Internal migration and health in South Africa: determinants of healthcare utilisation in a young adult cohort

Abstract

Background: In South Africa, human geographic mobility is high as people engage in both permanent and temporary relocation, predominantly from rural to urban areas. Such mobility can compromise healthcare access and utilisation. The objective of this paper is to explore healthcare utilisation and its determinants in a cohort of internal migrants and permanent residents (non-migrants) originating from the Agincourt sub-district in South Africa's rural northeast.

Methods: A 5-year cohort study of 3800 individuals aged 18 to 40 commenced in 2017. Baseline data have been collected from 1764 Agincourt residents and 1334 temporary, mostly urban-based, migrants, and are analysed using bivariate analyses, logistic and multinomial regression models, and propensity score matching analysis.

Results: Health service utilisation differs sharply by migrant status and sex. Among those with a chronic condition, migrants had 0.33 times the odds of non-migrants to have consulted a health service in the preceding year, and males had 0.32 times the odds of females of having used health services. Of those who utilised services, migration status was further associated with the type of healthcare utilised, with 97% of non-migrant rural residents having accessed government facilities, while large proportions of migrants (31%) utilised private health services or consulted traditional healers (25%) in migrant destinations. The multinomial logistic regression analysis indicated that, in the presence of controls, migrants had 8.12 the relative risk of non-migrants for utilising private healthcare (versus the government-services-only reference category), and 2.40 the relative risk of non-migrants for using a combination of public and private sector facilities. These findings of differential utilisation hold under statistical adjustment for relevant controls and for underlying propensity to migrate.

Conclusions: Migrants and non-migrants in the study population in South Africa were found to utilise health services differently, both in overall use and in the type of healthcare consulted. The study helps improve upon the limited stock of knowledge on how migrants interface with healthcare systems in low and middle-income country settings. Findings can assist in guiding policies and programmes to be directed more effectively to the populations most in need, and to drive locally adapted approaches to universal health coverage.

Keywords: Health and demographic surveillance system; Healthcare utilisation; Internal migration; Migrants; South Africa.

Fig. 1

Density of temporary migration (shown as percentage temporary migrant) in the Agincourt study population, in three successive five-year historical periods: 2003–2007, 2008–2012, 2013–2017

Fig. 2

a The Agincourt HDSS is located in the sub-district of Bushbuckridge, Mpumalanga province South Africa and is situated about 500 km north-east of Johannesburg (Map generated by ArcGIS version 10.4.1), b The map, generated using ArcGIS Desktop 10.8.1, indicates the distribution of migrant destinations

Fig. 3

Healthcare utilisation by age and sex, n = 3095

Fig. 4

Healthcare utilisation by migrant status (for those who used services in the past year), n = 1607

Fig. 5

Logistic regression: profile of migrants ((n = 3094, LR χ₍₆₎² = 356.63, p = 0.000)

Fig. 6

Logistic regression: health service use by migrant status among those with a prior diagnosis of a chronic condition (n = 335, LR χ₍₆₎² = 29.49, p = 0.000)