Probing the Context of Vulnerability: Zimbabwean Migrant Women's Experiences of Accessing Public Health Care in South Africa

Abstract

The economic meltdown and worsening levels of poverty in Zimbabwe led to a
significant increase in the number of women migrating to South Africa from 2005 to
2010 (Crush et al., 2015: 367). A Southern African Migration Programme (SAMP)
survey in 1997 found that 61% of Zimbabwean migrants were male and 39% were
female (Crush et al., 2015: 367). This suggested that there was an increase in the
number of women migrating to South Africa compared with other countries in
Southern Africa. This gives us reason to ‘speculate’ that the numbers could have
increased a decade later because of the economic crisis that resulted in large numbers
of people migrating out of Zimbabwe. Most Zimbabwean women are now moving
across borders independently of their spouses and partners in search of better and
sustainable livelihoods (Dzingirai et al., 2015: 13; Mbiyozo, 2019). Whilst some have
valid immigration documents, a large number of these women are undocumented,
which heightens their vulnerability to various structures of violence (Bloch, 2010;
Rutherford, 2020: 172).

Full text

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AHMR African Human Mobilty Review - Volume 7 No 1, JAN-APR 2021
Probing the Context of
Vulnerability: Zimbabwean
Migrant Women’s Experiences of
Accessing Public Health Care in
South Africa
Victoria M Mutambara* and Maheshvari Naidu**
* University of KwaZulu-Natal, South Africa
** University of KwaZulu-Natal, South Africa
South Africa has a professed inclusive health policy that articulates that everyone is
entitled to have access to health-care services, regardless of nationality and citizenship.
However, several challenges exist for migrant women in South Africa, in accessing
this health care. This paper, based on the experiences of Zimbabwean migrant women
residing in Durban, focuses on their experiences of seeking and accessing health-care
services in South Africa. Using a qualitative study design, semi-structured interviews
were conducted with 22 purposively sampled female participants aged 25–49 years.
This paper employs a structural-violence analysis to probe the underlying factors that
make it challenging for Zimbabwean migrant women to access public health-care
services in South Africa. The findings of this paper highlight that the lack of valid
immigration documentation, often makes it challenging for participants to access
services from public hospitals and clinics. The findings also reveal that the state of the
South African public health-care system predisposes migrant women to health risks.
Keywords: gender, migration, health access, violence, South Africa

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INTRODUCTION
e economic meltdown and worsening levels of poverty in Zimbabwe led to a
signicant increase in the number of women migrating to South Africa from 2005 to
2010 (Crush et al., 2015: 367). A Southern African Migration Programme (SAMP)
survey in 1997 found that 61% of Zimbabwean migrants were male and 39% were
female (Crush et al., 2015: 367). is suggested that there was an increase in the
number of women migrating to South Africa compared with other countries in
Southern Africa. is gives us reason to ‘speculate’ that the numbers could have
increased a decade later because of the economic crisis that resulted in large numbers
of people migrating out of Zimbabwe. Most Zimbabwean women are now moving
across borders independently of their spouses and partners in search of better and
sustainable livelihoods (Dzingirai et al., 2015: 13; Mbiyozo, 2019). Whilst some have
valid immigration documents, a large number of these women are undocumented,
which heightens their vulnerability to various structures of violence (Bloch, 2010;
Rutherford, 2020: 172). eir migration pathways and experiences are distinctive
from those of the men as they are more vulnerable to gender(ed) inequalities and
pervasive violations. Migrant women are at a heightened risk of multiple forms of
violence that include sexual and gender-based violence, exploitation, forced labor,
and health vulnerabilities (see Sigsworth et al., 2008; Fuller, 2010; Von Kitzing, 2017;
Mutambara and Maheshvari, 2019; Rutherford, 2020).
In spite of South Africa’s constitutional provisions that everyone has the
right to access health care, migrants and refugees encounter multiple challenges
(Munyewende et al., 2011; Crush and Tawodzera, 2014). This paper aims to contribute
to existing contentions on the challenges that migrants and refugees experience
when accessing health care in South Africa. It particularly examines the extent to
which underlying social and institutional factors of vulnerability make it challenging
for Zimbabwean migrant women to access public health care in South Africa. The
paper argues that when accessing public health care, migrant and refugee women
are predisposed to various structures of violence that can easily be misconstrued as
challenges that uniquely affect migrants and refugees only. The negative experiences
of migrant women in public hospitals and clinics cannot all be attributed to their
identity as foreigners. Instead, migrant and refugee women are also adversely affected
by the ‘crisis of care’ that affects any patient (citizen or foreigner) using the public
health-care system in South Africa.
CONTEXTUAL BACKGROUND
Health security and legislature
South Africa is one of the countries in the world that has some of the most progressive
laws and policies regarding migrants and refugees (see Queue, 2015). However, the
implementation of these policies has not been seamless and straightforward, and
the Immigration Act of 2002 (RSA, 2002) contradicts the other overarching laws
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that note that health-care facilities can assist undocumented migrants and refugees
requiring treatment. Under the ambit of the United Nations Charter (UN, 1945),
the Universal Declaration of Human Rights was adopted as a resolution. is step
strengthened the principle that every human being is entitled to inalienable rights
and as such spoke to the questions of how states should treat their citizens as well as
nationals from other countries (Bloch, 2010; Scheinin, 2016). Article 25 of the United
Nations Universal Declaration of Human Rights posits that:
Everyone has the right to a standard of living adequate for the health and
well-being of himself and of his family, including food, clothing, housing and
medical care and necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood, old age or other lack
of livelihood in circumstances beyond his control (UN, 1948).
e experiences of migrant women in accessing health care in South Africa can be
situated within the framework of the human security paradigm. e term ‘human
security’ gained momentum in the 1990s at the end of the Cold War between
Russia and the United States of America. It was ocially coined in the 1994 United
Nations Development Report and it proered the denition which encapsulated the
protection of all human beings from both physical and non-physical threats (UNDP,
1994). Emerging work on human security has broadened the denition of human
security to encompass “securing people of their physical safety, their economic well-
being, respect for their dignity and worth as human beings and the protection of
their human rights and fundamental freedom” (Dzimiri and Runhare, 2012: 193).
e concept of human security is based on human rights, and one of those rights
is any individual’s entitlement to proper health care or health security. Scholars like
Isike and Owusu-Ampomah (2017: 3179) assert that health security ensures access
to health-care systems and quality care; access to safe and aordable family planning;
prevention of HIV and AIDS, poor hygiene, teenage pregnancy, substance abuse; and
general well-being.
The 1996 South African Constitution was constructed around these principles
and asserts that South Africa belongs to all who live in it despite their place of birth
or citizenship and all are entitled to be treated with respect and dignity. This makes
health a basic human right, as all persons in South Africa have the right to access
health-care services (Mafuwa, 2015: 15). In other words, international human rights
laws bind states to provide health-care benefits for any individual residing in that
state’s territory. This means that documented or undocumented migrants in South
Africa have the right to proper health-care service on a non-discriminatory basis.
There are three ‘pieces’ of the legislature that guide South Africans on matters
relating to migrants and refugees. These comprise the National Health Act of 1998,
the Immigration Act of 2002, and the Refugees Act of 1998. According to Alfaro-
Velcamp (2017: 60) these laws are inconsistent and they contradict each other.

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The National Health Act 61 of 2003, Chapter 1 (2)(c) (RSA, 2003) stipulates that
the government will provide health care for the people of South Africa including
vulnerable groups such as women, children, the elderly, and people with disabilities.
However, the vulnerable do not include migrants and refugees, particularly those
who are undocumented who should be considered vulnerable because of their illegal
standing (McLaughlin and Alfaro-Velcamp, 2015: 32). The Refugees Act of 1998
(RSA, 1998) appears to be consistent with the National Health Act as it emphasizes
that refugees are entitled to basic health services. Chapter 5, section 27 (g) states that,
“a refugee is entitled to the same basic health services and basic primary education
which the inhabitants of the Republic receive from time to time” (RSA, 1998: 20).
However, the legislation does not refer to asylum seekers or other foreign nationals
(Ramjathan-Keogh, 2017: 134). According to Alfaro-Velcamp (2017: 59), the
Immigration Act of 2002 contradicts the preceding health laws, as it obliges health
care providers to ascertain the legal status of patients before administering care.
Section 44 of the Immigration Act states:
When possible, any organ of state shall endeavour to ascertain the status or
citizenship of the persons receiving its services and shall report to the Director-
General any illegal foreigner, or any person whose status or citizenship could
not be ascertained, provided that such requirement shall not prevent the
rendering of services to which illegal foreigners and foreigners are entitled
under the Constitution or any law (RSA 2002 – Section 44 substituted by
Section 42 of Act 19 of 2004: 51).
South Africa’s health system
South Africa’s health system is a two-tier health system where patients can either
have access to the public or private health-care system, depending on an individual’s
ability to pay (Mahlati and Dlamini, 2015). Public health care is funded by taxpayers
and the private sector provides services to those who can aord medical aid or pay
privately for health care. According to government policy documents, approximately
84% of the South African population depends on the government’s health sector
(Naidoo, 2012). e public health sector is divided into primary, secondary and
tertiary health services provided through various health facilities within dierent
provincial departments (Mahlati and Dlamini, 2015: 3). e primary level hospitals
include internal medicine, obstetrics and gynecology, pediatrics, general surgery, and
general practice. ey oen oer limited services that require the use of the laboratory
and patients do not need referrals to access services. Secondary level hospitals are
recognized by their functionality and they usually have ve to ten clinical specialties
within them. Hence, when someone is referred for secondary care it means that they
need a professional who has more specic expertise in whatever problem the patient
is experiencing. For instance, a rehabilitation centre is an example of secondary level
care. Tertiary level hospitals oer highly specialized equipment and expertise in
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areas such as coronary artery bypass surgery, renal or hemodialysis, neurosurgeries,
severe burn treatments, and other complex treatments and procedures. Patients are
transferred to tertiary level hospitals when primary and secondary level care is not
adequate for their condition (Young, 2016: 4). While primary care is free, secondary
and tertiary care is subsidized and patients are charged according to a uniform patient
fee schedule which determines the amount based on their income bracket and the
number of children they have, regardless of their nationality (Expatica, 2020).
In sub-Saharan Africa, South Africa is considered as one of the countries that
invests a lot of money in strengthening its public health-care system. However, the
results are not equivalent to what is spent (Malakoane et al., 2020). The public health-
care system serves a large proportion of the population and this adds pressure as the
system battles many challenges. Hospitals are severely under-resourced and doctors
and nurses are often demotivated because of the shortage of staff which consequently
compromises the quality of patient-care (Maphumulo and Bhengu, 2019: 4). As a
result, South African citizens who rely on the public health system experience health
vulnerabilities, like prolonged hours waiting in queues, abusive attitudes by staff,
and expensive treatment and care. Some hospital and clinic facilities are dilapidated
and most people worry that they may contract secondary infections whilst they are
seeking care in the public clinics and hospitals (Malakoane et al., 2020). These public
hospitals are the same facilities that migrants and refugees use, and their experiences
are worsened by several factors.
This paper employs the theoretical lenses of the structural violence theory.
According to Samantroy (2010: 6), violence is not always conspicuous; instead, it
is invisible and is always ubiquitous in social structures normalized by institutions
or regular experiences. The theory is used to show the various forms of invisible
violence that make it challenging for Zimbabwean migrant women to access public
health-care services in South Africa. Migrant women face several health risks and
barriers to accessing public health care which are exacerbated by multiple factors.
These include legal restrictions on their status as migrants, poor accommodation
facilities, language barriers, and the increasing manifestation of xenophobia which
includes prejudice and negative attitudes from health-care workers (Freedman et.
al., 2020: 9). Migrant women who are unemployed or working in the informal sector
are particularly vulnerable as they encounter economic insecurities that predispose
them to high levels of poverty, living in unhealthy environments in the urban
areas with poor ventilation and limited sanitation facilities, making them more
vulnerable to being infected by communicable diseases (Freedman et al., 2020: 6).
In instances when they need to seek health care, they usually cannot afford to pay
for treatment. Another factor that makes it challenging for migrant women to access
public health care, is legal immigration restrictions. Legal immigration documents
play a substantial part in accessing public health care. It is important to note that
a significant number of Zimbabwean migrants in South Africa are unskilled and
undocumented because of the strict immigration requirements that do not allow

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unskilled migrants to apply for temporary work permits (Landau et al., 2005;
Mbiyozo, 2018; Hlatshwayo, 2019; Moyo, 2020). Moreover, they are also exposed
to other structures of violence like “medical xenophobia” (Crush and Tawodzera,
2014: 659). The term xenophobia is defined as the “deep dislike of non-nationals,
whatever their source of nationality” (Landau et al., 2005: 4). Kollapan (1999) argues
that the term cannot merely be constructed and defined as attitudes; it must express
action or practice. This contention implies that the definition of xenophobia should
be constructed beyond dislike and fear; instead, it should include actions of violence
that result in bodily harm and damage to property (Harris, 2002: 170).
According to Kange’the and Duma (2013: 160), xenophobic violence occurs
in South African communities daily but many incidents go unreported. However,
there have been significant nationwide violent attacks on foreigners which took place
in April 2008 and October 2015. That violence was sparked by negative comments
about foreigners by the Zulu monarch, King Goodwill Zwelithini (Tella, 2016: 2).
The city of Johannesburg also recently – during March and October of 2019 –
experienced xenophobic riots (Montle and Mogoboya, 2020). The violence is usually
characterized by the sporadic looting of property and goods from foreign-owned
shops or vending stalls (Cinini and Singh, 2019: 62). Beyond the visible violence
carried out against foreigners, xenophobia can also be institutional or structural. It is
manifested in South African practices through the exclusion of and discrimination
against foreigners in spaces such as the education system, hospitals, banks, police
services and the Department of Home Affairs. This concurs with the views of Scheper-
Hughes (1995: 143), who contends that structural violence that is experienced every
day can be defined as, “little routines and enactments of violence” that are practiced
normatively in different administrative and bureaucratic spaces. In the public health
care setting, these “little routines” can be considered as the status quo, even though
for migrant and refugee patients it is experienced as an assault on their dignity and
integrity (see Price, 2012). This implies that xenophobia may be rendered normal,
as invisible enactments of violence. As coined by Crush and Tawodzera (2014) these
invisible enactments of violence can be termed “medical xenophobia” to encapsulate
the argument that some public health-care practitioners discriminate against and
express negative attitudes towards foreigners. In the same vein, Adjai and Lazaridis
(2013) further strengthen this argument and assert that in institutions, xenophobia
can be used to exclude foreigners by practice and not by the design of the policies.
Similar to the latter views, Crush and Tawodzera (2014) agree that other practitioners,
in the absence of official directives (or not), have the power to withhold services and
certainly play a pivotal role in how these services are delivered to foreigners.
However, several studies have provided a counter-narrative to the ‘single
story’ of medical xenophobia and migrants ‘perceptions’ on accessing health care
in South Africa. A recent study by Vearey et al. (2018: 96) reveals that despite the
immigration status and the length of stay in South Africa, non-nationals have access
to public health-care facilities, particularly clinics. They reported that their choice
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was mostly influenced by the fact that most of the “staff was nice”, showing that the
attitude of health-care providers is an important factor when it comes to migrant
women accessing services. Vanyoro (2019: 9) also puts forward the argument that
the experiences of non-nationals in the South African public health-care system
are complex and equivocal. Vanyoro’s study reveals that in Musina, a small border
town between Zimbabwe and South Africa, there was no adequate evidence to
show that non-nationals were discriminated against or denied treatment because
of their nationality, immigration status, and language. Vanyoro (2019) argues that
past work on medical xenophobia negates the idea that differences and outsiders
are subjectively and socially constructed and negotiated. This is critical to how
xenophobic discrimination is experienced (or not) by locals, migrants and refugees
across different spaces. This, therefore, shows that in order to access health care for
migrant women in South Africa, it is complex and equivocal and there is a wide range
of possible experiences.
METHODOLOGY
e ndings of this paper are based on a qualitative study with Zimbabwean migrant
women in Durban, South Africa. Twenty-two Zimbabwean female migrants were
interviewed. An overview of the demography of the women who were part of the
study is provided in Table 1.
Table 1: Demography of female participants
Participant Age Migration to SA Occupation Marital Status
1 39 2008 Tailor Married
2 32 2012 Hairdresser Married
3 30 2012 Hairdresser Divorced
437 2008 Hairdresser Married
5 30 2010 Hairdresser Married
6 36 2007 Hairdresser Married
7 49 2009 Maid/Hairdresser Widow
8 29 2008 Manicurist Married
9 28 2013 Hairdresser Single
10 26 2011 Hairdresser Married
11 30 2013 Street vendor Single
12 37 1999 Home-based crèche Married
13 35 2009 Tailor Divorced
14 41 2007 Street vendor Divorced

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15 40 2010 Home-based crèche Married
16 30 2011 Street vendor Divorced
17 27 2008 Street vendor Divorced
18 33 2010 Street vendor Single
19 35 2009 Street vendor Married
20 45 2007 Internet café Widow
21 25 2016 Maid Married
22 29 2010 Maid Single
Participants were aged between 25 and 49 years and self-employed in the informal
sector as hairdressers, street vendors, and informal tailors; home-based crèche
owners; and internet café attendants. Snowball and purposive sampling techniques
were used to recruit the participants. e study did not use the help of a specic
organization with the recruitment of participants, hence a key informant who was
a Zimbabwean woman was recruited to help identify possible participants in her
community. Semi-structured interviews were conducted in Shona since all the
interviewed women were Shona-speaking and the interviews were approximately
30–45 minutes long, depending on how the conversations unfolded. With the
permission of the participants, the interviews were recorded using a tape recorder.
Participant observation was also used as a data collection method. Interactions that
were less formal such as ‘hanging out’ at hair salons and sometimes at the informal
stalls set up in the streets, turned out to be a rewarding way of collecting relevant
data.
Data gathered through participant observation was recorded by note-taking
of all the distinctive behaviors and attitudes from the participants’ everyday lives.
The interviews were translated and transcribed into English, and thematic analysis
was conducted. This involved coding all the data before identifying and reviewing
key themes. Each theme was examined to gain an understanding of participants’
perceptions and motivations. To ensure that the research was ethical, potential
participants were informed beforehand of the nature and the purpose of the research,
and why they were being interviewed. They were informed that they could stop
the interview when they felt uncomfortable, and they would not be forced to say
anything they did not agree to say. Participants were assured of their confidentiality
and their real names were not used in the study. Ethical approval was obtained
from the University of KwaZulu-Natal Human and Social Sciences Research Ethics
Committee (HSS/2112/016 D).
FINDINGS
e ndings of the study showed that there were interconnected challenges to
accessing health-care services by Zimbabwean migrant women. ese included the
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need for legal immigration documents, xenophobia and discrimination, as well as
language and cultural barriers.
The need for legal immigration documents
e participants revealed that as foreigners they needed to have legal immigration
documents to access health-care services. ey indicated that when they visited a
hospital, they were expected to have valid passports and temporary or permanent
permits. Hospital administrators oen required their identication documents for
verifying their legal status and their eligibility for treatment. One of the participants
revealed that it was onerous to try and get treatment without producing documents
such as passports and proof of address:
For a person like me who does not even have a permit or even a passport, it is
very difficult to go to the clinic because they always need those things and your
proof of where you are staying [Participant 10].
For undocumented migrants, it is impossible to open up bank accounts or be
engaged in any activities that require paperwork. at means that they will likely
not have any denitive proof of residence required at the public clinics and hospitals
(Crush and Tawodzera, 2014: 660) One of the participants recounted the story of
another Zimbabwean woman she met at a local ante-natal clinic. She mentioned
that the woman was coming to the clinic for the rst time to register for her ante-
natal appointments. However, the clinic clerk refused to assist her because she did
not have a valid or legal permit. Although the woman tried to give the clerk her
husband’s asylum permit, the clerk said, “We do not want your husband’s permit,
we want yours”. e need for legal immigration forms of identication by health
professionals aected the women’s access to essential health care. e systematic
need for documentation from migrant women in the clinics restricted them from
accessing public health care and it inuenced some of the women to avoid going to
the clinic. Some of the participants noted that it was challenging to get treatment at
public clinics and hospitals if they did not present documents showing that they were
residing in South Africa legally. Hence, some of the participants opted to use private
health-care services, as they were more concerned about the patient’s ability to pay,
rather than legal immigration documents. Two of the women said:
Because of the stories I have heard of bad treatment in the hospitals, I normally
try not to go there; I would rather go to the pharmacy and get some pills. If it is
that serious, I am left with no option but to go to private doctors who are very
expensive. But they are better because they do not ask a lot of questions about
your passport and permit [Participant 1].
When you don’t have a permit, you are always worried about being caught by

15
the police. And sometimes going to places where they need your passport and
permit, it’s like exposing yourself and you already know that you will not get
any assistance [Participant 9].
Some of the participants viewed public hospitals and clinics as ‘places of fear’. It is
important to note that this study revealed what the participants perceived their access
to health-care services to be based on their own experiences and in some instances
on what they heard other people in their migrant community sharing regarding their
own experiences accessing care at public hospitals. Based on some of these shared
negative perceptions, some of the participants said that they feared being denied
treatment or their lack of legal immigration documents possibly attracting attention
from Home Aairs ocials and in turn being detained. is le them with no option
but to seek private health care or opting to use self-medication or over-the-counter
medication.
While most of the participants were self-employed, they worked in the informal
sector, living ‘from hand to mouth’ and were in no position to afford medical aid and
the exorbitant fees required at private health facilities. To avoid these high fees and
being asked for legal documentation at public health-care facilities, several of the
participants shared that they used over-the-counter medicine. Two of the women
said:
When I am sick, I usually go and buy medication at the pharmacy [Participant
9].
I have heard so many stories about hospitals in South Africa, such that I go to
the pharmacy. I am lucky that I have never been seriously ill ever since I came
to South Africa [Participant 2].
However, this increased t heir health risks as it involved self-diagnosis, even in instances
where some of the conditions possibly required treatment by a medical practitioner.
ese ndings resonate with Crush and Tawodzera (2014: 661), who articulate that it
is potentially dangerous for anyone, but in particular for undocumented migrants, to
continuously use over-the-counter medicine without seeking professional treatment
at a hospital, as they could be exposed to inappropriate medicine.
Communication
Several of the participants indicated that when they visited a clinic, some of the
nurses communicated with them in the local Isizulu language. e women recounted
that they were expected to know and understand the language. However, the
reality was that they could only understand the basic elements of the language, like
greetings. Beyond that, they were only able to communicate in English. However,
communicating in English and being unable to fully express themselves in a local
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language, was a visible and audible marker of dierence that led to some of the
participants experiencing discrimination and xenophobic attitudes from some of the
health-care workers. Some of the participants said:
When I gave birth, the nurse said something that I did not understand. I
responded in English and the nurse said she was irritated by people who speak
English. She then left the room and I was later assisted by another nurse who
was in the same ward [Participant 10].
I still remember at the hospital, I saw the experience of another woman; she
was not from Zimbabwe, but she was from Mozambique. It was not quite
pleasing, the way they were talking to her and the way they were handling her.
I felt like language was a huge barrier and she could not communicate well
[Participant 3].
e participants revealed that not being able to communicate in the local language,
heightened their vulnerability as some of the health-care providers used that to
scold the women and to show them that they did not belong. In instances where one
cannot speak the local language uently, the only solution would be for the patient
and the health-care provider to communicate in the language used most frequently
in business and commerce in South Africa, which is English. However, the use of
English by the Zimbabwean migrant women oen led to hostility and accelerated
the nurses’ negative attitudes towards them. e language barrier resulted in poor
communication and in most cases, it created fear and anxiety in the women when
they visited public health-care institutions.
Some of the participants also indicated that their identity as migrants who
spoke a different language subjected them to poor treatment even though they had
legal status. They felt that they were not cared for as people who needed health care.
Instead, their identity as being foreign, subjected them to poor treatment and judgment
from some of the health professionals. The participants regarded those actions as
xenophobic as they experienced discrimination from some health-care providers
who blatantly pointed out that they were not happy with migrants and refugees using
the same health-care system as South Africans. Some of the interviewed participants
revealed that the resentment that some health care professionals displayed towards
them was deeply entrenched in hatred and disdain for foreigners. This was revealed
in what some of them said:
I gave birth in 2016, and there was an older midwife who told me that I should
stop giving birth because the population in South Africa is increasing and they
did not need more foreigners. She told me that I was supposed to find other
means of not giving birth as this was not my country (Participant 9).

17
Especially at the hospital, if they see that you are a “kwere kwere” they will not
treat you well. I know of my neighbor who suffered terribly during birth in
hospital and the nurses would come and say, “is it you removed Mugabe, why
is it you are still here in South Africa?” (Participant 12).
Some of the participants also said that they had been denied treatment in hospitals
and they were told to go to other facilities:
Sometimes you go to the hospital and you expect that they will at least check
you and tell you what’s wrong. But you know they can give you excuses and tell
you that you were not supposed to come to the hospital and you should go to
the clinic. Is it I am here now and I need assistance? Why can’t they just assist
me? What if it’s a serious problem and they are busy telling me to go from one
place to another? [Participant 18].
One of the primary challenges in assessing the reasons why the participants faced
diculties when they tried to access public health care is the assumption (oen
held by the Zimbabwean migrant women themselves) that when they received poor
medical treatment from health-care workers, it was driven by the health-care workers’
xenophobic attitudes. However, a study conducted by Shaeer (2009) argues that it
is imperative to acknowledge that not all instances of poor treatment can be labeled
‘medical xenophobia’. Instead, the language barrier and the lack of understanding of
South Africa’s health-care system oen ended in many migrants and refugees seeking
care at the wrong facilities. According to Mojaki et al. (2011) the South African
health-care system follows a hierarchical referral system where health care providers
at the lower level of the health system seek the assistance of providers who have more
resources and capacity. Based on the latter narrative, it is possible that when some
of the participants were referred to other facilities, they possibly misconstrued it as
denial and ‘medical xenophobia’. Based on the denition of xenophobia (see Landau
et al., 2005), for it to be considered ‘medical xenophobia’, medical treatment has to
be wrongfully denied to migrants and refugees on the grounds of their nationality or
their legal right to live in South Africa. However, other reasons might lead to medical
care being wrongly denied. South Africa’s health-care system is regarded as being
in a state of disrepair and experiencing various challenges (see Maphumulo and
Bhengu, 2019). Among the various challenges is the shortage of sta, which implies
that public health-care workers oen work long-hour shis and they are likely to be
exhausted. In some instances, the exhaustion and fatigue they experience possibly
inuence their negative attitudes and behavior towards local and foreign patients
(Crush and Tawodzera, 2014: 666).
Challenges in accessing sexual and reproductive health care
Several of the participants also indicated that they had challenges accessing sexual and
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AHMR African Human Mobilty Review - Volume 7 No 1, JAN-APR 2021
reproductive health-care services. ey revealed that they did not feel secure about
the way they accessed contraceptives from public-health institutions, particularly
aer giving birth. is was recounted by one of the women:
I told the midwife that I was comfortable using birth control pills but, just
after giving birth, I remember I was injected twice and thought these were
anesthetic injections. Two months after giving birth, I was still experiencing
problems with bleeding. When I went to the local clinic, that was when I was
told that this was normal as I had been given the injection for birth control
[Participant 20].
In most cases, as the participants revealed, the women unknowingly started using
two birth control methods at the same time, which usually had negative eects. e
above narrative shows how some of the participants were unaware of the type of
contraceptives they were taking. is resonates with the ndings of Munyaneza and
Mhlongo (2019: 11) that migrant and refugee women are oen not asked for their
consent when they are administered contraceptives by injection. It is important to
note that failure to obtain informed consent from patients before administering
contraceptives is not something that only happens to migrant women. According to
Lince-Deroche et al. (2016: 101) local South African women usually use or continue
using contraceptives they did not consent to aer intentional or unintentional rushed
and substandard counseling with nurses. However, the ndings of this study revealed
that there are some instances unique to migrant women that adequately capture the
existence of ‘medical xenophobia’. One of the participants said:
The nurses came, and they did not even ask me, they just told me to roll up my
nightdress sleeve and I assumed they wanted to put me on the drip. When I
saw her take out the implant package, I immediately told her that I didn’t want
an implant. But she just continued, and she told me that the implant was for
five years and it was going to keep me from giving birth in a country that was
not mine. I later went to see a private doctor after a month for it to be removed
as it had a lot of side effects (Participant 4).
It is important to note that women’s bodies are at the center of sexual and reproductive
health rights, yet, in most instances, they do not have power over the decisions made
about their bodies and sexuality. Signicantly, for migrant women, this study revealed
that violations of their sexual and reproductive health rights were oen worsened by
dierent structures of insecurities like xenophobic attitudes. From the latter narrative,
the nurse mentioned that using a contraceptive that lasted for 5 years would prevent
the participant from giving birth in a foreign land, and this is indicative of some of
the xenophobic undertones that migrant women encounter when they access public
health-care facilities. e ill-treatment that the participants received, constructed

19
their identity as second-class citizens who do not quite belong or t into South
African society. e attitudes and sentiments from health-care professionals cause
the women to feel unwanted in a foreign land where they hoped to nd security and
better livelihoods. Despite the negative experiences from some of the participants, it
is also important to note that two of the women had positive experiences and they
felt that they were treated well when they accessed public health-care facilities. e
women recounted:
When I gave birth to Sunshine at Addington Hospital, I do not want to lie, I
received the best treatment [Participant 8].
The health system here in South Africa is much better than the one that
we have back home, where there are no doctors and the nurses are always
on strike. If you send someone to the hospital, it’s like you are giving up on
them and sending them off to die. Here, it is better. I have never faced any
challenges when I usually go to collect my pills for blood pressure and diabetes
[Participant 22].
DISCUSSION
It is clear from the narratives that several factors exacerbate the health risks of
Zimbabwean migrant women. South Africa is an inherently violent country and
migrants are particular targets of violence and they are oen exposed to xenophobic
violence (Crush et al., 2017; Munyaneza and Mhlongo, 2019). It is also a society
that suers from high levels of rape and sexual gender-based violence and migrant
women are not an exception. ey live precariously and their lives are at constant
risk, both during their journey to this country, and during their residence in South
Africa (Von Kitzing, 2017; Hlatshwayo, 2019).
Even though undocumented migrant and refugee women are entitled to their
universal human health rights, the inconsistencies in the policies and legislature
regarding the health care of migrants and refugees, subject them to various health
risks and vulnerabilities that make it difficult to access public health care. The legal
authority has been misplaced onto hospital administrators who do not have the
authority to decide people’s legal immigration standing (Alfaro-Velcamp, 2019: 64).
The most serious barriers and obstacles to their health, regardless of the Zimbabwean
migrant women being documented or undocumented, are their experiences of
discrimination and negative attitudes on the part of individual care providers.
Shaeffer (2009: 8) observes that, “the health rights that are afforded to migrants on
paper are belied by the harassment and denial they face in clinics and hospitals”.
The lack of documentation or identifying as foreign, exposed the women to
health risks. More than anything, the narratives show the power dynamics between
health-care providers and migrant women. In as much as health-care providers are
constitutionally obliged to serve every patient with dignity and respect regardless of
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20
AHMR African Human Mobilty Review - Volume 7 No 1, JAN-APR 2021
their nationality, they have a powerful position in the execution of their duties. In
some instances, that power was abused, making it difficult for the migrant women to
access proper health-care services. The women revealed that they experienced fears
of being reprimanded, being shouted at and their concerns being ignored.
It is important to note that the language barrier between the migrant women
and some of the health-care providers influenced the negative and discriminatory
attitudes. The inability to fully express themselves in English or the local language,
coupled with negative discriminatory attitudes towards foreigners by locals, made it
challenging for the migrant women to access quality health-care services in South
Africa.
The belief that the presence of foreigners in South Africa means that the
country’s population will grow, is deeply rooted in discriminatory and xenophobic
sentiments. The widespread negative beliefs and knowledge about migrants amongst
local South Africans influence individual health-care providers’ perceptions that if
foreign women gave birth in South Africa, they would be straining the country’s
resources and worsening South Africa’s structural, social and economic problems
(Crush and Tawodzera, 2014: 663).
More often, the health rights of migrant women are overlooked and infringed
because of the strong negative beliefs towards foreigners. As cited in Crush et al.
(2013), Benatar (2004: 81) asserted that most South Africans are not content with
the quality of the health-care system in public institutions. This is attributed to
staff shortages and increased workloads. However, some of the South Africans,
including the health-care providers, are of the view that the poor service delivery is
caused by an influx of foreigners, who they perceive as bringing infectious diseases
and socio-economic problems to the South African health-care system. Walls et
al. (2016: 14) articulated that although there is a clear indication of the increased
number of people moving into South Africa, the impact of migration on the health-
care system is debatable, with the assumptions and beliefs often driving responses
instead of data and evidence. The perceptions and views of the health-care providers
can be considered as being xenophobic, as they influence their thoughts, responses,
and behavior towards migrant women. Writing in the 1990s, a study conducted by
Jewkes et al. (1998) provides a counter-narrative to the latter view. It established that
both local and migrant patients suffered due to the poor health-care system, which
currently continues to deteriorate daily. Scholars like Crush and Tawodzera (2014: 9)
observe that the public health-care system in South Africa is heavily overburdened
and most public facilities struggle to provide sustainable quality health care. Hence,
in some instances, Zimbabwean migrant women might associate any kind of ill-
treatment in hospitals with xenophobia.
CONCLUSION
is paper evokes an understanding of the context of the vulnerability of Zimbabwean
migrant women when they are accessing the public health-care system in South

21
Africa. Although there are singular events that display the specic poor treatment of
migrant women when accessing public health care, it is important to highlight that
some of the incidents might possibly be misconstrued as being unique to migrant
women. e ndings of this paper highlight that the issues surrounding the access
of public health care are constructed on the assumptions and perceptions held by
migrant women themselves. Hence, it is possible that any poor treatment experienced
accessing health care can easily be associated with ‘medical xenophobia’. e term
‘medical xenophobia’ has been used several times in the literature, referring to the
negative attitudes and experiences that migrants encounter when accessing health
care (Crush and Tawodzera, 2014; Zihindula et al., 2015; Munyaneza and Mhlongo,
2019).
It is imperative to note that emerging research should not only focus on
the single story of migrant women being treated badly in hospitals, but it should
also consider the existence of other invisible structures of violence like language
barriers and the women’s lack of understanding of the state of the South African
public health-care system as reasons for some of the poor treatment they receive. We
cannot dismiss the fact that there is a thin line between ‘medical xenophobia’ and
a deteriorating South African public health-care system, which invariably leads to
vulnerability when accessing quality care and services, for both local and migrant
women.
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AHMR African Human Mobilty Review - Volume 7 No 1, JAN-APR 2021
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