Poor policies produce poor health. This is not a metaphor but a public health reality. South Africa’s Draft Revised White Paper on Citizenship, Immigration and Refugee Protection is presented as technical reform, but it is poorly evidenced, enforcement-driven and shaped by a securitised understanding of mobility. Its health consequences are profound, not only because of what it proposes, but also because of what it reinforces: an increasingly exclusionary model of universal health coverage (UHC), in which legal status determines who is allowed to be healthy.
Supposedly designed to advance UHC, South Africa’s 2023 National Health Insurance (NHI) Act explicitly excludes asylum seekers and undocumented migrants from accessing basic healthcare, permitting only limited access to treatment for notifiable diseases and emergencies. This is fundamentally incompatible with the idea of UHC. In its current formulation, the white paper solidifies this anti-universality approach. In doing so, it positions the departments of Health and Home Affairs as peculiar – and dangerous – bedfellows. The health system is increasingly expected to perform immigration control measures, while Home Affairs reforms are designed with no regard for their foreseeable health impacts.
How is it that two of the most far-reaching reforms of foundational national systems – immigration governance and healthcare – not only fail to align, but actively undermine constitutional and international human rights obligations? And why do both continue to privilege populist, xenophobic narratives over evidence-based public health outcomes?
Health does not exist in isolation from law and governance. Migration policy determines who feels safe accessing healthcare, who is turned away at reception, who gives birth without antenatal care and who avoids state institutions altogether. Where policies foreseeably shape health outcomes, failing to assess or mitigate their impacts is not neutral – it is a governance failure. On health, this white paper is not simply silent; it actively produces harm.
Sovereignty over health
For years, researchers, clinicians and civil society organisations have demonstrated that migrants are not responsible for the collapse of South Africa’s public healthcare system. The evidence is consistent: corruption, chronic underresourcing, governance failures, staff shortages and mismanagement do far more damage than migration ever has – a conclusion supported by South Africa’s own health and population data.
Yet political discourse has moved steadily in the opposite direction. Migration has been reframed as a threat rather than a reality to be governed, and access to services as something to be restricted rather than strengthened. The draft white paper codifies this trajectory, operationalising what the NHI already sets in motion. By centring legal status, documentation and enforcement as gateways to state services, the government consciously entrenches the idea that access to healthcare is not based on need, but on who the state decides belongs.
Silence that enables exclusion
Despite proposing sweeping reforms to civil registration, immigration status, asylum processes, enforcement powers and data systems, the white paper never once addresses access to healthcare. Clinics, hospitals, mental health services, HIV and TB programmes, UHC – all are absent. NHI is not referenced at all. This omission matters because silence is not neutral when the consequences are foreseeable.
More troubling still, the white paper can remain silent precisely because the NHI has already made exclusion politically acceptable. In this policy environment, health becomes secondary to sovereignty, and care becomes conditional.
Paperwork as a gatekeeper to care
The white paper positions civil registration and inclusion in the National Population Register as foundational to governance and access to the state, explicitly acknowledging that children born to undocumented migrants may not be fully registered and may only receive handwritten birth certificates. What it does not address is how those children are supposed to access healthcare – a striking omission given the 2023 high court decision affirming that all children under six years of age have the right to free public healthcare.
In practice, birth registration and identity documents are routinely required for clinic files, referrals, immunisation records, nutrition programmes and continuity of care. When registration is dependent on a South African ID or valid visa and becomes a prerequisite for recognition, it becomes – in effect – a prerequisite for healthcare. Children, pregnant women and people with chronic conditions are the first to fall through these cracks. The tragedy is that both NHI and the white paper create barriers to the early access and continuity of care that the public health system depends on.
Clinics turned into border posts
The white paper leans heavily into enforcement, fraud prevention, compliance and security, expanding administrative discretion without safeguards to prevent enforcement logic from spilling into access to essential services. This is not theoretical. We have already seen how exclusionary rhetoric translates into practice: clinics blocked by vigilante groups such as Operation Dudula, healthcare workers intimidated, and patients – including South African citizens – turned away based on accents, surnames or documentation, often with tacit state acquiescence.
By failing to draw a clear firewall between healthcare and immigration enforcement, the white paper reinforces what the NHI quietly normalises: a system in which clinics function as border posts. Responsibility is pushed downward, discretion upward, and accountability disappears. In such a system, people avoid care out of fear – and UHC becomes an empty slogan.
Legal precarity is a health risk
The white paper acknowledges that asylum seekers may wait extended periods for status determination but does not acknowledge the toll that prolonged legal uncertainty takes on mental and physical health.
Decades of research shows that legal precarity is associated with anxiety, depression, trauma-related distress and disengagement from state institutions. Yet the policy doubles down on enforcement without mitigation – no mental health safeguards, no continuity-of-care protections, no recognition that prolonged liminality itself causes harm. Supported by the exclusionary logic of the NHI, poor mental health becomes not an unintended consequence, but a foreseeable policy outcome.
Counted in death, excluded in life
The most telling illustration of the white paper’s priorities lies in how it treats migrants in death rather than in life. While access to healthcare is absent, the policy makes explicit provision for the registration and administrative management of migrant deaths, even where individuals were never fully recognised while alive.
The state appears more prepared to account for migrants once they have died than to ensure they can access healthcare while living. A system that excludes people from care but counts them in death is not merely administratively incoherent – it is ethically and epidemiologically unsound.
This is not only about migrants
When people are pushed out of the health system, diseases do not respect legal categories. Treatment interruptions drive drug resistance. Emergency care becomes the default. Trust erodes.
Efforts to achieve UHC are not threatened only by budgets or implementation delays. They are threatened by policies that quietly reintroduce exclusion while claiming to modernise the state. Both the NHI and the white paper normalise this silent exclusion – and the cost is borne not only by migrants, but by everyone who relies on the health system.
A choice that still can be reversed
None of this harm is inevitable. The white paper could explicitly protect access to healthcare irrespective of immigration status; firewall clinics from immigration enforcement; safeguard health data; recognise mental health impacts; require health impact assessments; and align itself with constitutional governance and public health principles.
This moment presents an uncomfortable but important possibility: reforming the white paper could reassert the constitutional principle that healthcare is a right for everyone, and in doing so, expose the incoherence – and potential unlawfulness – of exclusionary provisions within the NHI itself. Strengthening health protections in migration policy may force a necessary reckoning in health law.
South Africa has a choice. It can continue down a path that privileges sovereignty over health and criminalisation over care – or it can recognise that a universal health system cannot be built on exclusion.
If NHI is to mean anything at all, this white paper must be revised. Otherwise, it risks becoming another instrument through which health is sacrificed to politics – and everyone in the country pays the price. DM
Dr Rebecca Walker is a senior research consultant specialising in migration, health and human rights in southern Africa. She is based at the African Centre for Migration & Society (ACMS), University of the Witwatersrand, and is a steering committee member of Collective Voices for Health Access. Jo Vearey is an associate professor and co-director of the ACMS where she undertakes research in migration and health. Her research centres on the development of improved policy and governance responses to address the health needs of diverse migrant groups.