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Migration is increasingly recognized as a determinant of health. Research shows that in many cases cross-border migrants arriving in new countries are healthier than the host population. But the advantage often disappears as non-citizens face discrimination and challenges in accessing documentation, support services and employment.
The health and well-being of all individuals within a country’s borders must be taken into account. But African states have failed to design and implement health systems and responses sensitive to migration. Many non-citizens, asylum seekers and refugees are excluded from public health programs.
The impact of such exclusions is now being felt. COVID-19 illustrates how refugees, asylum seekers, internally displaced people and migrants are excluded from pandemic preparedness plans, including national immunization programs.
Evidence shows that the vast majority of migrants are currently excluded from state COVID-19 vaccine deployment programs. These forms of exclusion are likely to have far-reaching implications for public health. To effectively reduce the spread of COVID-19, everyone should be vaccinated. Otherwise, the virus will continue to spread as new variants emerge.
The African continent has the lowest COVID-19 vaccine coverage in the world. Only 2% of the population has received at least one dose of the vaccine. But beyond that is the question of how countries are implementing their own COVID-19 vaccination programs and who they are leaving behind.
Some countries include migrant populations. But the International Rescue Committee (IRC) reported in May 2021 that 60% of countries receiving their vaccines through COVAX had excluded refugees or displaced populations within their national plans.
We have conducted research exploring access to COVID-19 vaccines across the continent. Our findings and a case study from South Africa highlight the issues of vaccine nationalism, vaccine exclusion and reluctance and their likely effect at the population level.
Exclusion and violation of rights
Restricted access to vaccines is a clear example of discrimination against migrants. Not all migrants are undocumented and not all who are undocumented are vulnerable. But the exclusion of specific groups on the basis of citizenship, immigration, or document status violates their human right to health and affects the success of any vaccination program.
Our survey revealed how migrants and refugees are excluded.
First, migrant populations have simply not been included or been ignored in the vaccination deployment plans of many states. Few immunization programs across Africa clearly indicate if – and how – various groups of migrants will fit into the deployment. For example, an internal WHO report in May 2021 noted that in Nigeria, there are fears that more than 2.7 million internally displaced people are at risk of being completely ignored in current immunization plans. .
Second, even when non-citizens are explicitly included in plans, as in Kenya and Senegal, they can face obstacles. For example, in Kenya, refugees are afraid to come forward and access public services such as public health care. The same WHO report noted that Kenya could exclude hundreds of thousands of refugees due to a mismatch between policy and practice.
The risks of arrest, detention and deportation are significant in many states. If people don’t feel safe, COVID-19 vaccination programs will be less effective.
There are, however, notable exceptions on the continent – Rwanda, Cameroon and Senegal being three. For example, Senegal and Cameroon allow refugees to enroll in health facilities and designated municipal councils. Rwanda was one of the first 20 countries in the world to start immunizing refugees and asylum seekers alongside citizens. The national response plan prioritizes asylum seekers and refugees alongside health workers and key members of civil society and the community.
The case of South Africa
Exclusion, barriers to access and discrimination are clearly visible in Southern Africa, and more particularly in South Africa. The region presents various historical and contemporary migratory patterns. South Africa has the highest rates of cross-border migration. It is estimated that only 7% of South Africa’s population was born in another country.
Due to an increasingly restrictive immigration regime and a seriously compromised Home Office, many migrants in South Africa find it difficult to regularize their stay. As a result, those who start with a work permit or asylum seeker permit often find themselves – through no fault of their own – without valid documents.
For refugees and migrants in South Africa without papers, the consequences of not having papers are considerable. They are unable to access formal employment and bank accounts, and have difficulty accessing basic health care. Undocumented migrants live with the persistent threat of arrest and deportation.
When the vaccination rollout requires an ID number, passport number or refugee permit to register, there is no option for those who do not. Additionally, there is no clear guideline on how undocumented people – including South African citizens – can register for vaccination.
The South African government has included refugees and asylum seekers with documents in the country’s immunization rollout.
Reluctance to vaccination
Finally, a response to vaccine hesitation among local communities and migrant groups on the continent requires collective action between states, international humanitarian organizations and civil society. Besides a distrust of the vaccinations themselves, reluctance can take the form of a fear of being mistreated because of anti-foreign attitudes, or a fear of arrest or deportation.
For example, in the Central African Republic, rumors circulated of “foreigners” spreading the virus and even fears that international aid agencies could create the virus to earn money. In Rwanda, rumors and the spread of disinformation have gained ground in some areas.
More strategic thinking is needed to raise awareness, build confidence and define protective measures for those who fear getting vaccinated. As the International Organization for Migration has pointed out, reaching migrant communities, in appropriate languages and through appropriate communication channels, is essential to create demand for vaccines.
One approach would be to include civil society organizations, community groups and religious leaders in vaccine deployment programs.
One clear way to improve everyone’s security is to use firewalls. These offer legal protection to undocumented people, ensuring that they do not face any penalties when accessing state health services. Any information collected is used only by the health system.
Look ahead
According to Dr Matshidiso Moeti, WHO Regional Director for Africa, so far “… the continent has only received 1.7% of the 3.7 billion doses worldwide, and .. . only 1.5% of the population has been fully vaccinated ”.
Not only does the continent need more doses of vaccines, but countries must also include all migrant populations. Failure to ensure universal access compromises national responses to COVID-19. The consequences have extended far beyond these nations.
There is no room for hypocrisy. The international community cannot be challenged on vaccine nationalism if states do not themselves provide an inclusive national response. Without vaccinating everyone, no one is immune.
Jo Vearey receives external research funding, including from UK Research and Innovation (UKRI), the European Commission, AmplifyChange, the International Organization for Migration (IOM) and the World Health Organization (WHO ).
Nicholas Maple and Rebecca Walker do not work, consult, own stock, or receive funding from any company or organization that would benefit from this article, and have not disclosed any relevant affiliation beyond their academic position. .
By Rebecca Walker, Research Associate at the African Center for Migration and Society, University of the Witwatersrand And
Jo Vearey, Associate Professor, University of the Witwatersrand and
Nicholas Maple, Postdoctoral Fellow at the African Center for Migration and Society (ACMS), University of the Witwatersrand
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