Is it worth it? Addressing the calls for more data on the use of South Africa’s public healthcare system by SADC nationals

By Thea de Gruchy1, Rebecca Walker2, Jo Vearey1 & Laurel Baldwin-Ragaven3

Calls for more data by government officials and political parties play a central role in current discussions and debates surrounding the utilisation of South Africa’s public healthcare system by citizens of other Southern African Development Community (SADC) states. However, many of those demanding additional data often overlook or misrepresent what already exists. This happens by inflating the number of SADC nationals living in South Africa; speculating about non-citizens who utilise the public healthcare system; and, suggesting that masses of people travel here for the sole purpose of accessing our healthcare system.

Photo by James Outway

This strategy of manipulating and deliberately misrepresenting data or relying on anecdotes to support a particular political agenda is not new, but it is dangerous and damaging for everyone in South Africa. The scapegoating of SADC nationals by some government officials and anti-immigrant activist groups for the failure of the state to tackle widespread service delivery challenges affecting all users is commonplace, and often goes unchallenged. In the past year, this has resulted in anti-immigrant groups – such as Operation Dudula – blocking access to healthcare facilities. Although contrary to the ambitions of regional agreements, public officials are reconsidering the rights of SADC nationals to access healthcare in South Africa.  A key concern is the lack of accountability to which public officials are held when misrepresenting data or making clearly xenophobic statements.

Calls for Data

Calls for more data focus on determining the precise number of SADC nationals utilising public healthcare services. The rationale given for this is to assess the ‘burden’ placed on the healthcare system and to evaluate if resources are being shunted away from South African citizens. It is also proposed that this data will be used to explore mechanisms for charging neighbouring countries for providing services to their citizens living in South Africa.

There is no doubt that data is essential for effective health systems planning. However, any data collected must be of quality. Beyond simply collecting information, there must be technical efficiency to ensure reliability, which is a costly undertaking. To ensure quality, data must be collected from multiple sources, in safe and secure ways, that increasingly involves accessing electronic personal health information (ePHI). Aligning with South Africa’s digital health strategy, the requirements associated with the recently implemented Protection of Personal Information Act (POPIA) – which include nationality – must be met. For it to serve the intended function, and to justify the costs involved in its collection, data must also be analysed appropriately [and efficiently].

Costs and Benefits

Therefore, in considering the calls for collecting data on the migrant status of healthcare users, the costs and benefits of doing so must be weighed up. This includes: (1) determining what data is needed and why; (2) assessing the quality of pre-existing de-identified sources of data; (3) evaluating the ethical implications of collecting this data; (4) understanding the cost implications; and – most importantly – (5) guaranteeing that this data will be used efficiently. Ultimately: is it really worth it?

An unpublished 2015 study commissioned by SADC, in partnership with the International Organization for Migration (IOM) sought to explore a regional response and financing mechanism to population mobility and communicable diseases. The study found that it is not cost-effective for South Africa to collect data at the individual level relating to healthcare use by foreign nationals: even with the aim of billing SADC countries for their citizens’ use of healthcare in South Africa, the financial contributions made by SADC migrants to the South Africa’s economy far outweighed the administrative costs of such data collection and the costs associated with providing care to SADC nationals.

This means that the more cost-effective solution would be for South Africa to absorb the costs associated with providing services to SADC migrants as the country continues to profit from their contributions to the economy. This approach is also in keeping with the ambitions of the SADC Protocol on Health that calls on Member States to promote healthcare for all, reduce barriers to access and develop regional policies and plans.

Existing data

Legislation, including the South African Constitution, National Health Act, Refugee Act and the international human rights instruments ratified by South Africa, recognise and facilitate the right to health care services for all, including SADC nationals living within our borders. As such, existing sources of data for health systems planning already capture the use of the healthcare system by everyone, including non-South Africans.

A key source of health user data, based on the World Health Organization Routine Health Information System (RHIS), is the South African District Health Information System (DHIS). Since 1996, this system has collected facility-level information about all healthcare users to provide vital information for health systems planning. Additional data collection mechanisms have been developed to monitor and evaluate HIV and TB care and treatment. Since such clinical services are constitutionally guaranteed for everyone in South Africa, data naturally includes SADC nationals.

Beyond the Department of Health, Statistics South Africa routinely collects data from all people living in South Africa, including citizens as well as documented and undocumented migrants from SADC. The Departments of Social Development, Home Affairs, and Labour also collect data to capture the service delivery needs of anyone living in South Africa.

These existing data sources should be used to improve service delivery and render it equitably. However, fragmentation among and between these different sources undermines their utility and efficacy. For example, the creation of parallel Covid-19 health and hospital data collection mechanisms, having abandoned the DHIS in the early stages of the pandemic, underscores challenges with inefficiencies and lack of coordination. Research also indicates that the DHIS is undermined by misuse to the extent that it is unable to ‘support reimbursements and resource management.’ It is therefore questionable to be calling for additional data to be collected when existing mechanisms are not being used optimally.

Legal and ethical implications

In addition, the collection of personal information of any kind should not erode the human rights of the people who are subject to such data collection and place them in harm’s way.

In South Africa, although presenting an identity document is not a requirement for accessing primary health care services at district health facilities, research indicates that SADC nationals and South Africans without valid documentation are hesitant to access care even at that level. Routinely collecting data on the nationality of people seeking care would not only give additional impetus to facility staff who are inclined to obstruct access or discriminate against non-South Africans, it would place additional burdens on the healthcare system.

Noting the potential for role conflict, the South African Medical Association (SAMA) chairperson Dr Mvuyisi Mzukwa remarked that: “We are not the Department of Home Affairs”. Forcing healthcare providers and administrators to work as immigration officials is unethical as well as costly. Furthermore, the Uniform Patient Fee Schedule (UPFS)  states clearly that all SADC citizens – regardless of documentation status – should have the same access to health care services as South Africans, hence collecting nationality/documentation status is unnecessary. A full overview of the legislation can be found here.

Costs of Mixing Healthcare and Immigration

Avoiding health facilities out of fear of reprisal has financial implications. Research shows that those who do not possess documentation, including South Africans, are more likely to delay or avoid seeking care altogether rather than subject themselves to a vetting process at a government facility. If documentation is required to collect data about nationality and migrant status, this could result in higher costs to the healthcare system as more people delay seeking care. Waiting until an emergency situation arises, such as an untreated wound that becomes septic or a crisis during an unmonitored pregnancy, requires more specialised levels of care and places an additional cost burden on the healthcare system.

To enhance the accessibility of healthcare and promote the human right to the highest attainable standard of health for all, firewalls must be put in place between data that is collected by the Department of Health for planning purposes, and personal information collected by other departments, specifically the Department of Home Affairs. While SADC citizens currently struggle to access treatments to which they are legally entitled, the current draft National Health Insurance (NHI) Bill proposes to restrict their health rights further.

Blurring the lines between healthcare and immigration – both of which have become highly politicised – risks South Africa’s slide into a vigilante state through which the unnecessary and unethical collection of certain types of data can be used to fuel populism and xenophobia, subsequently limiting access to constitutionally guaranteed rights.

The Way Forward

As has been argued, the current frustrations with the healthcare system – and service delivery in general – have little to do with the fact that 6.7% of our population are foreign born. Instead, these crises result from failures of governance and technical inefficiencies. While these frustrations do not negate the need for improving the collection, analysis and utilisation of existing data, knowing the nationality of patients and the status of SADC migrants will not assist efforts to strengthen our healthcare system. Existing data collection mechanisms already capture the necessary population based indicators, which are essential for appropriate healthcare planning and budgeting.

South Africa must uphold its commitments to domestic legislation and regional agreements to inform migration-aware health systems planning and make more efficient use of available data. Calls for the individualised collection of nationality and migration status from healthcare users are simply another distraction: inappropriate, unnecessary, costly, and – ultimately –  will place an additional burden on an already over-stretched healthcare system, sabotaging efforts to improve access to quality healthcare for all.

1African Centre for Migration & Society, WITS University

2Independent Researcher & Research Associate, African Centre for Migration & Society, WITS University

3 Department of Family Medicine, School of Clinical Medicine, Faculty of Health Sciences, WITS University