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.

 

Advertisements

‘A kind of freak accident’ / My MA found it’s way to the M&G

So I’ve been making a bit of a song and dance about research communication, what it is, and how you’re meant to do it. And then, on Saturday evening a friend texted me to say that I’d been quoted in the Mail & Guardian. After much ‘wait…what’ emoji sending and the locating of a copy of this week’s M&G, we found on page 13, in an article about VFS and the Guptas, a quote from my Master’s research report.

I was more than a little surprise. Everything, and I mean everything, that I’ve been thinking about research communication had made me think that it would land up being a Sisyphean task. I would plot and plan how best to communicate my research and ultimately getting nowhere. And you, dear reader, would read blog post after blog post about how people just won’t engage with research. And then, out of nowhere, an obscure piece of academic writing (because that really is what a thesis is) that I wrote about 18 months ago gets used in the M&G.

My hope in the universe restored, I contacted Phillip de Wet, the journalist who had quoted me, to find out how he’d found the quote/thesis. I’m not quite sure what I was imagining he’d say. I suppose part of me hoped that he’d have some ‘lesson’ for me to take forth and use in my further research communicating. Instead:

‘Think of it as a kind of freak accident, perhaps; considering how little (of) what we publish is drawn from research, pretty much every instance is…’

giphy

*The M&G is behind a paywall these days unfortunately, I can’t even access the article electronically.

Post workshop / feeling overwhelmed by research communication

I feel like I may have created a bit of an impression that I actually know what research communication is and am really good at it. Let me put the record straight: that is not the case.

When I first set up the blog, I wanted to get a baseline for how well I have been communicating my research pre-blog so that in a year or two I can see if the blog has led to any improvements. So I sent out a Google Forms survey to friends and family with a couple of questions, for e.g.: where do I work; what does my job entail; what is my research about; what was I doing in the UK a couple of weeks ago.

The good news finding from my survey is that I can only improve…

Although friends and family are arguably not the primary audience I am trying to communicate my research to, they are a good place to start. Let’s face it, no one else is reading my blog yet!

I must admit, however, that thinking about who my primary audience is, is a little daunting. Largely  because they’re the same group of people that I need to use as research participants. My research around policy process – who influences policy, how is policy influenced, etc. – requires interviewing, working with, and critiquing policy makers, key stakeholders, and CSOs (Civil Society Organisations – what we now call NGOs I’m told). But these are the exact same people I need to communicate my findings to and who I hope will learn from my research. And let’s be honest, this is going to require a level of tact and subtly that I do not have!

So while I’m feeling suitably more au fait about writing press releases and facilitating workshops, successful research communication is going to require a lot more.

#sex #slavery / ethical considerations in research communication

We’ve just finished day 2 of the workshop, and I’m pretty sure the facilitator thinks I’m the most annoying person in the world. What?! I’m enthusiastic!

I’m really enjoying the workshop, but am a bit concerned that we haven’t once spoken about the ethics around research communication. We’ve discussed in depth the use of social media, but ethical considerations have not been given the same consideration.

From my experience, once you’ve developed a research proposal you send it to an ethics committee who assess whether you have sufficiently engaged with the ethical implications of your research and will provide for your participants’ needs. By, for example, providing them with an outline of the research and your contact details, and the details of support networks and care providers if you are talking to vulnerable people or asking personal questions.

While, to my knowledge, research communication is not subjected to the same degree of scrutiny, as researchers this is definitely something we should be thinking about. The most effective way to communicate your research may be to use an image of a participant, but is that ethical? Perhaps it may be to use the moral panics around women and children, #sex and #moderndayslavery, but is it ethical to indulge that panic even momentarily and even if it gets people to read your research? We’re being told to communicate our research as much as possible, but every study has its limitations, and those limitations are seldom acknowledged in our dissemination where we focus on the findings and evidence – because that’s what people/policy makers want – but surely that’s problematic?

But perhaps I’m being too difficult, maybe all of these things are ok. There’s so much terrible information and bad evidence out there, if you have to appeal to people’s love of panic or breeze past your study’s limitations what’s the harm really? At least people are reading your work?

 

Remember Kony 2012? / The importance of research communication

I’m currently at a three day science communication and engagement workshop facilitated by Dialogue Matters and organised by the British Council, Newton Fund, and ASSAf (Academy of Science in South Africa). In honour of my involvement in this event and because I might (secretly) enjoy blogging, I’ve decided to do a short three part series on science communication and my experiences of it to date.

Some of the research that I’ve been working on around policy process and the Trafficking in Persons Act has shown that South Africans, generally, are incredibly reactive towards any information that gets shoved in their faces. We don’t tend to be proactive and find information out for ourselves, we wait for information to come to us via Facebook or Twitter and then, without verifying it, repost or retweet and come to bizarre conclusions about the world. Anyone remember Kony 2012? This is largely what happened with the moral panic* around trafficking in South Africa – those who shouted their ‘facts’ loud enough and presented them in a glossy enough way were believed and were able to make trafficking – a phenomenon of which there is no evidence in SA – part of the national conversation.

So there’s definitely a need for those of us doing methodically sound research to do a better job of telling people about it so that we can avoid or defuse moral panics. Some have also, however, suggested that it’s an obligation of those doing research to communicate it better, or at all. Philosophically, I agree. But on a practical level part of me wonders whether we can expect a bunch of socially awkward academics, in a time of budget cuts, increasing class sizes, and decreasing research funds to find the time to do more with their research findings.

Luckily for me, I’m on a fully funded position with no teaching load, and plenty of time to blog!

 

*For those interested:

For more on moral panics see Cohen, S. 1980. Folk devils and moral panics: The creation of the mods and rockers. Oxford: Martin Robertson

‘Societies appear to be subject, every now and then, to periods of moral panic. A condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests; its nature is presented in a stylised and stereotypical fashion by the mass media; the moral barricades are manned by editors, bishops, politicians and other right-thinking people; socially accredited experts pronounce their diagnoses and solutions; ways of coping are evolved or (more often) resorted to; the condition then disappears, submerges or deteriorates and becomes more visible. Sometimes the object of the panic is quite novel and at other times it is something which has been in existence long enough, but suddenly appears in the limelight. Sometimes the panic passes over and is forgotten, except in folklore and collective memory; at other times it has more serious and long-lasting repercussions and might produce such changes as those in legal and social policy or even in the way the society conceives itself.’

A blog? In 2016?

 

Yup, that’s right folks, I’m starting a blog in 2016. I haven’t had one of these since I was 15 and I’m pretty sure the background involved butterflies. However, the contract that I signed when I started my PhD with the Migration and Health Project (maHp), includes a clause about writing a blog and communicating my research and the research process – so I’m stuck here, and you’re stuck with me trying to make sense of my research in public. My one consolation is that if my concerns and struggles are documented on the internet for all to see, I might avoid becoming that person at dinner parties who shouts ad nauseum about their work.

One of the focus areas of maHp is ‘knowledge production, dissemination, and uptake’. Research uptake/science communication describe a growing trend within the academy for researchers to do a better job at communicating their research outside of the university space, or even just outside of the obscure journal in which they managed to get their research published.

As such, I’ll be using this blog as a general space to talk about the research process and what my research entails and shows. Due to some concern about journals being willing to publish things that have already been published elsewhere, especially a publicly available blog, until I’ve actually published my findings, I’ll be posting more about the research process and the projects that I’m involved in than the research findings themselves.

For now, while I work on more exciting content for the blog, feel free to peruse the other pages and blogs that I’ve linked in to find out more about the work at ACMS and maHp.