The blaming of foreign nationals for the state of South Africa’s public healthcare system does nothing to fix the very challenges that those espousing this unsubstantiated rhetoric claim to want to improve.

In fact, and as others have pointed out (for example see here, here and here), this narrative of blame simply presents a distraction that successfully diverts the focus away from the very real financial and administrative challenges crippling the system.

As a result, this scapegoating of foreign nationals undermines efforts currently under way to improve the public healthcare system that about 80% of the population of South Africa is reliant on, while taking us further down a dangerous path of hostility and division.

We are again witnessing the apportioning of blame for the poor state of South Africa’s public healthcare system on foreign nationals. This time, we have not only heard government officials — including the Limpopo MEC for Health, Dr Phophi Ramathuba and (once again) the Minister of Home Affairs, Dr Aaron Motsoaledi — dangerously inflate the numbers of foreign nationals in South Africa and scapegoat them for the state of the country’s healthcare system, but we have also seen foreign nationals targeted verbally and blocked from accessing public clinics and hospitals.

This affects everyone reliant on accessing public healthcare: it restricts access to facilities and wastes the valuable resources of the Department of Health in having to respond to this, including, for example, the need to obtain an interdict against protesters.

Worrying misconception

This inflation of the numbers of foreign nationals in the country is worrying: nearly one-quarter of the South Africans interviewed in a 2019 survey conducted by the Human Sciences Research Council in Limpopo, KwaZulu-Natal, Gauteng and the Western Cape believed that the foreign-born population exceeded 50% of a country of 60.6 million.

In reality — as determined by the government’s own national statistics department, Stats SA — just under four million, amounting to 6.7% of the South African population, are estimated to be foreign nationals. This figure includes all categories of migrants, regardless of documentation status.

Critically, there is no evidence to suggest that foreign nationals place an undue burden on the public healthcare system. While officials will often make unsubstantiated claims about the numbers of foreign nationals using services in specific facilities, the minister of health has confirmed, in response to a question asked in Parliament in June 2022, that information on foreign nationals is not collected as part of South Africa’s Routine Health Information System.

There is no denying that South Africa’s public healthcare system faces multiple challenges, a reality recognised by the country’s National Department of Health. Just last week, Health Minister Dr Joe Phaahla publicly acknowledged that such challenges include “reduced funding, inefficiency, maladministration, corruption and poor management.”

He also stated that the government is, “ready to be held accountable in the improvement of quality of health services for the entire South African population”.

The task then should be to focus on holding the government to account for addressing these challenges, and not allowing dangerous discourse that fuels anti-immigrant activism and vigilantism to distract from the issue by scapegoating foreign nationals. 

As a systems problem, it is only by addressing service delivery that we can address the challenges facing South Africa’s public healthcare system. Interventions designed to progress towards Universal Health Coverage (UHC) — with an emphasis on “universal” — are needed to ensure that everyone in South Africa will benefit.

At a national level, South Africa has a progressive policy framework that supports UHC, and upholds the right to healthcare for all, clearly outlined in the Constitution, the Refugees Act and the National Health Act (see footnote).

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But current debates about how the right to health should be afforded to foreign migrants is — as always — polarised, with very little space for understanding the complex reality of South Africa’s relationship to migration and health.

The blaming of foreign migrants for resource, staffing and infrastructure challenges of the public health system is nothing new.

However, what is new — and increasingly gaining currency across political and public debates — is the suggestion that the rights afforded to everyone in South Africa to access healthcare are wrong and that immigration should be treated as a matter of national security.

This is reflected in amendments to the Refugee and Immigration Acts, the White Paper on International Migration and the restrictions outlined in the National Health Insurance Bill.

Most recently, it has been clearly shown in the suggestion by the ANC government, during its sixth policy conference, that South Africa should overhaul its entire governance of immigration, including reconsidering the country’s accession of the 1951 Refugee Convention and its 1967 Protocol.

Dangerous developments

These developments are dangerous for everyone in South Africa. They push the unsubstantiated idea that immigration is to blame for failures of the state to deliver services, for high crime rates and rising unemployment. They also provide fodder for growing anti-immigrant activism, typified by the increasingly violent actions of Operation Dudula and the South Africa First Party.

Blaming foreign nationals for a struggling public healthcare system serves as a convenient distraction from the real problems associated with service delivery. The suggestion that foreign nationals are the sole problem (and their removal is the sole solution) prevents us from understanding why the South African public healthcare system is struggling and what is needed to improve the quality of life for all in South Africa.

Moreover, this distraction stops us from holding officials to account for the actions required to improve the delivery of services to the majority of the population — citizens and non-citizens alike — who are reliant on the public healthcare system.

Ultimately, everyone loses: the scapegoating of migrants not only undermines progress towards quality healthcare for all, but also poses real risks to the health and wellbeing of everyone living in South Africa.

Footnote

Everyone in South Africa has the right to free emergency healthcare at the point of use — no fees can be charged before care is provided. All pregnant and breastfeeding women, and all children under six years of age, have the right to free services at all levels of healthcare regardless of nationality and documentation status. This includes all antenatal care, childbirth and vaccination services.

In South Africa, a means-tested co-payment system exists for all when accessing higher levels of care, ie hospitals; all users — including South African citizens — are means-tested on the basis of income and are charged accordingly. Individuals receiving social welfare grants or those who have no income are exempt from paying. 

This means test should be applied to South African citizens, permanent and temporary residents, refugees and asylum seekers, as well as both documented and undocumented SADC nationals. DM

Associate Professor Jo Vearey is Director of the African Centre for Migration & Society at Wits University and Vice-Chair of the international Migration Health and Development Initiative.

Dr Rebecca Walker is an independent researcher and associate of the African Centre for Migration & Society at Wits University.

Drs Dostin Lakika and Tackson Makandwa are postdoctoral research fellows at the African Centre for Migration & Society at Wits University.

Diego Iturralde is Chief Director for Demography and Population Statistics at Stats SA, co-chair of the South African Migration and Urbanisation Forum and former chair of the UN expert group on international migration statistics.