South Africa’s latest immigration white paper was approved just six weeks after public submissions closed. Collective Voices for Health Access combed through 18 of those submissions and found a clear pattern in concerns raised: exclusion, quietly institutionalised through documentation and digital systems increasing barriers in access to healthcare for migrants and South Africans alike.

The recent spate of anti-foreigner marches that took place in some South African cities over the last two weeks is a clear indication of just how normalised xenophobia has become in public life.

Groups such as March and March and Operation Dudula have mobilised around a familiar – and largely uncontested – narrative: that migrants are responsible for unemployment, crime, and mounting pressure on public services. No evidence, however, is provided for these inflammatory claims.

Minister in the Presidency Khumbudzo Ntshavheni described the protests as a security and reputation risk to the country, while Justice and Constitutional Development Minister Mmamoloko Kubayi will have to defend South Africa against charges of xenophobia at an African Union summit in June following a complaint lodged by Ghana. This followed a rare intervention from UN Secretary General, António Guterres, on South Africa’s Freedom Day, who warned against the escalating harassment and intimidation of migrants and foreign nationals.

Xenophobic rhetoric and scapegoating are nothing new in South Africa, nor is its role in mainstream political and social media discourse. But while public attention has been fixed on street mobilisation, inflammatory slogans and statements by politicians, a quieter and potentially more consequential shift has been unfolding through policy.

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In March, the Cabinet approved South Africa’s revised White Paper on Citizenship, Immigration and Refugee Protection.

At first glance, the document appears more moderate than earlier drafts – more carefully written, with some of the more extreme proposals, including the suggestion that South Africa withdraw from international refugee frameworks, removed. But beneath the softer language lies a deeper shift: the steady institutionalisation of exclusion through documentation systems, digitisation, and migration controls that increasingly frame migrants as a burden to be managed rather than people with rights. This will affect predominantly black people from the African continent.

The danger is not only the xenophobia visible on the streets. It is the quieter form of exclusion embedded in administrative systems and public policy – and this is the form that tends to endure.

Were submissions carefully considered? 

Cabinet took less than six weeks from the close of public submissions on the Draft White Paper to approve a revised text, raising serious questions about whether submissions were meaningfully considered. In response, Collective Voices for Health Access of civil society organisations, activists, healthcare workers, and researchers – established a public archive of the submissions shared with them and produced a synthesis of key concerns that, taken together, point to a troubling pattern.

The evidence is consistent: claims of an overwhelming “influx” of migrants do not withstand scrutiny, nor can pressures on the health system credibly be attributed to non-nationals. There is tangible evidence, however, of corruption, mismanagement, and tender rigging.

Locked out

Many migrants remain undocumented not by choice but because they are locked out of an asylum system that is dysfunctional and characterised by chronic backlogs, blocked access to registration and appeal mechanisms that fail in practice.

This is not only administrative inefficiency; it is the production of legal liminality, where people are rendered “undocumented” through systemic dysfunction rather than individual choice.

The policy, therefore, fails a basic constitutional test: it must be rational, evidence-based, and connected to fact; on current evidence, that standard appears to have not been met.

South Africa has committed itself to universal health coverage. The National Health Insurance Act promises access to healthcare based on need, not the ability to pay. Yet, alongside this commitment, a parallel policy trajectory is emerging – one that involves documentation, legal status, and administrative systems. Statistics South Africa estimates that approximately 13% of South Africans lack formal documentation, while many more struggle to navigate fragmented and under-resourced state systems to obtain IDs and passports, or register births, deaths, and marriages. Policies that hinge access on paperwork deepen existing exclusions rather than resolve them.

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This is not simply a migration issue. It is a governance issue.

The more access to care is filtered through the administrative system, the more vulnerable we all are to the failures of those systems. Rural communities, elderly people, those without IDs, people living in poverty, and anyone caught in bureaucratic limbo all face a disproportionate level of barriers when healthcare access, continuity of care, and public health become conditional on paperwork rather than medical needs.

At the centre of this shift is the growing role of documentation and digitisation.

Intelligent population register 

The white paper proposes an “intelligent population register” and expanded use of biometrics, without sufficient clarity on how these systems and the data they collect will be protected. For many people, access to documentation is already precarious or inaccessible – meaning inclusion in these systems may remain out of reach.

Digitisation also carries a subtle risk: the chilling effect. As data systems become more integrated across the government, concerns about information-sharing – real or perceived – can deter people from accessing services altogether. If visiting a clinic is seen as exposing oneself to immigration enforcement, the consequences are predictable: delayed treatment, avoidable illness, and greater long-term strain on the health system.

Internationally, there is growing evidence of health data being used in immigration enforcement contexts. Without a clear firewall 

between the departments of health and home affairs, similar dynamics could emerge in South Africa.

The 18 submissions analysed by Collective Voices for Health Access consistently emphasise the need for policy alignment, clear safeguards, and a separation between healthcare access and immigration enforcement. There is little evidence that these concerns have been meaningfully incorporated into the final policy framework.

There is an uncomfortable irony here. South Africa has positioned itself globally as a defender of constitutionalism, rights, and international law – willing to challenge more powerful states on matters of principle. Yet domestically, elements of migration governance are increasingly echoing a familiar playbook: tightening access to services, elevating documentation as a gatekeeper, and framing migrants as the source of systemic strain, despite evidence to the contrary.

At times, these arguments are repeated to the point of becoming a broken record. But the persistence of the problem demands persistence in the response. How many times must the same evidence be presented before it is taken seriously?

Ultimately, this extends far beyond migration. A system that produces exclusion, that people cannot realistically comply with, and that increasingly governs access through documentation rather than need, will not deliver universal health coverage. It will undermine it.

If South Africa is serious about building a health system that works, migration governance must align with that goal. That means addressing administrative failure, ensuring access is not contingent on documentation, and recognising that the system is not separate from society – it shapes, includes, and excludes all of us.

- Rebecca Walker, Thea de Gruchy, Sharon Ekambaram and Marlise Richter are part of Collective Voices for Health Access.

*The Collective Voices for Health Access is a consortium of progressive civil society organisations, activists, healthcare workers, and researchers working on issues of social justice and challenging xenophobia within the healthcare sector.

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