Vulnerable migrants obstructed from getting essential maternal and child healthcare
services due to Gauteng hospital payment policies and politics

By Dr Tasanya Chinsamy and Claire Waterhouse

In South Africa, reports of xenophobic incidents are a daily reality. Now migrants using the country’s strained public health system have become a hot-button issue as impartial access to healthcare has recently become highly politicised. Operation Dudula’s anti-migrant protestors targeted the sick and vulnerable outside Kalafong Hospital in Tshwane to reach a political objective. They profiled patients allegedly by skin colour and language, turning away anyone who failed to pass muster. The protestors also targeted Hillbrow Community Health Centre, where they intimidated migrants accessing care. Days earlier, Limpopo health MEC Dr Phophi Ramathuba berated a Zimbabwean patient, claiming migrants are “killing my health system”. In an interview, 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 the Constitution guarantees. This makes provision for everyone in the country to access healthcare regardless of nationality or documentation status.”
This affirmation is welcome. But is it a sincere position when, in Gauteng, the gatekeepers of the public health system have undermined this right?
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 health care for pregnant women and children under six.
In 2018, Médecins Sans Frontières (MSF) started providing basic primary health and psychosocial services to vulnerable communities around the Tshwane CBD and outlying areas where migrants live. We have witnessed a marked increase in migrants or asylum seekers without formal refugee status excluded from tertiary level care due to the imposition of fees.
At some of the main tertiary hospitals in Tshwane, pregnant and lactating migrant women and children under six regularly face challenges in accessing care if they lack appropriate documentation and cannot pay the higher fees for the essential services they need. The root of these rejections is “Circular 27 of 2020”, issued by the Gauteng Department of Health (DoH). It contains ambiguous wording regarding the “scheduling of fees for hospital services”.
The circular exempts pregnant women and children under six “irrespective of any other classification” from fees if they can’t afford it. But primarily, South African patients with ID documents and documented refugees’ 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 migrants or persons affected by statelessness – unless they need emergency services. This contradicts the National Health Act.
Many countries, including South Africa, adopted progressive national policies of not charging pregnant women and children. The Gauteng health system’s U-turn must be confronted to protect impartial medical care that saves and protects all lives.
MSF supports litigation against the Gauteng DoH in the Johannesburg High Court by SECTION27 and three migrant patients who were denied care.
Together, we ask that the Gauteng DoH clarify its ambiguous payment policies obstructing 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 the court will declare obstructionist Gauteng regulations as an unlawful contravention of the National Health Act.
33-year-old asylum seeker Eldred Kaseke* is one of at least 13 MSF service users who have suffered the negative impacts of Gauteng regulations around migrants in the last 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.
During a visit to a tertiary hospital, Eldred found out she must pay R848 for the initial consultation and follow-up visit because she is a refugee. And she would need to pay more for any medication and further consultations during her pregnancy.
Eldred is unemployed with little support. In short: the fees are unaffordable. Rebuffed and increasingly anxious, Eldred went to the Eastern Cape, where she previously got care 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. She was also left with extra costs and health risks because she had to go to the Eastern Cape for care.
Today, Eldred is 4 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 sure-fire 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 a life, obstructing care with high fees.
It is ultimately counter-productive for the healthcare system. 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 using preventive services.
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 migrant children. The politicisation of healthcare must stop. The Gauteng DoH must urgently clarify to hospital managers the implementation of “Circular 27 of 2020”.
It must also affirm a commitment to universal access to essential care regardless of nationality or migration status. The department must find sustainable solutions in the form of properly managed and resourced facilities. And it must end the obstruction of care for people like Eldred by ensuring equitable healthcare access for all people. If not, darker days are coming. – www.msf.org.za

Dr Tasanya Chinsamy is Medical Activity Manager, MSF Tshwane migrant health access project and Claire Waterhouse, Head of MSF Southern African Operational Support Unit

*Name changed to protect her identity