Internal migration and health in South Africa: determinants of healthcare utilisation in a young adult cohort

With increasing levels of international and internal migration in low- and middle-income countries, the health implications of mobility are a growing focus of attention. As countries seek to fulfil the targets set out in the United Nations Sustainable Development Goals, the need to consider geographically mobile populations in planning and policy has been emphasised [1]. In recognition of the sparse evidence on the migration and health relationship, development agencies, policy makers and the research community have been called upon to urgently address these knowledge gaps [2]. Understanding the dynamics of migration and health both regionally and globally is a public health priority. It is imperative in moving towards universal health coverage that mobile individuals are incorporated into policy and planning [3].

Internal migration, the movement of people within a country’s borders, and urbanisation have been proceeding more rapidly in Africa than many other regions. Africa’s urban population is expected to increase from 43 to 59% by the year 2050 [4], while the intensities and types of movements occurring within African countries are diverse and multifaceted [5, 6]. Comparable data on levels of internal migration in Africa are limited, with South Africa and Zambia displaying higher levels of internal migration among countries in the Southern African region [6]. Within South Africa, geographic mobility is prevalent as people engage in both permanent relocation, as well as circular and temporary movement. Circular migration was historically connected with the Apartheid system of movement control, where black South Africans, who were recruited to work in mines and urban centres, were restricted from permanently settling in these areas [7]. This resulted in members of the work force, typically male, oscillating between urban work places and rural permanent homes [8]. Indeed South and Southern Africa’s economic foundation was built on both internal and cross-border labour migration, with migrant remittances providing significant support to origin households and communities [9]. These interconnections between urban and rural areas have persisted post-Apartheid. In contemporary South Africa, the prevalence of internal migration, which is largely labour related, far exceeds that of cross-border movement, with the most recent population census indicating 5% of the population had moved within the country in the 5 years preceding the census, compared with 1% of the population having immigrated from outside of the country’s borders [10]. Internal migration in South Africa may take on multiple forms and is undertaken by a diverse range of individuals. Recent analysis of South Africa’s 2011 population census highlights age, gender and education as key individual-level predictors and correlates of internal migration [11]. Employment and job seeking are often drivers of such movement, with municipalities that have higher unemployment levels experiencing relatively higher levels of out-migration [11]. Internal migration is most commonly undertaken by young adults and internal migration streams, while still predominantly male, are becoming increasingly feminised [11, 12]. While the largest proportion of movements occurring internally in South Africa involve a net distribution toward more urban settlement types, there remain strong, continuing inter-connections between rural and urban areas of the country [10]. Interregional migration and urbanisation are typically associated with individual and societal socioeconomic improvement; yet, any migration poses a challenge to the planning of health and social systems, which is often premised on a stable catchment population. The temporary and circulatory nature of contemporary internal movements exacerbates this challenge. It is therefore important to gain a better understanding of the levels and trends of internal mobility in the country, as well as the impacts of such mobility on productivity, health and wellbeing.

The relationship between migration and health is complex and presents methodological challenges. The health status of migrants may differ from that of non-migrants prior to migrating, at the time of migration and thereafter, making it difficult to disentangle selection effects and the direct effects of migration [13, 14]. Indeed many comparisons of migrants and non-migrants (or urban and rural residents), while identifying differentials at a point in time, are insufficiently attentive to these selection mechanisms. Furthermore, the event of migration itself may produce health changes at key stages of the life course, often attributed to the stress of relocation or the action of repeated movements. Following relocation, migrants are often exposed to a different social, environmental and health regime [15]. These have been described as disruption effects that occur around the time of migration [16‐18]. It follows that mobility, which results in an altered set of circumstances, may compromise healthcare access and continuity of care for individuals requiring treatment for chronic conditions.

South Africa is a key setting in which to investigate these issues, not only because of the widespread manifestation of migration within the country, but also because the migration-health relationship in South Africa is likely to be a harbinger for other societies in transition in sub-Saharan Africa. Coupled with high levels of internal mobility, South Africa is experiencing an ongoing infectious disease (ID) burden with an estimated 19% of the adult population HIV positive [19]. At the same time a growing burden of non-communicable diseases (NCD) has been observed [20, 21]. South Africa’s internal migrants have a significantly higher burden of HIV compared with non-migrants and are at higher risk of HIV acquisition [22, 23]. A longitudinal study of premature mortality among internal migrants from the African Health Research Institute and the Agincourt Health and Demographic Surveillance Systems (HDSS) revealed that return migrants to these HDSS areas had a four times higher risk of mortality from AIDS/TB and NCD as compared with permanent residents, suggesting a marked mortality disadvantage among migrants [24]. Whether suffering from a non-communicable or infectious disease (or increasingly both), individuals with chronic conditions require ongoing treatment and regular medical follow-up [25]. However, many remain undiagnosed, commence treatment later than recommended, or are unable to adhere to long-term treatment, resulting in poor health outcomes [26‐28]. Migration, particularly migration of a temporary nature as is prevalent in South Africa, can compromise adherence to and continuity of healthcare. However, not enough is known about issues concerning healthcare access and utilisation among migrants in the country. Such information is vital to South Africa’s overall policy goal of achieving universal health coverage [29].

Barriers to healthcare utilisation have been investigated to a limited extent among non-migrant populations in South Africa, with issues regarding the perceived quality of public healthcare, costs associated with private healthcare, and migration status being highlighted as challenges [30‐32]. A few small specialised surveys or qualitative studies of cross-border migrants have identified barriers and difficulties in accessing services, and these studies are strongly suggestive of the issues that arise for internal migrants as well. Deficient access to information, language barriers, and negative interactions with healthcare providers all may discourage health seeking [33‐37]. Consequently, migrant populations appear less likely to engage with the healthcare system [38]. South Africa’s present health system does not adequately address such challenges of access amongst mobile populations [39, 40]. While emphasis is often placed on cross-border migrants, the fact that internal migrants are large in number, and are themselves often moving substantial distances to destinations that may be socioeconomically and linguistically very different from their origin, argues further for attention to this group.

To respond to the urgent need for a strengthened knowledge base, this paper examines self-reported health and healthcare utilisation among internal migrants and rural-based permanent residents (i.e. non-migrants) originating from the Agincourt HDSS in South Africa’s rural northeast. The paper examines the profile of migrants compared with non-migrants to provide insight into the demographic, socioeconomic and health dimensions upon which migrants are selected. It further aims to identify the determinants of healthcare utilisation by migration status in the presence of appropriate statistical controls, and adjusting for the underlying propensity to migrate. We hypothesise that migrants are less likely to access health services compared to non-migrants, and that factors such as sex (gender), employment status and migration geography may contribute to differential health service use.

Internal migration, largely a labour-related activity, incorporates a substantial proportion of South Africa’s working population who contribute directly to the economic base of the country, and the livelihoods of rural households and communities. Securing quality public healthcare for internal migrants will make a substantial contribution to their ongoing health and productivity and thus, indirectly, to the wellbeing of their origin communities and society. This is the broad motivation of the Migrant Health Follow-Up Study on which this paper is based. This analysis of baseline data from the MHFUS adds to the limited knowledge about the health of internal migrants, and offers important insights on how they interact with the healthcare system in South Africa. This is particularly pertinent to current South African discourse and engagements around the planning and implementation of National Health Insurance which aims to provide quality and accessible to health care to all [29, 47].

The study was designed to include both migrants and permanent residents of the rural sub-district population in order to examine the demographic, socioeconomic and health dimensions upon which migrants are selected. In keeping with general selectivity findings about migration in other parts of the world, migrants in this cohort of 18 to 40 year-olds are more likely to be male, and have relatively higher levels of education compared to non-migrants [48, 49]. At the same time, the large proportion of female migrants in the cohort (41% of migrants), resonates with the period trends observed in the Agincourt surveillance population as a whole, and elsewhere in South Africa, concerning the increasing feminisation of internal, labour migration [50].

With respect to selection on health-related characteristics, our multivariate results point to important variation in the conditions associated with who becomes a migrant. Individuals who received a diagnosis of a chronic condition and those who reported a positive HIV status are also more likely to be migrants. Such results suggest a positive selection (favouring healthier individuals) in the migration process. Nevertheless, migrants’ self-rated health was lower compared to non-migrant participants alluding to the possible disruptive effects of movement on perceived health, or the effects of increased expectations and a change in the reference category to a more advantaged (urban) population. Such health assessments reflect a combination of individual characteristics and expectations, prior health experiences and engagement with health services systems, and an individual’s reference group [51]. This observed difference in self-rated health highlights the important ways the migration process may interact with these factors. Our subsequent statistical modelling (for use of services and for source of care) recognises this selectivity and is designed to compensate for it and retrieve informative estimates in the manner of an experimental intervention.

Our results notably show that migrants and non-migrants utilised health services differently, both in overall use and in the type of healthcare consulted. These findings of differential utilisation hold under statistical adjustment for relevant controls and for underlying propensity. Non-migrants were significantly more likely to have accessed health services in the preceding year as compared with migrants. Among those in our sample with a diagnosis of a chronic condition, non-migrants were again more likely than migrants to have sought health services. This highlights possible barriers to access where migrants with chronic conditions may not follow up on their healthcare as readily as non-migrants. Reasons reported by those who failed to access treatment suggest that time constraints, being treated poorly on a previous visit, and congestion at health facilities in urban areas may translate into lower levels of service use. Additionally, health service utilisation was far more common in females (both migrant and non-migrant) compared with males. This is consistent with findings from other studies that have examined patterns of health service use by gender in South Africa specifically and Southern Africa generally [40, 52], as well as in other high-income country contexts [53].

A strong finding of the study is the difference between migrants and non-migrants in the type of health services they accessed. There are a number of possible explanations for why migrants appear to use more private health services as well as traditional healers. Private services may be more readily available in urban areas, and are sometimes provided by large companies; in addition, migrants - more likely to be employed - may have more resources to direct towards healthcare and choose a private rather than government provider. Both private healthcare facilities and traditional healers are more expensive than government healthcare facilities, suggesting that migrants may be able to pay more for the convenience and time-efficiency of private care [54]. Research conducted on the use of traditional healers in the Agincourt sub-district shows that traditional healers treat a wide range of illnesses which suggests that cultural familiarity provides a reason for migrants seeking treatment from traditional healers, potentially influenced by type of condition [55]. Another possible reason for more frequent use of private health services and traditional healers among migrants relates to challenges in accessing public health services at the destination place (these may include navigating the urban setting, transportation, and time constraints). Knowledge about public health services seems better in the place of origin, and going to a public health clinic is more likely done from home. Finally, the difference between migrant and non-migrants in the types of services accessed may be reflective of the limited healthcare options available to rural residents. These findings lay the ground work for qualitative investigations of health seeking behaviour and experiences of utilising services, which will be nested in future waves of the MHFUS.

Migrants accessing private healthcare at their migration destinations will likely need to traverse both public and private health systems and/or re-engage with rural public health systems on return home to rural origin areas, all of which increases the risk of disruption in care. Of further importance are those 48% of the study participants who make no use of health services, since they may be particularly susceptible to illness, including HIV. Poverty, geographical constraints, and high transportation costs, and in some cases, combinations of these barriers all contribute towards ultimate health service use or lack thereof [31, 47, 56, 57]. These results raise questions about the perceived quality of care, a possible lack of information on public health services or the ability of those who are employed, and better resourced, having wider set of healthcare options. Detailed information of the kinds of conditions for which migrants and non-migrants seek help when presenting to public versus private sector providers, as well as further detail on the distances travelled and reasons for not seeking care are questions that we aim to explore in subsequent rounds of the study, and through qualitative research methods.

Following-up mobile populations is challenging; and in the present study we acknowledge limitations relating to small losses to follow-up among individuals who may be particularly mobile and/or differ from the interviewed participants in relation to particular characteristics. As much as the survey instrument focused on capturing a broad range of aspects on migration, the high levels of mobility and circularity encountered in this study population challenged aspects of the research design, especially capturing detailed geography of repeated visits to different health providers. We further recognise that there are multiple approaches to classifying migrants (in relation to distance and length of residence in a destination) and these will be expanded in further analyses.

Longitudinal studies can show how migration and urbanisation influence risk factors for health conditions and access to treatment. While our study setting draws on a specific district-sized origin population, the social behaviour we observe is indicative of broader patterns throughout the region, with lessons for health transitions underway in other parts. The extent to which rural households are linked to urban-dwelling temporary migrants is not well known. It is not illuminated by the South African national census, which gives a snapshot of where people reside on census night. Many single-person or small households enumerated in urban settings are likely to be members of rural households situated elsewhere, to which they will return in times of leave or ill-health [24, 58]. The high prevalence of temporary migration from rural households in northeast South Africa, especially for young adults, illustrated with respect to the Agincourt HDSS population, reflects a typical pattern for rural Southern Africa, yet this population remains less visible and their health challenges insufficiently understood.

This paper, based on data from the first wave of the MHFUS, contributes new evidence to improve our understanding of the migration and health relationship through the analysis of determinants of health service utilisation amongst internal migrants and permanent residents of a typical South African rural sub-district. Migrants and non-migrants in the study population were found to utilise health services differently, even in the presence of multiple statistical controls, with migrants interacting less readily with the health system as compared to non-migrants, and making far greater use of private sector facilities over public health services. These findings, which will be enhanced in future longitudinal follow-up rounds, offer important insights on how migrants interface with healthcare systems in transitioning contexts like South Africa. As such, the study assists in providing evidence to support the development of health and social policy to provide effective healthcare for internal migrants as part of developing locally adapted approaches to universal health coverage. Achieving the intent of the legal, political and health-systems development processes underway concerning National Health Insurance in South Africa can be greatly enhanced by recognising the as-yet-unmet needs of South Africa’s sizeable internal migrant community.