When Elise M’s* 18-year-old daughter tried to kill herself with an overdose of pills last year, the ambulance that Elise called took them to nearby South Rand Hospital, in the Johannesburg suburb of Rosettenville. But nurses at the hospital refused to admit her.
“They pointed to a sign on the wall saying non-South Africans have to pay R5,000, [US$457]” recalled Elise. “I offered my cell phone, but they said, ‘No, this is not a pawn shop.’”
Elise, who is an asylum seeker from the Democratic Republic of Congo (DRC), had to beg a lift from a neighbour to take her unconscious daughter to another hospital where she was finally helped.
Stories like Elise’s have become commonplace among refugee communities all over Gauteng in the past year. The province, which is South Africa’s most prosperous and encompasses the cities of Johannesburg and Pretoria, is also home to the highest concentration of migrants, including asylum seekers and refugees.
National health policy guarantees asylum seekers, refugees and undocumented migrants from other SADC (Southern African Development Community) countries, the same rights to treatment at public sector hospitals as South African citizens. They are supposed to pay only what they can afford, based on their income.
However, last August, Gauteng’s provincial health department distributed a draft set of guidelines for managing non-South African patients that appears to have sowed confusion among healthcare providers and resulted in patients like Elise’s daughter being denied critical care.
The root of the confusion seems to stem from the guidelines’ definition of foreign patients as including refugees and asylum seekers. Such patients, according to the guidelines, should be charged in full before being treated. Lower down, it lists refugees and asylum seekers (but not SADC citizens) as among the categories of foreign patients who should in fact be charged according to income means testing.
Free treatment entitlement
Although the guidelines note that foreign patients, with or without documentation, should not be refused emergency treatment, there is no mention of pregnant women and children under six, who are entitled to free treatment whatever their nationality, according to the national health department’s Patient Classification Manual.
“The Gauteng guidelines are not legally sound and have the possibility of very negative consequences; we’re seeing people being incorrectly classified and charged,” said Jo Vearey, a senior researcher with the African Centre for Migration and Society (ACMS) at Witwatersrand University and a member of the Johannesburg Migrant Health Forum, which campaigns for migrants’ access to health services.
Vearey also pointed to a section of the guidelines which encourages hospital staff to report “any illegal foreigner or any person whose status or citizenship could not be ascertained” to the Department of Home Affairs.
“Suggesting that frontline providers should be acting as home affairs officials is potentially detrimental to public health,” she said.
Faced with treatment fees they cannot afford, most migrants simply leave and try their luck at another hospital, said Kaajal Ramjathan-Keogh of Lawyers for Human Rights (LHR), which is also part of the Migrant Health Forum. “They don’t know what their rights are and they’re afraid to raise any questions,” she told IRIN.
Language barriers only add to the problem. Anna*, 40, another asylum seeker from DRC who does not speak English or Zulu, was told by one doctor that she needed to pay for an interpreter. “So I went and found one,” she told IRIN, speaking through an interpreter. “By then the medication for my son had finished. They shouted at me and accused me of selling the medication.”
Until recently, the most commonly reported problem experienced by migrants and asylum seekers trying to access health care were the xenophobic attitudes of some staff at the province’s hospitals and clinics.
“They don’t give you their attention,” said Anna. “The only question they ask is, ‘When are you going home?’”
She and her two children are survivors of sexual violence and on anti-retroviral (ARV) treatment for HIV. Although she has not been turned away or charged when accessing the essential drugs, she has had to endure taunts of “kwerekwere” (a derogatory South African term for African migrants) and loud accusations by nurses that she was procuring the ARVs in order to sell them back home.
Thembalani*, a Zimbabwean migrant who gave birth at Thembisa Hospital in August, was referred to the hospital’s high-risk antenatal care clinic for high blood pressure during her pregnancy. “When they asked me where I came from, I told them I was from Zimbabwe and that is where the problem started. They went on to insult me about how we were increasing their work load and how we loved getting pregnant,” she told IRIN.
“With every week I attended, I was subjected to verbal abuse about how we were affecting service delivery and despite arriving early, I would be taken to the back of the queue with fellow Zimbabweans.”
Other migrants IRIN spoke to recounted having to give birth on the floor of labour wards or on waiting room benches because nurses refused to attend to them.
Ramjathan-Keogh commented that the Gauteng guidelines were giving health workers with xenophobic attitudes an excuse to turn away foreign patients who cannot afford to pay fees.
In July, LHR fought a court battle to secure life-saving heart surgery for a 12-year-old Somali girl who had been refused admission at Steve Biko Academic Hospital in Pretoria, allegedly because her brother could not pay a R250,000 (S22,856) deposit.
Although xenophobia is not limited to health workers in Gauteng, refugee rights organizations in other provinces, including Limpopo, KwaZulu-Natal and the Western Cape, told IRIN that they had not heard cases of refugees and asylum seekers being charged upfront for hospital treatment.
Even at Gauteng hospitals, “there’s no consistency from one hospital to the next, and it depends who you’re meeting on that day,” said Thifulufheli Sinthumule of the Consortium for Refugees and Migrants in South Africa (CoRMSA).
Gauteng’s Department of Health did not respond to questions from IRIN and has also yet to meet with the Migrant Health Forum, despite repeated requests and even a promise of facilitation by the national health department.
The Forum has produced a leaflet aimed at helping refugees and asylum seekers navigate their way through the public health care system.
“People often approach [the health system] at the wrong level,” said Ramjathan-Keogh. “When they should go to primary level [clinics], they go to tertiary [hospitals] and are turned away without being told where to go.”
At the primary health care level, all services are free and few foreign patients report having difficulties.
*not a real name