NHI: Understanding the implications of excluding immigrants from health care provision

If you don’t know this by now, I’m not quite sure what rock you’ve been living under, but South Africa is moving towards national health insurance. Whilst in theory I think a lot of us like the idea of cutting out medical aids (yes, please!) there remain a few practicalities that need to be ironed out.

But first, it’s important to note why universal health insurance could be a fantastic move for RSA. At the moment, less than 20% of the population are on medical aid, but 80% of all healthcare specialists work within the private healthcare sector. Post-apartheid, healthcare provision and access in RSA has not become more equitable, and, in theory at least, the NHI could finally address this.

At the end of last year, the National Health Insurance (NHI) White Paper was released. A White Paper is essentially the second step in the process of making an Act. The first is the production of a Green Paper. Comments that are made on the Green Paper are then taken into consideration in the writing of the White Paper which lays out what government is intending to do with the Act. Submissions on the White Paper are then invited (these were to be made by 31 May – the JHB Migrant Health Forum, of which ACMS is a part, made a submission) before a Bill is drafted.

The White Paper says a lot of things that can’t all be discussed in a blog post, and obviously what I’m most interested in is what it says about health care access for migrants (by migrants I’m referring exclusively to non-national, cross-border migrants in this piece).

Currently – according to legislation – everyone physically in South Africa is entitled to free primary health care. This includes the 3.5% of the population that are non-nationals, although there is some leeway for the Minister to exclude specific groups. All health care should be free for pregnant and lactating women and children under 6 in SA. And refugees, asylum seekers, and undocumented migrants from SADC should be means tested the same as South Africans when accessing hospitals (this is in accordance with the Uniform Patient Fee Schedule against which anyone accessing public health care is assessed).

Of course, we all know that this is not the reality – migrants are often denied health care. But that’s for another blog post.

The NHI would, as currently constructed, make the following four changes:

  1. Refugees* would be entitled to “basic health care services” funded through a special contingency fund that will be set up (s121). It’s worth noting that no definition has ever been provided for what “basic health care services” are;
  2. Asylum seekers* would only be entitled to emergency medical care and treatment for notifiable conditions (i.e. seriously contagious diseases like Ebola or the Zika virus) (s122);
  3. Any other migrant* would have to pay in full for any health care accessed, even at a primary level (s123); and
  4. Lastly, there is no mention of coverage for pregnant or lactating women or children.

Whilst a lot can be said about the constitutionality of these changes, I’ll leave that to a lawyer and focus on the practical implications.

Excellent research that has been done on migrants who access health care in RSA and it basically says three things:

  1. In order to migrate you have to be relatively healthy, so when migrants arrive in RSA they’re usually a good deal healthier than the local population. Migrants then assimilate into the local population and become less healthy – this is when they start to seek health care in RSA. Finally, when migrants get quite sick, they tend to return home. Migration is an economic strategy – if you can’t make money, you’re not going to stay in a place which is highly xenophobic and unwelcoming;
  2. Migrants do not overcrowd our health care facilities – they use them as would be expected by any population group. In fact, the discrimination that migrants face often means that they don’t seek health care when they should and thus become even less healthy. We should be encouraging migrants to use our health care facilities and remain healthy as this is beneficial to our whole population especially given the HIV and TB epidemics in RSA; and
  3. Migrants contribute an enormous amount to the RSA economy. The idea that RSA is losing money through providing health care to migrants is simply not true – the presence of migrants in RSA brings in more money than we could possibly spend on their health care.

The changes proposed by the NHI would simply lead to a less healthy migrant population, and therefore general population, and decreasing efficacy in public health initiatives around HIV, TB, and any new nasty contagious diseases that occur. The fact that we might save a little through denying vaccinations to non-national children is inconsequential when you think about how much a measles outbreak would cost.


Some of the submissions on the White Paper can be accessed here.

*Whilst legal permanent residents and documented refugees are provided for, these two categories of migrants really make up a small number of the overall migrant population in RSA mainly because DHA hate granting refugee status or legalising the stay of migrants.