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

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.

The authors' abstract, as published at the source. Discover Social Science and Health, 2026 · DOI ↗