Medical xenophobia is widespread among South African health workers — especially nurses — in Gauteng health facilities, reports MedicalBrief. A University of the Witwatersrand study found that a majority of health workers believe that migrants should return to their home countries for health care, while a significant number also held the view that migrants only came to SA for health care.
Published in PLOS One, the study – the first survey in Africa to quantitatively examine public health care providers' attitudes to migrants – found that the response of health provider was "complex and nuanced". Although ambivalent to the health-care needs of migrants, health workers strongly held that they provided the same quality of care to migrants as to South Africans. "This divergence might suggest that they honour their professional and ethical obligations, even though they may not be that sympathetic to the needs of migrants", the study noted.
The study participants were predominantly South African (98.4%) and women (77.6%), with nurses constituting the largest group of study participants (51.9%). A quarter of all study participants worked at central hospitals.
About a fifth of those surveyed reported that they had witnessed discrimination and differential treatment of migrants in their work settings. Just over 31% of medical doctors reported witnessing discrimination or differential treatment more frequently than other categories of health professionals. Enrolled nurses and nursing assistants had lower scores for sensitivity to the needs of migrants, suggesting that their views were more exclusionary.
While some health-care providers said they never discriminated against migrants or delayed care to migrants, the study found significant indicators of discrimination among enrolled nurses and nursing assistants; those aged 25–34, as well as above 55 years in age; and those who had been at the same health institution for over 10 years. Conversely, working in a district hospital and in a primary health care (PHC) facility were predictors of less exclusionary views.
Category of health care professional and type of health care facility were predictors of participants’ views on delaying care because of migration status. In particular, enrolled nurses and nursing assistants had a significantly higher score than allied health professionals indicating higher agreement that they had delayed care because of migration status. Participants from regional hospitals, district hospitals and PHC facilities agreed less that they had delayed care than those from tertiary hospitals.
With regard to the view that migrants and refugees should return to their home country for health services, gender, category of health care professional, and place of birth were significant predictors. Female participants scored higher than men, while professional nurses, enrolled nurses and nursing assistants had significantly higher scores the allied professional reference group. Providers born outside of South Africa had significantly lower scores than those born in South Africa, indicating less exclusionary views.
Female providers had a significantly higher score than male providers on the view that migrants only come to South Africa for health care services. Professional nurses, enrolled nurses and nursing assistants, and medical doctors had higher scores, indicating agreement with this view on migrants only coming to South Africa for health care.
Background to study
A major global priority is to achieve universal health coverage (UHC) for all people, regardless of citizenship. In South Africa there is contestation about the number of migrants, but the 2011 census estimated around 2.2 million immigrants, with a total population of 51.8 million people. In 2020, the International Organization of Migration (IOM) estimated this number to be around 4 million; and highlighted that South Africa was one of the top 20 destinations for migrants, due to an increase in intraregional migration, with the majority of migrants coming from neighbouring Mozambique and Zimbabwe.
Legally, there is a constitutional right to health care for all individuals regardless of nationality, but access to health services for migrants is complex, especially for those without formal documentation. At the health facility level, the decisions of hospital managers or administrators could exclude migrants from health care, which is contrary to the Constitution and a violation of their human rights. The proposed National Health Insurance (NHI) system policy document lacks clarity on health care for migrants and refugees. Chapter 2 of the 2019 NHI bill makes provision for complete cover for permanent residents, refugees, and asylum seekers, but only limited cover for “illegal foreigners”.
A 2017 systematic review of health professionals in primary health care (PHC) settings providing care to refugees and asylum seekers found that political decisions affect frontline clinical practice, resourcing priorities, health professional roles and healthcare access. In South Africa, one study pointed out that despite an enabling legal framework, health care access for migrants is variable in practice and influenced by health system factors, health managers’ responsiveness and xenophobic attitudes by health professionals.
In a 2011 qualitative study with Zimbabwean migrants in Cape Town and Johannesburg, coined the term “medical xenophobia”, defined as the “negative attitudes and practices of health sector professionals and employees towards migrants and refugees on the job”. Medical xenophobia included the insistence by managers or health care providers that patients show identity documentation prior to receiving care. It also included delay or denial of treatment on the basis of nationality, refusal to communicate with patients in a common language (such as English) or to allow the use of translators, and/or verbal abuse and xenophobic statements and insults.
A 2017 qualitative study in Durban, South Africa described the medical xenophobia faced by refugees from the Democratic Republic of Congo (DRC) including the insistence on documentation, insensitive comments and other discriminatory practices from providers. Another small qualitative study that explored the experiences of eight women refugees and their attempts at utilising reproductive health care services in Durban’s public sector also reported incidents of medical xenophobia.
The study setting was all the public health care facilities in Gauteng Province. The province is the most densely populated in South Africa, with an estimated total population of 14.7 million. In 2018, Gauteng Province was host to the largest proportion of migrants (47.5%) in South Africa.
In Gauteng Province, the public health care system consists of four central hospitals, two regional tertiary hospitals, and nine regional hospitals. The province has one specialised mother-and child-hospital that functions at the level of a regional hospital, with some tertiary services. The 11 district hospitals in the province provide general, inpatient hospital services, and the six specialised hospitals provide psychiatric services, tuberculosis services, infectious diseases and rehabilitation services. The primary health care (PHC) system consists of a network of 30 community health centres (CHCs) and 290 PHC clinics that provide ambulatory care services.
The study population consisted of all health care providers that provide ambulatory care services in Gauteng public health facilities. This included medical doctors (both generalists and specialists), professional nurses (with four years of training), enrolled nurses (with two years of training), and nursing auxiliaries or assistants (with one year of training), dentists, occupational therapists, physiotherapists, and pharmacists. Data on health professionals from the Gauteng Department of Health showed that in 2018 there were a total of 5,102 medical doctors, 12,058 professional nurses, 6,424 enrolled nurses, 6,050 nursing assistants, and 3,288 allied health professionals.
This was the first survey in South Africa, and indeed in Africa, that we know of that quantitatively examined the perspectives of health care providers on public health care services to migrants. Most of the study participants were female (77.6%) and nurses (51.9%). This is not surprising as the majority of health care providers in South Africa are nurses, and women. In 2018, the South African Nursing Council (SANC) statistics showed that 90% of nurses were women.
In South Africa, the widespread promotion of human rights has occurred in recent history since the country’s democracy, and may have less traction in older generations. The discriminatory attitudes in the younger age groups is more concerning. The findings suggest that legislative changes such as South Africa’s Bill of Rights are essential, but do not guarantee changes in attitudes or behaviours. The effect of age on discriminatory views on migrants has also been found in a 2019 survey on social cohesion by the Gauteng City-Region Observatory (GCRO) in South Africa. The study found that participants 55 years and older were more inclined to agree with the view that migrants should be sent home, while respondents between the ages of 25 and 39 years old were more likely to accept/endorse violence against foreigners.
The expressed discriminatory views in our study are concerning, as health care providers are required to uphold professional and ethical standards of care. The various health professional Oaths emphasis service to humanity, practicing with conscience, treating all patients with dignity, pursuing justice, and advocating on behalf of vulnerable and disadvantaged patients. A combination of strategies is needed to ensure that migrant-sensitive health services are provided, and that all patients in the Gauteng public health service are treated with respect and dignity, regardless of nationality. There should also be adverse consequences for those health care providers that continue discrimination against migrants, and they should be reported to the relevant health professions council for possible disciplinary action.
These views could explain our finding that participants did not agree with the inclusion of migrants and refugees in the proposed NHI scheme. It is still of concern that most health care providers hold this view, given that they have a critical role to play in the achievement of UHC. Scholars have suggested that health care providers work in constrained conditions, exacerbated by migrant-unfriendly regulatory frameworks, policies and the political rhetoric of government officials that amplify xenophobic sentiments in South African society. Health care providers may reflect the political rhetoric of xenophobia. This context might explain the social exclusionary views of some of the health workers in our survey. Moreover, agreeing that migrants only come to South Africa for health care may not indicate anti-migrant attitudes, but may reflect the current reality given the virtual collapse of the health systems in their home countries, as in the case in Zimbabwe.
Study details
Social exclusion and the perspectives of health care providers on migrants in Gauteng public health facilities, South Africa
Janine A White, Duane Blaauw, Laetitia C Rispel
PLOS One, 28 December 2020
Abstract
Background
Universal health coverage (UHC) for all people, regardless of citizenship, is a global priority. Health care providers are central to the achievement of UHC, and their attitudes and behaviour could either advance or impede UHC for migrants. Using a social exclusion conceptual framework, this study examined the perspectives of health care providers on delivering health services to migrants in public health facilities in Gauteng Province, South Africa.
Methods
We used stratified, random sampling to select 13 public health facilities. All health care providers working in ambulatory care were invited to complete a self-administered questionnaire. In addition to socio-demographic information, the questionnaire asked health care providers if they had witnessed discrimination against migrants at work, and measured their perspectives on social exclusionary views and practices. Multiple regression analysis was used to identify predictors of more exclusionary perspectives for each item.
Results
277 of 308 health care providers participated in the study–a response rate of 90%. The participants were predominantly female (77.6%) and nurses (51.9%), and had worked for an average of 6.8 years in their facilities. 19.2% of health care providers reported that they had witnessed discrimination against migrants, while 20.0% reported differential treatment of migrant patients. Exclusionary perspectives varied across the different items, and for different provider groups. Enrolled nurses and nursing assistants were significantly more exclusionary on a number of items, while the opposite was found for providers born outside South Africa. For some questions, female providers held more exclusionary perspectives and this was also the case for providers from higher levels of care.
Conclusion
Health care providers are critical to inclusive UHC. Social exclusionary views or practices must be addressed through enabling health policies; training in culture-sensitivity, ethics and human rights; and advocacy to ensure that health care providers uphold their professional obligations to all patients.
Data Availability: The Human Research Ethics Committee (HREC) (Medical) of the University of the Witwatersrand in Johannesburg has imposed restrictions on the data, because it contains sensitive and confidential information on health care providers. Researchers who meet the criteria for access to confidential and sensitive data can contact the university’s senior information scientist (nina.lewin@wits.ac.za), or the HREC administrator (zanele.ndlovu@wits.ac.za).
[link url="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244080"]Full study in PLOS ONE (Open access)[/link]