Continuity of medical care for migrant workers

Introduction:  Hundreds of thousands of southern Africans are cross-border or internal rural-urban migrants who oscillate between the areas in which they work and their home areas.  Social and occupational factors result in high burdens of diseases in these migrant workers, human immunodeficiency virus and tuberculosis prominent among them. Treatment may be initiated by medical services in the work areas (e.g. by workplace programmes), but if patients are unable to continue working they usually return to labour sending areas. Ensuring continuity of medical care is complicated by logistical and resource issues: for example, health services in labour sending areas may be inaccessible and are often less well resourced than those in industrialised areas, and treatment protocols may vary across countries.  Treatment interruption or drug change may affect recovery of individuals, but importantly may promote drug resistance and the spread of disease in labour sending areas. Multi-drug resistant  tuberculosis is of particular concern.   A number of steps to enhance continuity of care has been recommended and some implemented. Some of these are long-term and ambitious, strengthening health systems in labour sending areas is an example, but others are more focussed: detailed standardised patient-held medical transfer cards; shepherding selected patients from one facility to another; and inter-country standardisation of treatment protocols are examples. Despite these efforts continuity of care remains problematic and a high-level multi-country southern African meeting is to review the problems and identify solutions.   This paper will review the literature on continuity of care issues in the region, and critically comment on current and proposed solutions; those arising from the multi-country meeting will be included. The solutions should be of interest to many regions of the world with high levels of migrancy.