Picture: Oupa Mokoena/African News Agency(ANA) – Police intervene in the violent clashes between EFF members and Operation Dudula, who targeted sick and vulnerable people, whom they profiled in order to stop foreigners from getting access to medical services at Kalafong Provincial Tertiary Hospital in Pretoria, South Africa on September 1, 2022.

By Dr Tasanya Chinsamy

In South Africa, reports of xenophobic incidents are a daily reality but the use of the country’s strained public health system by migrants is now a hot-button issue as impartial access to healthcare has become highly politicised in recent days.

To reach a political objective, Operation Dudula’s anti-migrant protesters targeted the sick and vulnerable outside Kalafong Hospital in Tshwane where they profiled patients, allegedly by skin colour and language, turning away anyone who failed to pass muster. The protesters also targeted Hillbrow Community Health Centre where they intimidated migrants accessing care. Days before, in a Limpopo hospital, MEC for health Dr Phophi Ramathuba was filmed berating a Zimbabwean patient, claiming that migrants are “killing my health system”. During a television interview a grandstanding politician, Gayton McKenzie, said he would switch off a foreign national’s oxygen to save a South African.

After days of silence the South African Government finally publicly condemned the xenophobic protests by Operation Dudula, emphasising that “the right to access basic health services is a basic human right that is guaranteed by the Constitution… which makes provision for every person in the country, regardless of their nationality or documentation status to access healthcare”.

This affirmation is welcome, but is it a sincere position when, in Gauteng Province, the gatekeepers of the public health system have undermined this right to access to care for certain groups of migrants?

Unlike the anti-migrant protesters outside hospitals and clinics, who use physical intimidation to turn migrants away, some Gauteng hospitals use policies that directly contradict South Africa’s National Health Act, which stipulates free healthcare for pregnant women and children under six.

Working on HIV and TB care in South Africa since 2000, in 2018 Doctors Without Borders (MSF) started providing basic primary health and psychosocial services to vulnerable communities around the Tshwane CBD and outlying areas where migrants live. What we have witnessed is a marked increase in instances where migrants or asylum seekers who do not have formal refugee status are excluded from tertiary level as a result of the imposition of fees.

At some of the main tertiary hospitals in Tshwane, non-South African pregnant and lactating women and children under six regularly face challenges in accessing care if they lack appropriate documentation and are unable to pay the higher fees for the essential services they need. At the root of these rejections is a document known as “Circular 27 of 2020”, issued by the Gauteng Department of Health (DoH), which contains ambiguous wording around the “scheduling of fees for hospital services”.

Although the circular itself states all pregnant women and children under six “irrespective of any other classification” can be exempted from paying fees if they cannot afford to pay, it is primarily South African patients with ID documents and documented refugees whose ability to pay is evaluated. Some senior hospital managers view this circular as an instruction from the Gauteng DoH to deny means testing and free (or lower-fee) services to pregnant and lactating women and children if they are asylum seekers, undocumented persons or persons affected by statelessness – unless they need emergency services. This contradicts the National Health Act.

Many countries, including South Africa, have adopted progressive national policies of not charging pregnant women and children, but the Gauteng health system’s U-turn on this path must be confronted to protect impartial medical care that saves and protects all lives.

This is why MSF supports litigation against the Gauteng DoH in the Johannesburg High Court by Section 27 together with three patients who were denied care. Together, we ask that the Gauteng DoH clarify its ambiguous payment policies that have been used to obstruct access to care.

We ask that the court reaffirm access to free healthcare for all pregnant and lactating women and children under six – including persons seeking asylum, undocumented persons and persons affected by statelessness.

We hope that the court will declare obstructionist Gauteng regulations as an unlawful contravention of the National Health Act.

Until then the status quo remains deeply distressing for patients.

Thirty-three-year-old asylum seeker Eldred Kaseke* is one of at least 13 MSF service users who have suffered the negative impacts of Gauteng regulations in the past 12 months. At 29 weeks pregnant and having already suffered a miscarriage and the death of another child shortly after birth, she was found to have high blood sugar levels during a clinic visit for her current pregnancy. Hers is considered a “high-risk pregnancy”, meaning potential complications could affect the mother, the baby, or both. Eldred was duly referred to a secondary level hospital that deemed her case too complex for them and referred her to a tertiary hospital in Gauteng for specialist review.

After a visit to the tertiary hospital Eldred was told that, due to her status as an asylum seeker, she would need to pay R848 for the initial consultation and follow-up visit – and she would need to pay more for any medication and further consultations for the duration of her pregnancy. Eldred is unemployed and minimally supported and simply cannot afford these fees. Rebuffed and increasingly anxious about the risks to her and her unborn child, Eldred decided to leave Gauteng and seek help in the Eastern Cape, where she had previously been seen at a tertiary hospital.

The Gauteng public health system has failed Eldred by requiring her to pay high fees for essential antenatal healthcare that she is fully entitled to receive under the National Health Act and which was not available at primary health clinic level. Gauteng health authorities also imposed cost and health risk burdens on her by leaving her with no option but to travel to the Eastern Cape in the hope of getting the care she requires.

Today, Eldred is four weeks from a full-term pregnancy. The uncertainty of where she will be able to safely give birth weighs her down.

The effective denial of access to child and maternal healthcare services for people like Eldred in Gauteng has many severe, negative health consequences. Obstructing access to timely, quality healthcare services increases the risk of preventable maternal illness and death. Obstructing women from consistently accessing the appropriate level of antenatal care during the course of their pregnancy is a surefire way to miss early opportunities to identify and minimise pregnancy-related risks to health. More fundamentally, the Gauteng health system betrays medical ethics by endangering life rather than protecting and saving life, obstructing care with high fees. It is ultimately counter-productive for the healthcare system, because it is far more cost effective to provide routine antenatal care and planned delivery for complex cases than to allow vulnerable patients to deteriorate until they require resource-intensive emergency care and must be admitted, since no hospital can deny them urgent care.

Requiring payment for curative care at public hospitals, especially in an atmosphere of xenophobic intimidation, dissuades vulnerable people from taking up preventive services as they will avoid health facilities and the risk of confrontation. This has major consequences for antenatal care coverage for pregnant women, or those accessing contraception and family planning services. It also has detrimental effects on vaccination rates and access to other essential health services for young children.

This politicisation of healthcare must be stopped.

The Gauteng DoH must urgently give clarity to hospital managers about the implementation of “Circular 27 of 2020”, while affirming a commitment to universal access to essential care regardless of nationality or immigration status. The department must find sustainable solutions in the form of properly managed and resourced facilities and end the obstruction of care for people like Eldred by ensuring equitable access to healthcare for all people living in South Africa. If not, darker days yet are coming.

*Name changed to protect her identity

Chinsamy is a Medical Activity Manager with the Doctors Without Borders (MSF) Tshwane migrant health access project & Claire Waterhouse, head of MSF Southern African Operational Support Unit.

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