A top South African health official has gone viral for accusing foreign patients of burdening the country’s health system in an attack that ignores law, decades of foreign policy and an absence of data.

Laura Lopez Gonzalez

“If tuberculosis was a snake,” former South African Health Minister Aaron Motsoaledi was fond of saying, “its head would be in South Africa.”

Before becoming the minister of home affairs in 2019, Motsoaledi’s 2009 appointment as health minister marked in many ways the end of AIDS denialism that claimed more than 330,000 lives. South Africa soon went from health policy pariah to poster child, often becoming the first in Africa to pioneer advances in HIV and tuberculosis (TB). 

People living with HIV are at an increased risk of developing TB. With high HIV rates, TB remains a leading cause of death throughout the Southern African Development Community (SADC). 

And South African mines had become net exporters of TB by the time Motsoaledi took office.

Health is interconnected in Southern Africa

Complicated social, economic, and labour conditions translate to high HIV rates in mining communities on the continent. Add in cramped living conditions, other mining-related lung diseases — and poor access to healthcare — and the stage was set: South African mines had some of the world’s highest rates of new TB cases by 2012.

For centuries, the mines relied on migrant workers from SADC countries. like Mozambique, Lesotho and Eswatini. These men left nearby countries healthy but often returned home from the mines sick with TB or silicosis, a degenerative lung disease caused by inhaling silica dust during gold mining.

South Africa reaped the rewards of migrant labour but none of the costs of caring for it, SADC health ministers argued. Motsoaledi agreed. In 2012, health ministers released a SADC declaration on TB in the mines that called for, in part, for countries to harmonise their national HIV and TB treatments to enable cross-border care. 

For this and other TB work, Motsoaledi received international awards.

In policy, he carried on a decades-long SADC tradition recognising health in the region was interconnected.

In public, however, he increasingly attacked foreign patients for allegedly straining the country’s health system, although he only ever cited data from a handful of Johannesburg maternity wards as evidence. 

In 2019, Motsoaledi ended his run as health minister, leaving completely intact a set of national laws and directives that to this day enshrine the right to healthcare in South Africa for migrants, mainly from SADC. 

SADC meanwhile continues to explore ways of improving healthcare in the region by, for instance, pooling medicine procurement between countries to ensure better prices — and fixing the cross-border billing mechanisms between nations dating back to at least 1995. 

These mechanisms are supposed to allow countries to bill each other for patients treated at hospitals or for laboratory testing. that have historically sent patients and laboratory samples over borders for care and testing. In the era of Covid-19, intra-country cooperation on health is expected to increase.

South Africa’s Covid-19 response was heavily reliant on data. Still, the health department has never and still does not collect information on the number of foreigners using healthcare facilities, current Health Minister Joe Phaahla recently told Parliament.

If migrants are the burden politicians say they are, the lack of data to back this or devise a solution is a profoundly uncharacteristic gap for the South African health department. 

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Meanwhile, the country has yet to prosecute at least a half dozen high-profile individuals implicated in billions of rands of alleged healthcare graft for which there is data.  

But the costs of politicians’ continued utterances by politicians are beginning to show.

In the wake of recent viral videos from one health official re-iterating claims of a migrant health burden, Phaahla spent part of last week negotiating with vigilantes who have spent weeks demanding patients show proof of documentation before they can enter a public hospital near Pretoria. Already, the group has managed to turn away at least one pregnant woman with a life-threatening condition, says Doctors Without Borders. 

And it’s not just foreigners caught in the crossfire, says a South African woman who was accused of being an immigrant because of, she believes, her darker skin colour.

“Because of my skin colour, I should walk around with my ID? It broke me,” she told TimesLive. “I have my ID, but I chose not to show it to them. That’s not how it’s supposed to be because who are they? Next time, [you will get discriminated because of] how you are dressed.”

Who is entitled to free healthcare in South Africa?

South Africa’s 2003 National Health Act provides certain types of free care to anyone, regardless of documentation, until the legislation is amended to say otherwise.

• Everyone is entitled to free healthcare at clinics and free abortions.
• All pregnant and breastfeeding people and children under the age of six also get free health at clinics and hospitals.
• No one can be refused emergency care.
• A 2007 national health department directive also guarantees free HIV and TB care and treatment to anyone regardless of status because infectious diseases have no borders. 
• Regarding hospital care, refugees, asylum seekers, and undocumented SADC migrants should be treated like South African citizens at hospitals, meaning they will undergo a means test to determine what they will pay for hospital care. 
• Undocumented people from outside SADC who attend hospitals — except pregnant or breastfeeding people, those seeking an abortion or children under six — are expected to pay the full fees as laid out in the national schedule. However, the provincial health departments can impose additional procedures and fees for groups of people.

Source: South African public interest law firm Section27

An edited version of this piece appeared in The Continent magazine.