Good intentions, explosive consequences

William Saunderson-Meyer writes on the recent ruling taking a scalpel to "health xenophobia"


It’s a humanitarian triumph but politically dangerous. It’s a policy based on good intentions but it may kneecap an already buckling public healthcare system and stoke already explosive levels of xenophobic populism.

The Gauteng High Court this week ruled that provincial health departments must provide free health care at all facilities to pregnant and lactating women and children under the age of six, irrespective of nationality or documentation.

The order, issued by Deputy Judge President Roland Sutherland, has been hailed by health activists as an example of enlightened constitutionalism that should shame a developed world which, virtually without exception, uses those two criteria — nationality and proof of identity — to ration access by foreign outsiders to expensive taxpayer-funded healthcare. 

Dr James Smith of Doctors Without Borders commended the “landmark ruling” affirming free access to essential South African public health services for vulnerable groups, irrespective of nationality. “We know that charging for healthcare is one of the biggest barriers to care-seeking in South Africa and globally. 

Section 27’s Mbali Baduza welcomed the “important precedent”, which was a blow to the “health xenophobia that has been on the rise in certain provinces”.  Sharon Ekambaram, of Kopanang Africa Against Xenophobia, said the matter was “but one component of a broader crisis of institutionalised xenophobia.” 

The order followed a court application by Section 27, the public interest law centre, out of concern that refugees who, through no fault of their own lacked documentation, were being denied medical care. Initially, it was opposed by the national and Gauteng health departments but, at the last moment, the State Attorney folded and negotiated the wording with Section 27. 

The agreement invalidates the care guidelines of the Gauteng Health Department, which are informally followed by several other provinces. To the disinterested observer, the guidelines seem to have been an honest and admirable attempt to respect the constitutionally enshrined right to health care while dealing with the reality of trying to balance virtually infinite demand against decidedly limited budgets.

In South Africa, at a primary level, there has always been unrestricted patient access for whoever needs it. Anyone can walk into any state clinic or medical centre and receive treatment, with no questions asked. Emergency care, too, is free — including at private hospitals — to those who cannot afford to pay.

However, at secondary and tertiary facilities, there has been a throttle because of cost and scarcity considerations. Advanced medical interventions — those demanding sophisticated equipment and highly trained doctors and nurses — were provided free only to South African citizens who did not belong to medical schemes, as well as to documented refugees and asylum seekers. Everyone else paid a means-tested fee.

The order changes this. From now, it will be illegal for any health facility or health practitioner to deny free treatment to any pregnant and nursing mothers and their young children. 

It also makes it illegal even to attempt to classify these patients with the view of assessing whether they should make any contribution to the costs of their care.

The only exceptions are that free care will not be provided if they belong to a medical scheme or have come to South Africa with “the specific purpose of obtaining health care”. 

And there lies the rub. How can one possibly determine the medical insurance status of someone, or whether they have come to South Africa in search of better care than that which is available at home, when no classification and fee determination process is allowed?

In effect, the order means that South Africa’s public health facilities, already struggling to cope, can no longer turn away the many thousands from elsewhere in Africa who understandably seek an alternative to the collapsed medical systems of their home countries.

Frontline provinces like Limpopo, North West, Mpumalanga, KwaZulu-Natal and Gauteng — where there is already considerable friction between local and foreign patients as they compete to access medical treatment — will now face further pressure.

The scale of the problem is hotly disputed. According to the South African Health Review, in 2019 only 4% of public hospital admissions involved foreign nationals, mainly in the form of obstetric, gynaecology and trauma patients. However, the data is limited, difficult to track, and susceptible to manipulation by moral crusaders and politicians.

Anecdotally, foreign intake figures are much higher. That is pretty much what one would expect of a country boasting world-class health facilities on a continent where, overwhelmingly, public healthcare is both atrocious and always incurs some charge, often unaffordable, for the patient. 

But the frankest and most politically incorrect assessments of the foreign-national impact on the South African health service have come from within the government itself. Despite its ideological commitment to the “single Africa” narrative, the ANC is painfully aware that the financial and electoral costs of allowing untrammelled foreign access are mounting. 

Former Health Minister, Dr Aaron Motsoaledi told a nursing conference said a few years back that “the weight that foreign nationals are bringing to the country’s [health system] has nothing to do with xenophobia” but with reality. These foreigners, said Motsoaledi, were becoming an unsustainable burden. 

Last year, now speaking as Home Affairs Minister, Motsoaledi again identified foreign patients as endangering an already struggling system. Over 70% of births in Gauteng, Limpopo and Mpumalanga were to Zimbabwean and Mozambican women, he said.

According to Jack Bloom, the Democratic Alliance’s shadow MEC of Health in Gauteng, the proportion of foreign births in that province is more than 25% of total births. Health Minister Dr Joe Phaahla told parliamentarians that in some Johannesburg, Pretoria and Limpopo hospitals, 40%—60% of mothers giving birth are undocumented migrants.

“If this demand for services by our neighbours keeps on increasing,” Phaahla noted, “it will reach a stage where it is not sustainable.” He mooted, as a solution, billing the countries of origin of foreign patients. In light of this week’s court order, that now seems unlikely.

Similarly doomed are attempts by public hospitals to claw back costs by charging full fees to foreigners who can afford it. Steve Biko Academic Hospital in Pretoria, for example, was charging foreign patients R12,000 for a Caesarean. But, under the “no patient classification for fees” order, this will no longer be possible.

It’s not only in obstetrics, gynaecology and child health that the system is being gamed. Seriously ill foreign nationals reportedly fly to South Africa and present at an Emergency ward falsely pretending to be in acute medical distress. They are then admitted and treated free of charge.

Given the pressures that doctors and nurses work under, it is not surprising that many of them have a dim view of such shenanigans. A PLOS One study in 2021 found that the majority of health workers believed that migrants only came to South Africa for health care services; that they should not be covered in any future National Health Insurance; and that if ill they should be compelled to return to their home countries for treatment.

These are not the extreme views that the social justice warriors portray them to be. 

While specifics of course vary, in the United States, Canada, Australia, the United Kingdom, and the European Union, non-resident foreigners can mostly access only primary medical services, unless they have medical insurance or pay upfront (sometimes at a higher rate than the country’s citizens pay) for advanced care. In some EU countries — also in Russia, a nation that the ANC much admires — undocumented foreigners are simply denied treatment. 

But most telling is the policies of our immediate neighbours. 

In Botswana, Namibia, and Mozambique, non-nationals pay for all medical services except emergency care. In Zimbabwe, nothing is free, not even emergency care. And in both Botswana and Zimbabwe, undocumented migrants are denied any medical care, at all.

Health activists, most of whom have access to South Africa’s top-class private hospitals through medical schemes, should be more circumspect with their pejorative labels. Neither financial prudence on the part of the government, nor justifiable resentment on the part of the public, necessarily equates to “health xenophobia”.

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