OIM - Good practices

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Good Practices for Succesful Referrals and Linkages to Health and Non-health Services in Communities with

High Migrant Stock: Bushbuckridge and

Nkomazi, Ehlanzeni District in Mpumalanga Province, South AfricaThe opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the International Organization for Migration (IOM). The designations employed and the presentation of material throughout the publication do not imply expression of any opinion whatsoever on the part of IOM concerning the legal status of any country, territory, city or area, or of its authorities, or concerning its frontiers or boundaries. IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants. _____________________________ Publisher: International Organization for Migration 17 route des Morillons P.O. Box 17 1211 Geneva 19

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Email: hq@iom.int Website: www.iom.int Cover photo: From left: (1) Change agents conducting health promotion during door-to-door visit at the Orlando informal settlement in Nkomazi. © IOM 2022 (2) Road sign indicating the proximity of the Knows No Borders Project implementation sites in South Africa to the Lebombo border with Mozambique. © IOM 2023 (3) Change agent testing a beneficiary for HIV during an awareness campaign at Martins farm in

informal settlement in Nkomazi. © IOM 2022 (2) Road sign indicating the proximity of the Knows No Borders Project implementation sites in South Africa to the Lebombo border with Mozambique. © IOM 2023 (3) Change agent testing a beneficiary for HIV during an awareness campaign at Martins farm in Nkomazi. © IOM 2021 (4) Community dialogue on sexual and reproductive health and HIV needs at Block B in Nkomazi. © IOM 2021

Required citation: Chawhanda, C. and T. Mawadzwa (2025). Good Practices for Succesful Referrals and Linkages to Health and Non-health Services in Communities with High Migrant Stock: Bushbuckridge and Nkomazi, Ehlanzeni District in Mpumalanga Province, South Africa. International Organization for Migration (IOM), Geneva. _____________________________

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PUB2024/087/ELChristine Chawhanda and Tronny Mawadzwa Good Practices for Succesful Referrals and Linkages to Health and Non-health Services in Communities with

High Migrant Stock: Bushbuckridge and

Nkomazi, Ehlanzeni District in Mpumalanga Province, South Africaiii GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH

in Communities with

High Migrant Stock: Bushbuckridge and

Nkomazi, Ehlanzeni District in Mpumalanga Province, South Africaiii GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA ACKNOWLEDGEMENTS We thank IOM for entrusting TK Research Consulting with the project. We are indebted to the SRHR-HIV Knows No Borders (KNB) Project team in South Africa for their support during the data-collection process, their work with the participants and their assistance with the datacollection process. Additionally, we thank the project beneficiaries who dedicated their time to sharing their information and stories, which were instrumental in the success of this documentation. We would also like to thank the KNB Project’s change agents, for the invaluable role they play in linking community members to health and non-health services. We would also like to express our gratitude to the field team members and supervisors for their dedication to collecting quality data for t he study.v GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA CONTENTS Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii List of figures and tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

List of figures and tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii List of acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Key recommendations........................................ xiii Regional level........................................... xiii Government level, South Africa ........................... xiii IOM .................................................. xiii Introduction: Context and background . . . . . . . . . . . . . . . . . . . . . . . . 1 The Project purpose ........................................... 2 Study objectives and questions ................................... 2 Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Migration patterns and trends ................................... 3 Migration and sexual and reproductive health and rights – Human immunodeficiency virus .................................. 3 Referral system and linkages to care .............................. 4 Sexual and reproductive health and rights – Human immunodeficiency virus Knows No Borders Project community referra l system .......... 7 Health referrals ........................................... 7 Non-health referrals ....................................... 8 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Study design .................................................. 9 Study settings ................................................. 9

Study population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Data-collection tools ........................................... 9 Data-collection methods....................................... 10 Desktop review.......................................... 10 Key informant interviews .................................. 10 Focus group discussions ................................... 10 Sampling .................................................... 11 Recruitment and training of field staff ............................ 12 Data management and analysis.................................. 12 Data analysis ............................................ 12 Ethical consideration .......................................... 12 Strengths and limitations of the study ............................ 13vi CONTENTS Research findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Migrants’ health-seeking behaviour ............................... 14 Change agents’ roles and responsibilities .......................... 15 The Knows No Borders community referral and linkage system within the cross-border community ................. 15 Relevance of the Knows No Borders community referral and linkage system ............................................... 16 Strengthening the community referral system ..................... 17 South Africa referral system .................................... 19 Best practices that influenced referral completion in communities with high migrant stock ........................................ 19 Factors that inhibit referral completion in communities with high migrant stock ................................................ 21 Strengthening cross-border referrals ............................. 22 Effectiveness of health passports in cross-border referrals ........... 23 Support for change agents ..................................... 24 Successful referral stories ...................................... 25 Conclusion and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Key recommendations to strengthen referral in communities with high migrant stock ........................................ 27 Regional level............................................ 27 Government level, South Africa ............................ 27 IOM ................................................... 27

Key recommendations to strengthen referral in communities with high migrant stock ........................................ 27 Regional level............................................ 27 Government level, South Africa ............................ 27 IOM ................................................... 27 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29vii GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA LIST OF FIGURES AND TABLES Figure 1. Referral and linkage process ............................... 5 Figure 2. Referral patterns from 2018 to 2023 ........................ 7 Table 1. Project sites ............................................. 9 Table 2. Sample for key stakeholders ............................... 11 Table 3. Focus group discussions per district ......................... 11ix GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA LIST OF ACRONYMS AIDS acquired immunodeficiency syndrome ARV antiretroviral ART antiretroviral therapy CHC community health centre COVID-19 coronavirus disease DOH Department of Health FGD focus group discussion GBV gender-based violence HIV human immunodeficiency virus IOM International Organization for Migration KII key informant interview KNB Knows No Borders

SADC Southern African Development Community SRH sexual and reproductive health SRHR sexual and reproductive health and rights STI sexually transmitted infection UHC universal health coverage YVP young vulnerable peoplexi GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA EXECUTIVE SUMMARY IOM is implementing a project in the Southern Africa region titled Sexual and Reproductive Health and Rights (SRHR) – HIV/AIDS Knows No Borders Project (KNB) in six countries: Eswatini, Malawi, Mozambique, South Africa, Zambia and Zimbabwe. The project’s target population are migrant sex workers and YVP aged 10–29 years who reside in communities with high migrant stock in the six countries. In South Africa, the project is implemented in three subdistricts: Nkomazi and Bushbuckridge in Mpumalanga’s Ehlanzeni District and as of January 2024, Musina subdistrict in Limpopo’s Vhembe District. Access to health and non-health services is a challenge among both migrants and non-migrants, as well as sex workers, particularly those in communities with high migrant stock. Consequently, the KNB Project has developed a community referral and linkage system to link migrants, non-migrants, YVP and sex workers to health and non-health service points in the communities of Nkomazi and Bushbuckridge subdistricts. The referral system project has reported success since implementation. Hence, this study documents the effectiveness of the community referral and linkage system. As a result, this study intended to investigate further and achieve the following objectives: (a) Document the strengths and weaknesses, as well as the relevance of the community SRH referral system on health and non-health service delivery; (b) Determine the effectiveness of the community SRH referral system; (c) Determine the factors that influence referral completion; (d) Identify ways to strengthen cross-border referral;

(a) Document the strengths and weaknesses, as well as the relevance of the community SRH referral system on health and non-health service delivery; (b) Determine the effectiveness of the community SRH referral system; (c) Determine the factors that influence referral completion; (d) Identify ways to strengthen cross-border referral; (e) Document success stories that have resulted from clients being linked to care through the project.

Methodology: A rigorous qualitative method was employed to document the KNB community referral and linkage system. This involved data collection through the following: (a) FGDs; (b) in-depth interviews with change agents, migrants, non-migrants and sex workers; and (c) KIIs with key stakeholders facilitating community referral and linkage services. The study was conducted in selected sites within two districts of the Mpumalanga Province – Nkomazi and Bushbuckridge – ensuring a comprehensive and representative analysis of the referral system. The selected villages have been recipients of the SRHRKNB project interventions since 2016 due to the high concentration of migrants from Mozambique and Eswatini. Ethical approval was granted from Pharma Ethics and the Mpumalanga DOH Research Committee. Thematic content analysis was used to analyse the qualitative data.

Findings: While the Constitution of South Africa and the National Health Act uphold the right to health for all, including migrants, concerns persist that the existing legal and policy instruments do not fully address vulnerable populations’ specific health and non-health-care needs. The study found that the South African health-care system, with its provisions for facilities to access patient information and share relevant details with the referred facility using referral letters, plays a crucial role in the referral process. The established referral pathways are designed to ensure continuity of care. However, the implementation and utilization of these services can be challenging because referral practices are not standardized within the health-care system and patients’ preference for certain facilities.xii ExECUTIVE SUMMARY The study highlighted the multifaceted challenges that communities affected by migration face in accessing health and non-health services. These challenges include a lack of legal documentation, stigma and discrimination and language barriers. Many migrants visit clinics or hospitals without proper referrals

ExECUTIVE SUMMARY The study highlighted the multifaceted challenges that communities affected by migration face in accessing health and non-health services. These challenges include a lack of legal documentation, stigma and discrimination and language barriers. Many migrants visit clinics or hospitals without proper referrals or documentation from their country of origin, making it difficult to determine their past medical history, including important information, such as clinical reviews, previous management, medication regimens and any follow-up requirements. When seeking health services, individuals must provide identification and proof of residence, which can present challenges for migrants, especially those who are irregular. This situation often forces migrants to self-refer or use documents that do not belong to them, leading to misidentification. The study revealed that community health-care workers, such as the change agents of the KNB Project, play a crucial role in linkage to care, promoting and encouraging the utilization of SRHR and HIV services, as well as non-health services among migrants, non-migrants and sex workers. Consequently, the health-care providers and other stakeholders who participated in the study emphasized the importance of increasing the number of change agents to improve outreach and ensure more patients receive the necessary support and services. The KNB community and referral system reported positive outcomes through the work implemented by change agents. The good practices that enabled the success of the community referral and linkage system include the following: (a) establishing good relations with beneficiaries; (b) accompanying beneficiaries to health or non-health service points; (c) making follow-ups with beneficiaries to check if they did go and receive the services; (d) good relationships with health-care workers; (e) capacity -building received by change agents; and (f) regular visits at health facilities to educate patients on SRH services and their importance. The study found that providing continuity of care for seasonal migrant workers and cross-border patients who lack complete medical documentation is a significant challenge, and maintaining effective cross-border referral systems can be difficult. At the institutional level, the study identified that a lack of transportation for beneficiaries and resource constraints at health facilities, including staff shortages and limited ambulance services, prevent individuals in host communities from accessing the care they are referred for.

patients who lack complete medical documentation is a significant challenge, and maintaining effective cross-border referral systems can be difficult. At the institutional level, the study identified that a lack of transportation for beneficiaries and resource constraints at health facilities, including staff shortages and limited ambulance services, prevent individuals in host communities from accessing the care they are referred for. T o strengthen cross-border referrals, participants suggested that the health system consider strengthening the awareness of legal and policy frameworks related to referrals, fostering cross-border health collaboration between countries that share borders to strengthen health-care integration and enhance datacollection and identification systems. The participants also indicated that implementing bilingual (Portuguese and English) health cards could also improve health facilities’ ability to understand patient information and provide appropriate care and treatment. There is a need to improve health literacy and awareness of the implication of cultural practices on health among migrants and host communities.xiii GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA Key recommendations Regional level ■ Implementing bilingual (Portuguese and English) health/clinic cards would likely improve the ability of the health facilities to correctly understand patient information and administer appropriate care and treatment, especially for migrants from nonEnglish-speaking countries. Government level, South Africa ■ The findings indicate the need for a more connected, centralized health-care information management system that can consolidate patient records and enable better care coordination between providers and facilities in border communities. Improving data-sharing and increasing community-level support services are key priorities. ■ Strengthen the referral system at primary health-care level through formalizing and ensuring clear and streamlined referral protocols for host communities and migrants. This will include capacity-building on the importance of referral and linkage processes among migrants and host communities. ■ Increase mobile or community-based SRH and HIV testing services will improve accessibility and address barriers, for example, fear of stigma at clinics, especially for vulnerable populations, to

clear and streamlined referral protocols for host communities and migrants. This will include capacity-building on the importance of referral and linkage processes among migrants and host communities. ■ Increase mobile or community-based SRH and HIV testing services will improve accessibility and address barriers, for example, fear of stigma at clinics, especially for vulnerable populations, to create a more inclusive and supportive en vironment. IOM ■ Increase financial support: The role of change agents needs to be strengthened by ensuring they have the necessary resources (financial, transport, technical support and human resources) and support to conduct regular home visits and outreach activities. This will broaden the catchment area and hence increase the project ’s reach. ■ Conduct more capacity-building sessions with health facilities about the community referral and linkage system that KNB change agents are fac ilitating. ■ Establish strong partnerships and communication channels between change agents and healthcare providers to enhance the referral system is paramount, and this will continue to increase the success rate of completions. ■ Increase awareness campaigns to ensure understanding of the existing legal and policy framework for migration and health issues among stakeholders, including health-care providers, and sensitization of migrants, sex workers and YVP about their rights. This will alleviate the barriers experienced by migrants in accessing health facilities, such as discrimination and stigma. As for health-care providers, it will improve their knowledge of UHC for all.A wall mural depicting gender-based violence at Yadini Tavern in Mangweni, Nkomazi . © IOM 20241 GOOD PRACTICES FOR SUCCESFUL REFERRALS AND LINKAGES TO HEALTH AND NON-HEALTH SERVICES IN COMMUNITIES WITH HIGH MIGRANT STOCK: BUSHBUCKRIDGE AND NKOMAZI, EHLANZENI DISTRICT IN MPUMALANGA PROVINCE, SOUTH AFRICA

INTRODUCTION: CONTEXT AND BACKGROUND SRHR and HIV/AIDS are critical aspects of overall health and well-being, with profound implications for individuals, communities and societies. However, ensuring access to comprehensive SRHR and HIV services remains challenging, particularly in communities with high migrant stock. Migration involves the movement of people across national or international borders. The migration process brings about unique

SRHR and HIV/AIDS are critical aspects of overall health and well-being, with profound implications for individuals, communities and societies. However, ensuring access to comprehensive SRHR and HIV services remains challenging, particularly in communities with high migrant stock. Migration involves the movement of people across national or international borders. The migration process brings about unique challenges and vulnerabilities that can significantly impact the SRHR and HIV outcomes of individuals and communities. Migrants frequently face social, economic and legal barriers that hinder their access to essential health-care services, including those related to SRHR and HIV (Sanni, 2023). Migrants, especially those with an irregular immigration status, often have limited financial resources, lack health insurance and have restricted access to health-care services, all of which can impact their ability to seek and receive both health and non-health services. Language barriers, cultural differences, discrimination and fear of legal repercussions can further compound these challenges, leading to inequitable access to care (IOM, 2020a). Language barriers have been reported to impede effective communication between migrants and health-care providers, leading to difficulties in understanding health-care processes, including referrals (Chawhanda et  al., 2022). Furthermore, traditional beliefs, cultural practices and religious considerations may influence migrants’ perceptions of illness, treatment preferences and the value they place on referrals to health-care services (ibid.). While cultural and religious beliefs play a significant role in health-care decision-making among migrants, the legal and policy frameworks governing migration have a considerable impact on their access to and uptake of health-care services, including referrals. Documentation requirements, restrictive immigration policies and a lack of clarity regarding entitlements to health-care services can create barriers and discourage migrants from seeking referrals (IOM, 2020b). Similarly, the presence or absence of non-health services, including social support networks, can influence the utilization of health-care referrals among migrants. In a foreign land, migrants may become isolated and acclimatizing may take longer; thus, they may not have access to strong social networks that can provide them with information and emotional support to facilitate access to health-care services.

services, including social support networks, can influence the utilization of health-care referrals among migrants. In a foreign land, migrants may become isolated and acclimatizing may take longer; thus, they may not have access to strong social networks that can provide them with information and emotional support to facilitate access to health-care services. As a result, limited health information and awareness of available health-care services can influence migrants’ understanding and utilization of health services, including referrals. Limited access to healthcare facilities, particularly in rural areas, can affect the referral process for migrants and non-migrants. Unequal distribution of health-care resources, long waiting times and geographical barriers can impact the ability to receive timely referrals and access appropriate health care (IOM, 2018). IOM takes pride in its change agent model, which enables peers to become communicators and advocates of change in the communities. Change agents are lay community members committed to serving their communities by influencing, supporting and advocating for successful programme implementation (ibid.). Within the health system, change agents play a crucial role in addressing the challenges of accessing services by conducting health promotion and subsequently referring migrants and non-migrants to health and non-health services, resulting in increased uptake of these services (ibid.). Referral and linkage to2

INTRODUCTION: CONTExT AND BACKGROUND care systems are vital in addressing barriers to accessing health services for migrants, non-migrants and sex workers and ensuring that individuals receive timely and appropriate SRHR and HIV services. While health services play a critical role, non-health services, social support systems, community organizations and legal aid agencies also have an important part to play in addressing the broader determinants of SRHR and HIV outcomes among migrant populations.

The Project purpose The SRHR-HIV KNB Project seeks to improve sexual and reproductive health (including HIV-related) of both migrant and non-migrant YVP (10–29), sex workers and the destination communities living in migration-prevalent communities. The KNB Programme envisages an environment where the SRHR and needs of migrants, sex workers and YVP are institutionalized in policies and programmes. T o this end, the Project has focused on combining demand creation, strengthening service provision and creating

migration-prevalent communities. The KNB Programme envisages an environment where the SRHR and needs of migrants, sex workers and YVP are institutionalized in policies and programmes. T o this end, the Project has focused on combining demand creation, strengthening service provision and creating an enabling environment to ensure that rights-bearers can exercise their SRHR. The approach includes health promotion, capacity -building, multisectoral coordination and collaboration, and cross-border engagement. Through this approach and strategies, the Project has ensured that local-level (downstream) priorities inform higher-level (upstream) regional dialogue, agenda-setting and policymaking. Specifically, the Project’s objectives are as follows: ■ Healthy choices: The target population have safe sexual behaviour and greater freedom of choice about their HIV and SRH services by December 2026. ■ Access to services: Increased access to and utilization of quality SRH-HIV and other support services by December 2026. ■ Creating an enabling environment: By December 2026, the target population’s SRH-HIV rights and needs will be progressively addressed through changed sociocultural norms, policy reforms and implementation at local, national and regional levels. The KNB Project has shown that access to health and non-health service providers is a challenge among migrants, non-migrants, YVP and sex workers. Consequently, the KNB Project has developed a community referral and linkage system to link members of communities of destination, sex workers and migrants to health and non-health service providers. The community referral system is reported to have achieved an over 80 per cent referral completion success rate during the first and second phases of the Project. This is significant considering that the Project is being implemented in migration-prevalent communities of Nkomazi and Bushbuckridge, where mobility hinders access and utilization of health and non-health services. Hence, IOM has tasked TK Research Consulting with a study