Migration, gender and health system responses in South Africa: A focus on the movement of healthcare users and workers

This project will examine how migration and population mobility affect the South African health system, how the health system responds and adapts as a result of migration and population mobility, and crucially, how gender intersects with these processes. It will adopt an intersectionality approach.

The research will be undertaken in South Africa, a country that has historically faced high levels of migration - both inward, outward, and internal. The research focuses on mobility of patients and health workers into and out of South Africa and interactions with the public health system. It will involve the application of a range of innovative qualitative and quantitative research methods.

Specifically, the research will involve examining: a) levels of migration of healthcare users and workers within, into, and out of South Africa; b) healthcare experiences of migrant, non-migrant and mobile healthcare users, and migrant and non-migrant health workers; and c) how the South African health system responds to these user and/or worker movements. Given the increasing recognition of the gendered nature and effects of migration, the research explicitly explores gender and how gender shapes the above experiences. We will develop recommendations for how the health system in South Africa, and elsewhere, could improve responses to migration and population mobility including gendered aspects.

It will include an innovative method of tracking patient movement over time using social media (WhatsApp), which will generate new data on how movement by patients into and out of South Africa interacts with their health systems use. This is paired with a new quantitative analysis of existing data sets on movement of patients and health workers into and out of South Africa. Specifically, this quantitative analysis includes analysis of the Tourism South Africa border survey, and the first ever analysis of patient mobility as it is regulated under the bilateral agreements between the South African government and 11 neighbouring countries.

This research project is situated in the field of health policy and systems research and develops a novel analysis to understand better how gendered aspects of migration and mobility affect the health system, drawing on a case study of health workers and patients in South Africa. It specifically examines the complex interactions of migration, gender and health systems taking an intersectionality approach.
Research will analyse the movement of patients out of and into the public health system in South Africa, through novel investigation of existing data sets and generation of new quantitative and qualitative data by tracking mobile healthcare users over time using the social media application whatsapp.
Applying this highly innovative approach, we will develop new understanding in the field of health systems, including methodological approaches to researching migration and mobility, and to applying intersectionality and gender as a lens in health systems research. This builds directly on the work by Gilson and Sheikh conceptualising the health system as consisting of software and hardware aspects, and especially Gilson's work that has highlighted how the complex and 'messy' interactions between people - patients and providers - shape the health system. Moreover, the research proposed takes forward the work by the RiNGs Consortium which has developed a framework for integrating a gender perspective into health systems work, and drawing on the field of intersectionality by Hankivsky, examines specifically the intersection between gender, migration and health system. It thus applies some of the most exciting theoretical approaches and frameworks in health systems to some of the most pressing issues.

This proposed project is a research collaboration between researchers at the London School of Hygiene and Tropical Medicine (LSHTM), the Africa Centre for Migration and Society (ACMS) at the University of the Witwatersrand (Wits), the University of Cape Town (UCT) and the South African Department of Health (DoH). It has been developed to address one of the most pressing issues facing health systems globally and at national level in South Africa - the impacts of and response to migration and its intersection with gender. The proposal responds specifically to needs identified through exploratory research undertaken by the investigators in South Africa which in turn informed the Global Agenda for Migration Research published in the Lancet in 2017. The project has been designed to directly inform policies and build capacity amongst researchers, policymakers and implementers, to make health systems more responsive to the intersection between gender and migration in South Africa and globally. It will do so by generating new knowledge and a series of innovative impact activities.

Building capacity on gender, migration and health systems
At provincial and national levels in South Africa:
- Findings from the research will inform on-going training of national and provincial staff organised by the International Organization of Migration (IOM), World Health Organization (WHO) and DoH on migration and health.
- The research has been co-designed by senior DoH staff. Co-I Modesinyane the International Health Coordinator in the DoH has actively participated in all aspects of the research process.
- It is envisaged that this closer collaboration on migration and health will significantly increase the DoH capacity to respond to these issues. Modesinyane's participation is supported by the participation of senior DoH staff on the advisory board (Yogan Pillay).
- Informing teaching on MSc in Public Health programmes at Wits and the UCT.
- Findings from the research will also be presented and tested through seminar presentations both at the ACMS and UCT, and the Johannesburg Migration Forum a civil society coordinating mechanism in which Vearey is closely involved.
- A regional launch of findings will take place at the ACMS in year 3 of the project.
- The project will build directly on the networks of researchers and civil society developed by Vearey's maphSA project (a Wellcome Trust Investigator Award on migration and health), which already has developed a strong network an online platform and twitter handle.
- Co-I Modesinyane actively participates in the regional activities relating to migration and patient mobility at the level of the Southern African Development Community (SADC) and the African Union).

At global level
Findings will be of great interest and relevance to policymakers and researchers working on migration and those working on health systems at globally. Indeed, the activities here have been designed in collaboration with the health team and the IOM. They include:
- Development of a global short course on health and migration. It will become a permanent course offered jointly by LSHTM, the ACMS and UCT.
- A project website and twitter account, which will act as a hub for findings of the research team.
- Presentation at national and international conferences, with the Health Systems Research Symposium key.
- Publication of findings in academic journals.
- Present seminars and workshops to policymakers, researchers, media and the general public in case-study countries, with support of the LSHTM Press Office: A key aspect here will be the Geneva launch of the project's findings in Year 3 to ensure reach to international policy makers.
- Researchers will also build on the existing collaboration with initiatives such as the WHO EURO Summer School on Migration and Health, where Hanefeld is a contributor/presenter to disseminate findings.
- A series of webinars to discuss project findings and methods