old male migrant from Mozambique living without documentation. After losing informal work, he could not afford private care. When he visited a public clinic, staff requested a South African ID card and refused service. He stopped insulin injections for over a month. Eventually, he developed a foot ulcer, which became infected, requiring aggressive hospital treatment — an avoidable complication of interrupted chronic care.

Why these barriers persist

Institutionalized xenophobia and administrative discretion

Although laws guarantee universal access, frontline discrimination remains widespread. A 2024 study in Pretoria concluded that medical xenophobia is “institutionalized and embedded” in the healthcare system. Staff often operate without clear guidance and rely on personal discretion, sometimes denying care to migrants. Anti-immigrant groups exacerbate this problem, physically blocking access in some facilities.

Policy shifts and legal liminality

Recent legislation, including the 2023 National Health Insurance (NHI) Act and the 2024 White Paper on Citizenship, Immigration, and Refugee Protection, has narrowed access for asylum seekers, refugees, and undocumented migrants. Even constitutional obligations fail to protect migrants in practice. These developments highlight a gap between legal rights and practical access.

Poverty, precarity, and social networks as coping strategies

Migrants frequently live in informal settlements, work low-paid jobs, and lack insurance. Consequently, they rely on social networks: sharing leftover medication, consulting street-level pharmacists, or delaying care. While these strategies provide temporary relief, they carry high health risks and do not ensure long-term well-being.

Promising models and NGO-led interventions

Despite systemic barriers, some initiatives show promise:

MSF Tshwane Migrant Project: Provides medical, psychosocial, and social support for migrants excluded from public services.
COVID-19 vaccination campaigns for migrants: Demonstrated feasibility of inclusive public health interventions.
Advocacy efforts: Civil society groups push for amendments to NHI proposals to explicitly protect migrant access to essential care.

These examples indicate that inclusive, rights-based care is feasible even in resource-constrained environments.

Policy gaps and structural weaknesses

Analysis reveals five interlocking problems:

Legal and policy contradictions: Constitutional rights versus newer exclusionary laws.
Lack of implementation guidelines: Facilities often lack clear directives on treating undocumented migrants.
Institutionalized xenophobia: Discrimination and extra-legal fees persist despite legal protections.
Economic vulnerability: Migrants cannot afford private care or medications.
Interrupted continuity of care: Movement across facilities or provinces leads to lost records and treatment disruption.

Without addressing these gaps, interventions will remain piecemeal and unsustainable.

Recommendations: a roadmap for action (2026–2028)

For national and provincial health authorities

Issue binding implementation guidelines: Mandate chronic care for all, regardless of documentation, and train staff to reduce discrimination. Timeline: 6 months.
Strengthen health information systems: Develop anonymous or coded patient records for migrants to maintain continuity across facilities. Timeline: Pilot 12 months; scale by 2028.
Allocate dedicated budgets: Ensure funding for migrant-inclusive chronic care under NHI.

For NGOs and community organizations

Expand migrant-friendly clinics: Provide chronic disease management and social support.
Advocacy and legal action: Push for policy amendments and safeguard migrant health rights.
Community education and peer support: Empower migrants with information on rights and adherence support networks.

For researchers and public health practitioners

Collect robust data: Track chronic disease prevalence, treatment interruption, and outcomes among migrants.
Implementation research: Evaluate NGO-led clinics and outreach programs for effectiveness and scalability.

Conclusion

When migrants cannot access affordable medication, they face self-medication, interrupted treatment, disease progression, preventable complications, and death. These outcomes not only harm individuals but also undermine public health and increase system costs.

South Africa legally guarantees universal health rights, yet systemic barriers prevent migrants from exercising these rights. To uphold social justice and public health, coordinated action is essential. Departments of Health must issue clear guidelines; NGOs must expand migrant-friendly services; researchers must fill data gaps; and civil society must hold institutions accountable.

Only through inclusive, rights-based policies and interventions can chronic disease care in South Africa reach everyone who lives here.

Limitations and research gaps

Existing research is limited, particularly large-scale quantitative data on chronic disease prevalence and treatment adherence among migrants. Most data comes from small studies or NGO reports. Longitudinal research is urgently needed to understand long-term health outcomes and system costs.