Examining the ways in which structural violence, austerity, and health governance shape migrant exclusion in public healthcare in South Africa

Abstract Migration is a critical social determinant of health, yet South Africa’s (SA) governance frameworks remain poorly equipped to address the structural violence faced by international migrants and resulting deep and intersecting inequities in health. Despite constitutional guarantees of Universal Health Coverage (UHC), international migrants routinely face administrative exclusion through discretionary gatekeeping by frontline healthcare workers and rising xenophobia within healthcare facilities—challenges sharpened under conditions of austerity, political insecurity and weak public health governance. Whilst all reliant on the public healthcare system in SA face challenges in access, the abrupt 2025 suspension of PEPFAR and USAID-funded programmes has further destabilised the system. Concurrently, anti-migrant vigilante mobilisation at public healthcare facilities has intensified exclusionary rhetoric. This paper examines how structural violence—including its gendered dimensions, which shape whose suffering registers as a policy concern and whose exclusion accumulates unaddressed—bureaucratic discretion, and what Torres et al . (2022) refer to as “bordering through care”, shape everyday access to public healthcare for migrants in SA. The paper analyses how SA’s health system reproduces exclusion under the guise of legal frameworks and through scapegoating foreign nationals for a poorly performing healthcare system. The development of SA’s National Health Insurance (NHI) should be a strategic opportunity to achieve UHC yet it revokes healthcare access for asylum seekers and undocumented migrants. Healthcare workers are not immigration officials, nor should they be required to be, and healthcare facilities should not operate borders to police healthcare users. The paper proposes a rights-based, migration-aware and gender-responsive governance framework that responds to structural violence, calling for renewed political commitment to dignity, accountability, and UHC for all who live in SA.

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Publication Details

Journal
Discover Social Science and Health
Published
2026-10-18
DOI
https://doi.org/10.1007/s44155-026-00503-6
Primary Topic
Migration, Racism, and Human Rights
Type
article
Field-Weighted Citation Impact
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article

Examining the ways in which structural violence, austerity, and health governance shape migrant exclusion in public healthcare in South Africa

Anuj Kapilashrami, Tawanda Nyikadzino, Sonia R. Bhalotra, Sostina Spiwe Matina et al.
Discover Social Science and Health
Migration, Racism, and Human Rights
article

Examining the ways in which structural violence, austerity, and health governance shape migrant exclusion in public healthcare in South Africa

Anuj Kapilashrami, Tawanda Nyikadzino, Sonia R. Bhalotra, Sostina Spiwe Matina, Thea de Gruchy, Mbasa Dlamini, Rebecca Walker, Thobeka Sweetness Nkomo, Thulisile Zikhali, Martin Drewry, Jo Vearey, Santino Severoni, Kamaldeep Singh Bhui, Roomi Aziz, Alison Swartz, Lydia Moyo, Laura Kachale, Neha Adsul, Amita Bhide, Mukul Bhowmick, Srishti Jaitely, Pedzisayi Leslie Mangezvo, Kolitha Prabhash Wickramage, Miriam Orcutt, Shilajit Sengupta, Noorjehan Joosub, Tadesse Kassa Woldetsadik, Renos Papadopoulos, Wellington Mvundura, Ingrid Palmary, Diego Iturralde, Irudaya S. Rajan, Avni Amin, Stanley Muravha, Vichheka Ly, Josien Van Der Kooij, Anushree, Gill Green, Floris Swanepoel, Kunthea Soch, Kajoli Gokarn, Andrew Bateman, Modisenyane Moeketsi, Abigail Fairhall, Sivakami Muthusamy, Bangyuan Wang, Adetola Oyenubi, Lenore Longwe, B. Camminga, Shamiso Madzivire, Obindra Chand, Aparna Joshi, Fadzie Chipato, Phindile Ngobese, Gina Reinhardt, Milena Simic, Blessing Mukurava, Surekha Patil, Sisanda Gqoboka, Leakhana Ouk, Tanatswa Chineka, Doofan Udendah, Makara Orn, Devanik Saha, Xinze Li, Aastha Niranjan, Delan Devakumar, Tiffah Zauya, Ashleigh Stimpson
article en

Abstract

Abstract Migration is a critical social determinant of health, yet South Africa’s (SA) governance frameworks remain poorly equipped to address the structural violence faced by international migrants and resulting deep and intersecting inequities in health. Despite constitutional guarantees of Universal Health Coverage (UHC), international migrants routinely face administrative exclusion through discretionary gatekeeping by frontline healthcare workers and rising xenophobia within healthcare facilities—challenges sharpened under conditions of austerity, political insecurity and weak public health governance. Whilst all reliant on the public healthcare system in SA face challenges in access, the abrupt 2025 suspension of PEPFAR and USAID-funded programmes has further destabilised the system. Concurrently, anti-migrant vigilante mobilisation at public healthcare facilities has intensified exclusionary rhetoric. This paper examines how structural violence—including its gendered dimensions, which shape whose suffering registers as a policy concern and whose exclusion accumulates unaddressed—bureaucratic discretion, and what Torres et al . (2022) refer to as “bordering through care”, shape everyday access to public healthcare for migrants in SA. The paper analyses how SA’s health system reproduces exclusion under the guise of legal frameworks and through scapegoating foreign nationals for a poorly performing healthcare system. The development of SA’s National Health Insurance (NHI) should be a strategic opportunity to achieve UHC yet it revokes healthcare access for asylum seekers and undocumented migrants. Healthcare workers are not immigration officials, nor should they be required to be, and healthcare facilities should not operate borders to police healthcare users. The paper proposes a rights-based, migration-aware and gender-responsive governance framework that responds to structural violence, calling for renewed political commitment to dignity, accountability, and UHC for all who live in SA.

Discover Social Science and Health
Uppsala University (SE), University of the Witwatersrand (ZA)
Openalex Percentile: Top 9%
Migration, Racism, and Human Rights
DOIOpen Access PDFOpenAlex
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