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Agricultural migrant workers navigating the Western Cape health system: From Access to Continuity of Care in settings with histories of anti-migrant violence in South Africa

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BACKGROUND: South Africa’s large population of internal and cross-border migrants has a constitutionally-guaranteed right to health. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, as is the general population. Poor continuity of care can increase the burden on the health system of inadequately managed chronic conditions. Access to healthcare and continuity of care reflect both patient agency and the health system. Community health workers play an important role in linking communities and patients to health services and vice versa.
PURPOSE: This study examines how agricultural migrants in the Cape Winelands District of Western Cape Province navigate the healthcare system including securing continuity of care, and explores the role of CHWs in this process, in order to inform policy and practice. In this poster we report on preliminary analyses of migrants’ perceptions of health and health care in De Doorns, Cape Winelands District, Western Cape.

METHODOLOGY: Document analysis, chart audits, 67 individual interviews and focus group discussions with a purposive sample of agricultural migrants, Community Health Workers, health facility staff and managers in De Doorns, Cape Winelands District. We also conducted non-participant observation through accompanying CHWs while they worked (1 day each with 3 CHWs). Data was analyzed through thematic analysis, constructing care trajectories, and descriptive statistics.

PRELIMINARY FINDINGS:

Waiting vs having to return to the clinic

• The clinic serves patients based on an appointment system, which migrants say is not working. Patients not identified as being in need of critical care are given an appointment, to return another day. Migrants claim that they go to the clinic only when in need, and being turned away deters them from wanting to return. Some report going into debt to go to a pharmacy to buy medication, since the clinic has not tended to their immediate needs.
• Extremely long wait times at the clinic are faced by all migrants (and reportedly by all users). These wait times are the reason for which the appointment system was put in place. However, this research is showing that the desired outcome has yet to be achieved. As agricultural migrants come for employment purposes, missing days of work sitting at the clinic waiting, despite having appointments, puts them in a difficult position with their employers and deter them from future visits which are often required.

Language and quality of care

• Language is cited as a key barrier in accessing care for migrants. Non-English and non-Afrikaans speaking migrants claim that they cannot communicate with clinic staff, and that are denied services if they do not come with a translator at the time of their visit.
• A perceived non-friendliness of staff towards migrants is commonly reported.
• Migrants report using the referral system and travelling with medication to avoid defaulting on their treatments.

Lack of familiarity with Community Health Workers

• Most respondents report never having interacted with CHWs. While some have an idea of what role they play in the community, others claim to not even know their purpose.
(Il)legality, stigma, and the legacy of xenophobic and everyday violence
• Migrants without legal documents or ID claim that they are being denied services, are being treated negatively and/or are fearful of going to a clinic without papers.
• While this research has not indicated xenophobia to be as predominant a concern for migrants as it has been in past years, it still is a barrier. When migrants call for an ambulance, respondents claim it does not come on time (or sometimes not at all) as health authorities on the other end detect a 'foreign' accent. They report often asking “locals” to make the calls.
• Violence marks everyday life. Respondents report that people are routinely robbed and assaulted, and are afraid to leave their homes without urgent need. Many state that they are counting the days to leave, waiting for their work season on the farm to end.

DISCUSSION:

While agricultural migrants come to South Africa for work, health is a priority for them and they report significant efforts to stay healthy and to seek care when they are sick, so they can work. Clinic and hospital staff claim that the migrant population is increasing every week. While healthcare workers and managers do not agree with all of the barriers and concerns the migrants state, they are in agreement that many of the concerns are valid, and the overall South African health system needs to be strengthened in order to serve the overall growing population better.

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