Dear Health Minister Dr Joe Phaahla,
You recently announced in Parliament that your department will conduct a study on the treatment of foreign nationals at public health facilities in South Africa.
Minister, we welcome your announcement, but it is worth highlighting some complexities.
According to you, it is not foreign nationals but rather undocumented migrants that are the issue. You also singled out foreign nationals (pregnant women) seeking maternity services as the major concern.
Last week you told MPs in the National Council of Provinces’ Select Committee on Health and Social Services that in some cases, people don’t live in South Africa but cross the border to access medical services, particularly maternity services. You said this happens in Tshwane, Johannesburg, and Limpopo. You told MPs that it is estimated that between 40 and 60% of mothers who deliver in some hospitals are undocumented immigrants.
However, part of the problem, Minister is the lack of reliable data about both undocumented and documented foreign nationals in South Africa. We have not been able to find any substantiation for the estimate you quoted.
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When dealing with claims that ‘foreigners burden the healthcare system’, it is important to remember that in South Africa, only 3% of the population are foreign-born, and the number of migrants and refugees using the South African healthcare system is most likely in line with this percentage. In fact, it might well be lower since some foreign-born people would have become South African citizens. Either way, the 40 to 60% estimate you quoted hardly seems plausible – at best it applies only to a few facilities at the extreme end of the scale, at worst it is simply inaccurate.
That said, the study you propose might provide more reliable data on what is happening in maternity wards across the country. This will be very welcome.
Some anecdotes of mistreatment
Minister, you told MPs you asked a team from your department to work with provinces and do a formal assessment as part of a study to get proper records and not just rely on anecdotal evidence to address the issue.
This is good if we want to make evidence-based interventions. However, the faces behind the experiences in our health facilities are also important. Through SECTION27’s Advice Office, we have captured many experiences of foreign nationals who could not access maternal and child health services.
In June 2021, *Maggie (31), an asylum seeker from the Democratic Republic of Congo (DRC), delivered her baby girl at a Pretoria railroad station, assisted by security guards, and watched by several onlookers.
Maggie said she was forced to give birth at Mamelodi train station because she had nowhere else to go. The delivery had followed a five-hour ordeal during which she travelled a total of about 60 kilometres, including a 45-minute train ride from Johannesburg while she was in labour.
Maggie said she had no other choice. She said she had been turned away by two government-run hospitals because she was carrying an asylum seeker permit. After the birth, Maggie and her husband say things got worse. Even though their baby was turning blue, they were sent away from another hospital until they finally found one that would take them in.
Another woman who lives in Johannesburg and is undocumented says she is sitting with a bill for R63 000 after her five-year-old child spent eight months (June 2021 to January 2022) in a Johannesburg hospital for burn wounds. She says her child was discharged but still needs follow-up medical attention, but she avoids going back to the hospital because of demands for payment.
Earlier this year, she went back to the hospital for treatment for herself but was asked to pay a R390 consultation fee first, so she stopped going. “I would beg on the streets at the traffic lights and look for money to buy medicine at the local pharmacy,” she told us. “Even now I am not healed.”
Another woman from Zimbabwe, who has been in South Africa for over ten years, said she was denied maternal care at a clinic while she was pregnant because she is undocumented. She gave birth in October 2021.
“They kept turning me back, giving the excuse that I had no papers, and I didn’t have any money. I was worried because my time was coming closer… When I went to the clinic at seven months, they only gave me a card but did not even book me and told me never to come back,” she said.
She said when she went into labour, she got herself to the clinic. She said she was insulted by staff, but they eventually called an ambulance. The birth was complicated, and she had to have a caesarean.
‘medical tourist mom’ a myth
There is an assumption that all foreign nationals (read black and African) travelling to South Africa are travelling to access public healthcare services. You, minister, yourself told MPs that your department has found in several health facilities, “clear evidence of people from neighbouring countries coming specifically for health services”.
However, it is well documented that foreign nationals often enter the country for a safer life and economic reasons (jobs).
To blame these foreign nationals for government’s own failure to properly organise or manage the public health services, is arguably at most the worst kind of xenophobia and at the very least, blatantly dishonest.
Many of the problems we see in accessing healthcare services are largely due to poor organisation of public services, human resources, and supply management – things that have been simmering for years and which have been affecting both foreign nationals and those born in South Africa who depend on the public health system.
So, the idea of the “medical tourist mom” is little more than a convenient myth, Minister. A clause in the National Health Act allows people travelling for medical care to be charged, although proving women are travelling for medical care would be difficult.
The South African Constitution says the most basic forms of healthcare should be made accessible to all who reside in South Africa. The Act states clearly that all uninsured pregnant and breastfeeding women and children younger than six can receive free healthcare, regardless of their nationality. Spotlight recently published an article explaining what the South African law says about medical xenophobia that you can read here.
Too many health workers, however, for various reasons, are refusing to provide services as required by this legal framework.
It should be stressed that the Immigration Act is very clear that someone providing humanitarian assistance to undocumented individuals cannot be liable for prosecution – that includes everyone from the receptionist to the surgeon. It is not the obligation of healthcare providers to act as immigration officers.
What some label medical xenophobia stems from misconceptions about the impact of migrants on South Africa’s healthcare system, with the public and even many government officials believing that foreign women are burdening the system by coming to the country to give birth. Some migrants and refugees are denied access to healthcare simply because they are foreign nationals. I dread Minister, your recent comments will only make this worse.
What can be done?
The details of the proposed study are still unclear and hopefully, in the coming weeks, you will provide more information. So, as we wait on details and eventually the findings, Minister, there is a range of basic things government can start doing – some of which should have been in place already.
These are some basic things one would expect from this study.
At the very least, Minister, your study should focus, assess, and address medical professionals’ attitudes and knowledge of the rights of migrants/foreign nationals.
Foreign nationals also generally appear to know little about their rights in South Africa. Your study can start by evaluating what measures are in place and if they are sufficient in creating awareness of foreign nationals’ rights as patients. One way to remedy this is by amending existing literature and public education posts on patient rights to include the rights of foreign nationals. There should also be clear communication with contact information and advice on how to report allegations of mistreatment. It is also important to translate this literature and public postings into a language foreign nationals can understand.
Your study should also look at the availability of interpreting services in health facilities. Most healthcare facilities don’t provide interpreters and some foreign nationals, such as those from Somalia or the DRC, have a particularly hard time understanding health information. South Africa’s failure to disseminate health and rights information to these communities leads to failure to access treatment, late diagnoses, and increased morbidity and mortality in these patients.
These are basic things, Minister, that will benefit all patients regardless of nationality.
In an attempt to ensure there is documented evidence of mistreatment and denial of health services to some foreign nationals, your study should also look at existing processes that are in place when treatment is denied. Health authorities should require in cases where service is refused in public health facilities, that this is documented on a form with the name of the person making the decision and the reason why treatment was not provided. The department can also mandate and ensure that all referrals among public health facilities are provided in writing.
At the very least, clear communication is needed from the health department and you, Minister, about the rights of foreign nationals and what staff members should do when foreign nationals seek care. At present, this kind of communication is lacking and so we continue to see people being turned away, even in emergencies.
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Furthermore, we should scrap all policies that exclude foreign nationals – regardless of status – from accessing healthcare, especially vulnerable groups. The department needs to have a “sensitisation programme” to address attitudes of medical staff and conduct mandatory, ongoing training for healthcare staff on the rights of patients, especially foreign nationals.
Minister, you also stressed the costs issue and told MPs that among the proposals suggested to deal with the issue is to send the bill to the patients’ governments or embassies so that they can pay for the services.
It is interesting how this sentiment keeps popping up in government pronouncements on issues around foreign nationals – as an issue of costs and blame for burdening the system and not framed in terms of rights and access. This conveniently enables government (in this case, your department) to dodge accountability by not just misdiagnosing what fuels our crumbling public health system, but also shifting blame to absolve government from its constitutional duty.
Let’s hope that the study you propose Minister will ask the right questions, be rigorously and independently conducted, and once and for all dispel the convenient myths about foreign nationals, that, unfortunately, even you seem to have fallen for.
*Mphahlele is a paralegal at SECTION27’s Advice Office.
NOTE: This is an article written by an employee of SECTION27. Spotlight is published by SECTION27 but is editorially independent, an independence that the editors guard jealously. The views expressed in this article are not necessarily those of Spotlight.