Urban health and migration in South(ern) Africa: a regional public health priority

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1. Jo Vearey, PhD Associate Professor 28th September 2017 ICUH, Coimbra jovearey@gmail.com Urban health and migration in South(ern) Africa: a regional public health…
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  • 1. Jo Vearey, PhD Associate Professor 28th September 2017 ICUH, Coimbra jovearey@gmail.com Urban health and migration in South(ern) Africa: a regional public health priority www.mahpsa.org
  • 2. • Migration and urban health in southern Africa: some key concerns – Current thinking and scholarship; existing evidence; gaps – Migration as a determinant of (urban) health; temporality; spatiality – Importance of internal movements – Increasingly politically sensitive; global securitisation agenda • Implications for research and action: some conceptual suggestions – A social determinants of health approach – Towards a research agenda for southern Africa – Changing the focus: empirically and theoretically
  • 3. (Where) Is migration in (global) urban health?
  • 4. • Calls on member states to promote equitable access to health promotion, disease prevention and care for migrants. Four priority areas have been identified for achieving the WHA resolution: 1. Monitoring migrant health; 2. Partnerships and networks; 3. Migrant sensitive health systems; and 4. Policy and legal frameworks.
  • 5. Migration is recognised as a determinant of health migration  health migration can determine health migration  health health can determine migration
  • 6. Social Determinants of Health http://www.who.int/social_determinants/en/
  • 7. The Southern Africa Development Community (SADC) Diversity Heterogeneity (contexts: migration; urbanisation; health systems; governance; communicable diseases)
  • 8. 1. Southern Africa is associated with mixed migration flows: internal > cross-border; livelihood seeking > forced migration; urban refugees; marginalised and hidden migrant groups; spaces of vulnerability; negative assumptions persist 2. Current public health responses do not engage with, migration and mobility: implications for communicable disease control (TB and HIV, malaria); chronic treatment continuity; challenges in accessing the public system for non-nationals 3. Public health and social welfare systems are overburdened and struggling: challenges are raised in a context of high inequality where nationals are also struggling to access their basic rights 4. SADC is increasingly recognised as a weak regional governance structure: 5. Structural violence - increasing anti-foreigner sentiments and xenophobic attitudes: migration management is associated with increased securitisation; a lack of regional responses; a restrictive immigration act; limited understanding of migration dynamics; violence; fear; securitisation of health
  • 9. © Modise 2014 Communicable diseases • Transmission • Predominantly move from lower to higher HIV/TB prevalence • Treatment continuity • Referrals • Harmonisation of protocols Mental health and psychosocial concerns • Trauma • Daily stressors • Violence: direct and structural Key migration and health concerns (1) home/pre-departure  transit/journey  interception  destination  return
  • 10. Spaces of vulnerability • Urban areas • Informal settlements • Dense inner-city • Farms • Detention centres • Informal workplaces • Refugee camps • RROs • Border spaces Key migration and health concerns (2) Sexual and reproductive health • Family planning/contraception • Testing, treatment for STIs (including HIV) • Safe termination of pregnancy • Antenatal care • Delivery choices • PMTCT home/pre-departure  transit/journey  interception  destination  return © Buella 2014
  • 11. Structural determinants: policies, practices and societal attitudes (global, national, provincial, local) Cross-borderorinternalmigrant Healthyonarrival(“healthymigranteffect”) Livelihood activities Sexual identity Sexual decisions Urbanisationexperience: entrytothecentral-cityortheperiphery Poor access to basic services (water, sanitation, refuse collection, electricity) Poor access to basic healthcare (including HIV and TB prevention, treatment and support) Poor access to safe and secure housing (homelessness) Unsafe and insecure living and working conditions (violence) Problems in accessing documentation Barrierstopositivesocialdeterminantsofhealth: weakrightstothecity Length of time in the city Negativeimpactonhealthandwellbeing Fragile livelihood system Exploring the complexity of health and migration in the city Problems in accessing education Poorhealthoutcomes: morbidityandmortalityinthecity returnhome(“salmoneffect”)–morbidityandmortality backhome Age Documentation status Food and nutrition insecurity securitisation agenda, xenophobia, anti-foreigner sentiments, othering, stigma, discrimination Dependents Disability (physical and mental) HIV status Gender Limited social networks Urban experience Dailystressors
  • 12. © Monica Mabasa, 2010 Recommendations for action (1) Migration and health is more than migration and HIV and/or TB. • Psychosocial and mental health; sexual and reproductive health; determinants of health Apply a social determinants of health lens. • Healthy urban governance; a WoG approach; migration-in-all-policies (MiaP) Improved data on migration and health is needed. • Numbers of migrants; numbers of HIV and TB clients who are mobile; strategies employed by mobile clients; referral systems Advocate for a migration-aware public health response in RSA and regionally. • Work with multiple levels/spheres of governance: regional, national, local; involve state and non-state actors; the urban-rural continuum Do not exceptionalise cross-border migrants. • Internal migrants are greater in number and a larger development challenge, and are often worse off than cross-border migrants
  • 13. Recommendations for action (2) Mobilise a renewed – and revised - regional conversation for developing a coordinated response to health and migration. • SADC Consultancy on Regional Financing Mechanisms; social rights portability: state and non-state actors; internal and cross-border mobility Learn from the SADC Declaration on TB in the mining sector. • Political leadership; private sector; naming and shaming Migration as a key developmental issue • The role of developmental local government Engage with national AIDS councils to ensure migration and mobility acknowledged in NSPs. • Beyond migrants as a ‘key population’; work towards a migration-aware response Learn from and upscale simple interventions. • Health passports; roadmaps for treatment access; referral letters; treatment packs for planned movements; patient-held records
  • 14. Existing research The right to health • A focus on healthcare and the health sector – Access to public healthcare systems • HIV and communicable diseases • “High risk groups” – Miners; truck drivers; partners of migrants • Food (in)security, informal settlements, HIV and migration • Access to socioeconomic rights – Housing – Livelihoods – Water and sanitation – Safety • Cross-border migrants • Trauma, violence and migration • Focus on South Africa Emerging issues A public health approach to migration • A focus on the social determinants of health (SDH) – Health > HIV; the health system as a key SDH; plural health systems; multi-sectoral; multi-level • Healthy migration for development • The governance of health AND migration – Local, national, regional, global – Internal migration and mobility • Costing studies • Non-communicable diseases (NCDs) • Human rights, migration and sexuality • Sex work and migration v’s trafficking • Regional focus; south-north and south- south exchanges • Methodological approaches – Visual; involved methodologies; ethics MigrationandhealthinsouthernAfrica towardsaresearchagenda
  • 15. Overlapping vulnerabilities: gender; food insecurity; lack of cash; living on the periphery; struggle to meet basic needs The social determinants of health: socioeconomic and political context; structural determinants; intermediary determinants livelihoodseeking migrationand mobility Inequality HIV TB Governance (response): healthy urban governance; intersectoral action; health in all policies; developmental local government Inequity Access to positive determinants of health: basic services; healthcare; housing; education; secure livelihood activities; food security spaces of vulnerability
  • 16. Some suggestions for a way forward: – Strengthening research capacity on migration and health: postgraduate training and mentorship; fundraising; cross-border collaboration – Building international and cross-border partnerships: collaboration; south-north and south-south exchanges – Exploring data and methodologies: engaging with complexity – Research translation: policy involvement (public health imperative)
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