# “Closing the gap in the wrong direction” migration, health policy, and the exclusion of asylum seekers, refugees and undocumented migrants from healthcare access in South Africa

## TL;DR

South Africa's recent health policies are excluding asylum seekers and undocumented migrants from healthcare, contradicting constitutional rights and global health goals.

## Contribution

This study reveals how institutionalized exclusion is codified in new health policies, undermining universal healthcare access for migrants.

## Key findings

- Legal and policy shifts systematically narrow healthcare access for asylum seekers and undocumented migrants.
- Mental health needs of migrants are severely neglected despite constitutional protections.
- Civil society organizations serve as unsustainable safety nets in the absence of formal healthcare access.

## Abstract

The right to health requires that healthcare systems be available, accessible, acceptable, and of good quality for all, regardless of legal or migration status. While South Africa’s Constitution and international commitments uphold this right, recent policy developments—such as the 2023 National Health Insurance (NHI) Act and the 2024 White Paper on Citizenship, Immigration, and Refugee Protection—mark a shift toward institutionalised exclusion. Discriminatory practices that were once informal are increasingly codified in law, aligning healthcare policy with a broader securitisation agenda and undermining progress toward Universal Health Coverage (UHC).

This paper draws on a multi-method research design combining a structured policy review of South African, regional and global frameworks, with semi-structured interviews (n = 25) conducted with healthcare providers, civil society actors, and government stakeholders between 2022 and 2025. Data was analysed using thematic analysis to explore how formal policy and informal practice interact to produce exclusion.

Findings reveal that legal and policy shifts are systematically narrowing healthcare access for asylum seekers, refugees, and undocumented migrants. Four intersecting themes emerged: (1) legal regression and policy securitisation; (2) policy by practice: informal exclusion and administrative discretion; (3) legal liminality and mental health and; (4) civil society as an unsustainable safety net. Despite constitutional protections, migrants are routinely denied care, misclassified, or subjected to unlawful fees. Mental health needs, in particular, remain severely neglected. The study highlights the limits of rights-based advocacy in a hostile policy environment and calls attention to the need for structural reform.

South Africa is not merely failing to meet its UHC goals—it is actively retreating from them. Exclusionary practices, once informal, are now guiding policy. Ensuring healthcare is truly accessible, acceptable, and sustainable for all requires urgent policy, legal, and institutional reforms to protect healthcare access for all, irrespective of status. Without these actions, the most vulnerable will continue to be excluded from essential services, undermining both constitutional values and global health goals.

The online version contains supplementary material available at 10.1186/s12889-025-24751-4.