Experiences of healthcare workers in providing services to migrants in Botswana

Abstract

Background

The experiences, perceptions and attitudes of healthcare providers play a crucial role in shaping migrants’ access to and quality of healthcare services. While the existing literature extensively examines migrants’ access to health care, it provides limited insight into the challenges health professionals face in providing care to this population. This study examines the experiences of healthcare providers in Botswana focusing on their attitudes, challenges and perceptions in providing care to migrants.

Methods

A descriptive qualitative design was adopted. Data were collected through semi-structured interviews with 20 healthcare workers between May 2019 and July 2019. The interviews were recorded, transcribed verbatim, and thematically analysed to identify recurring patterns and themes.

Results

Health professionals in different service sectors experienced similar difficulties in providing care to migrants. Healthcare providers noted that they encountered several difficulties when working with migrants, such as issues associated with referring migrant patients, limited understanding among migrants of the local healthcare system, communication obstacles, financial hurdles, and constraints in delivering healthcare to migrants.

Conclusion

The study highlights systemic and communication barriers that hinder healthcare for migrants. To address these issues, targeted training is required to enhance cultural competency, enhance communication strategies, and synchronise public health policies with the requirements of the migrant population to decrease ethical dilemmas for health care providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07716-4.

Background

The number of migrants worldwide has steadily increased over the past five decades. In 2020, an estimated 281 million people lived in countries other than their home country [1]. The growing number of migrants creates challenges in meeting migrants’ health needs. In reality, migrants often face unequal medical treatment when accessing healthcare institutions in host countries. Botswana Immigration Statistics estimated 160,644.00 migrants with a total population of 2,024,904 million [2]. In 2020, the United Nations Department for Economic and Social Affairs estimated the number to be around 110.300, and stressed that migration to Botswana was heavily influenced by industrial developments and the mining sector in the country [3]. According to the IOM, the majority of migrants in Botswana were from neighbouring Zimbabwe, and an estimated 40, 000 Zimbabweans are among Botswana’s workers, most of whom work in agriculture, construction, education, healthcare, manufacturing, and financial services among other sectors [4]. Botswana’s Constitution does not explicitly provide for the right to health, but a liberal and progressive interpretation of other relevant provisions would give those living in Botswana, including migrants, the right to access health services. The wording of the Botswana Bill of Rights does not discriminate between citizens and other persons of Botswana in the enjoyment of the rights enshrined in the Constitution (Sect. 3, Botswana Constitution). These rights include protection of the right to life, inhumane treatment, and discrimination. It is also important to note that constitutional rights in Botswana do not extend to socio-economic rights such as the right to health, shelter, and clean water. Botswana’s health delivery philosophy prioritizes providing quality and affordable health services through a decentralized model, with primary health care as its foundation [5].

The public sector, which is primarily government-funded, offers healthcare services at little to no cost for citizens, ensuring widespread access to essential care [5]. Botswana’s healthcare system is governed by several key policies aimed at ensuring the provision of equitable and comprehensive healthcare services to all residents, including migrants. The National Health Policy and the Integrated Health Service Plan are the primary documents outlining the country’s health strategies and objectives [6]. The National Health Policy of Botswana emphasizes universal health coverage and equitable access to healthcare services [5]. The public sector dominates, with over 80% of services accessed through public health facilities, offering free services at referral hospitals and primary clinics [6]. Private hospitals serve those with private medical aid [7]. Healthcare services are organized into different levels based on service complexity, with 27 health districts ranging from mobile stops and health posts to primary hospitals, district hospitals, and three referral hospitals [7]. However, despite these policy frameworks, access to healthcare remains a challenge for non-citizens due to systemic and legislative barriers. The Public Health Act and related policies often require documentation or proof of legal status, which many migrants lack, thereby limiting their access to essential health services. This restriction is further reinforced by concerns over the financial burden that migrant healthcare places on the national health system. The provision of healthcare services to the migrant population is often perceived as costly for the host country due to scarce resources [8]. This negative observation of migrants can be extended to the health sector, where healthcare workers become embroiled in contentious discourses and ethical challenges surrounding the provision of healthcare to vulnerable immigrant groups [9]. While some studies have described the health status of migrants and examined how migrants perceive service use in their receiving countries, there seems to be little focus on the perspectives of healthcare providers and the challenges they face in providing healthcare in migrant environments.

A systematic review by Suphanchaimat et al. [8] highlighted several significant challenges faced by healthcare providers, which include navigating different cultural beliefs, managing limited institutional resources, and dealing with the tension between healthcare ethics and national laws that often restrict migrants’ access to care. Another review identified specific issues in refugee healthcare settings, such as language barriers, cultural differences, gaps in healthcare providers’ knowledge and skills, and inefficient healthcare systems [10]. Similarly, a related study reported that healthcare professionals encounter difficulties when treating refugees and asylum seekers, which are further influenced by policy decisions affecting clinical practice, resource allocation, and professional roles [11]. These challenges are compounded by broader systemic issues, including inadequate training, lack of time, professional support, referral difficulties, higher costs, and staff shortages [11]. Additionally, the health system’s response is shaped by a fluid political landscape and growing hostility towards migrants among policymakers [11, 12].

While these systemic barriers have been widely examined in high-income countries, there is limited research on how frontline healthcare workers in Africa navigate these challenges. Although global research extensively documents the barriers faced by migrants in accessing healthcare, limited studies focus on the frontline healthcare providers in Africa who deliver these services [13]. Most studies emphasize patient perspectives, leaving a critical gap in understanding the lived experiences, attitudes, and ethical dilemmas faced by healthcare providers in migrant-receiving contexts such as Botswana [13, 14]. Despite the increasing focus on migrant healthcare access in Botswana, studies have yet to examine the experiences of healthcare providers themselves. In Botswana, Oucho and Ama [15] pointed out that the main barriers to access to healthcare for migrants and refugees are higher payment fees for access to reproductive healthcare, lack of follow-up care for migrants or refugees identified as HIV-positive, proof of immune status of CD4 counts or viral load testing, and lack of referral rights to clinics/hospitals for migrants and refugees to perform further health assessments. Another study by Moroka and Tshimanga [16] examined barriers to and use of health services by cross-border migrants and identified the following major barriers: cost, negative attitudes of medical staff, fear of police or immigration, language, and desire for another doctor. Lesetedi and Moroka [17] examined the attitudes of Zimbabwean migrants towards citizens in Botswana and reported that most immigrants exhibit some form of reverse xenophobia.

Although these studies provide valuable insights into migrant access barriers, they do not explore the perspectives of those delivering healthcare services [13]. Healthcare provider experiences in delivering care to migrants in Botswana remain underexplored, particularly in the context of systemic barriers, policy limitations, and resource constraints. Unlike studies in Europe and North America, where migrant health policies are well-integrated, Botswana faces fragmented implementation of health regulations for migrants, impacting healthcare workers’ decision-making and service delivery. Understanding the perspectives of healthcare workers is essential because they are the frontline actors who interpret, apply, and often adapt policies in real time. Their insights reveal practical challenges and opportunities that may not be captured in formal policy documents. Therefore, this study addresses this gap by examining healthcare providers’ attitudes, perceptions, and challenges in delivering care to migrants in Botswana. By providing empirical evidence from healthcare workers, this research contributes to policy discussions and workforce training aimed at improving migrant healthcare integration in Botswana and similar African contexts. By offering a subjective account of healthcare stakeholders’ experiences and perceptions, this study also contributes to the broader literature on migrant access to healthcare, highlighting the relationships between key stakeholders and their influence on public health.

The challenges faced by healthcare providers in providing healthcare to migrants can be explained using a four-level model of the healthcare system adapted from [18] (Fig. 1). The proposed model can help identify key factors related to problems and find solutions to them. The challenges faced by healthcare providers can be explained by (1) how they interact with migrant patients and the individual factors affecting access to health care. These individual factors include the availability of proper documents, legal status, payment barriers, language barriers, and knowledge of the healthcare system. (2) Factors associated with healthcare providers include attitudes towards migrants, lack of knowledge about services that migrants are entitled to, professional ethics vs. work ethics, and discretion. The third level of the model addresses the interaction between healthcare providers and workplace (healthcare facility) factors, including health governance and resource availability. Finally, the political and economic environment can influence the challenges faced by healthcare providers. This includes how health is regulated through policies, laws, and regulations that define migrant patients’ eligibility for healthcare.

Fig. 1.

Conceptual framework. Source: Adapted from Reid et al., (2005)

Methodology

Design

The study employed a descriptive qualitative research design, using one- and in-depth semi-structured interviews to examine the experiences of healthcare providers in Botswana, focusing on their attitudes, challenges, and perceptions in providing care to migrants. For this study, experiences refers to healthcare providers’ attitudes, perceptions, and challenges in delivering healthcare services to migrants in Botswana.The study was conducted in Gaborone and Francistown, two major cities in Botswana. Gaborone, the capital, is located in the southeast near the South African border and serves as the country’s economic center, housing numerous government offices, financial institutions, and businesses. Gaborone has over 15 public clinics providing primary care, maternal and child health services, and treatment for common illnesses and injuries. Five clinics (three with maternity services and two without) were selected for the study. Francistown, the second-largest city, is in the northeast and is well-connected by road and rail to Gaborone and neighbouring countries.

Francistown has around 10 public clinics offering similar essential healthcare services. Four clinics (two with maternity services and two without) were included in the study. These cities were selected due to their higher population densities that increase the demand for health services and increase the challenges and make them ideal for examining these problems. As a rule, urban areas have a more diverse population in relation to socio -economic status, ethnicity and health. Many cross -border migrants live in cities to maintain job opportunities and access to social services. Cities also have different health guidelines and administrative practices compared to rural areas. The examination of these variations helps to assign ethical guidelines to different urban contexts. The concentration on cities enables the study to record a wide range of challenges that healthcare providers face in complex urban health environments. Furthermore, considering the key role of the District Health Management Team (DHMT) Coordinator and antiretroviral therapy coordinators, who typically work at the DHMT headquarters (regional office), the DHMT office was also included as an additional study site. Including this site enabled the research team to gain broader insights into healthcare provision for migrants from a policy and coordination perspective. The integration of the DHMT office also facilitated access to stakeholders involved in healthcare decision-making and implementation at the regional level. The fieldwork was performed by the first author between May and July 2019.

Participants

Healthcare providers who had worked at the clinic for at least two years and had provided medical care to migrants were eligible to participate. Healthcare providers who had worked for one year or less were excluded because it was assumed that they did not have much experience in dealing with migrants.

Recruitment

A purposive sampling method was used for the recruitment process in which the researcher identified suitable participants from clinics. The nurse in charge of the clinic was asked for permission to conduct the study in the health facility. The lead researcher contacted potential respondents in person and by telephone and explained the objectives, inclusion, and exclusion criteria. The interviews explored the experiences of healthcare providers in providing healthcare services to migrants. The key areas include (1) background information, (2) entitlement to healthcare among migrants, (3) main difficulties faced by healthcare providers in the provision of healthcare services, and (4) changes in the provision of healthcare services to migrants. Interviews were conducted with 20 healthcare workers (15 nurses, two doctors, one district Health Management Team Coordinator, and 2 antiretroviral therapy coordinators (one interview session per participant, lasting for approximately 70–80 min. The interviews were conducted in English.

The final sample for this study comprised 20 healthcare providers, as presented in the demographic characteristics table. Although data saturation was reached after 11 interviews, meaning no new themes were emerging, interviews continued until 20 participants were engaged. This decision was made to strengthen the rigor, depth, and diversity of perspectives, given the varied roles and facility locations of participants. Continuing data collection beyond the point of saturation also allowed for further confirmation and refinement of emerging themes. This approach aligns with qualitative research practice, where additional data can support credibility and trustworthiness, particularly when working with a heterogeneous sample. Therefore, while saturation was a guiding principle, all 20 interviews were included in the final analysis to ensure a comprehensive understanding of healthcare workers’ perceptions regarding access to health promotion for migrants in Botswana.

Data management and analysis

This study followed the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to ensure that all essential elements of qualitative research reporting were addressed [19]. An interview guide was used to conduct face-to-face interviews with healthcare providers. The guide was designed to collect demographic information and explore key issues such as healthcare entitlements for migrants, provider experiences, service access, and policy application. This paper focuses primarily on the challenges encountered by healthcare providers, with additional findings to be presented in future publications. A pilot study involving four healthcare providers across two clinics helped to modify the guide and improve alignment with the study’s objectives. The guide was developed by the lead researcher and refined with input from co-researchers. All interviews were audio-recorded, transcribed verbatim, and imported into Atlas.ti version 9 for analysis. A deductive thematic analysis approach was used [20, 21-22], guided by the study’s research questions and supported by a four-tier health systems model [23]. The analysis followed Braun and Clarke’s [21] thematic analysis approach, which involved the following stages:

1. Familiarization: The lead researcher read and re-read all transcripts to gain an overall understanding of the content and context.

2. Initial Coding: Sentences and key phrases were used as units of meaning. The lead researcher developed initial codes based on the research objectives, while also allowing for inductive (emerging) codes from the data itself.

3. Collaborative Review: Co-researchers independently reviewed and coded transcripts. Coding outputs were compared, and differences were discussed until consensus was reached, ensuring consistency and reducing bias.

4. Categorization: Related codes were grouped into broader categories reflecting patterns and similarities across interviews.

5. Theme Development: Categories were refined into overarching themes that captured the core challenges faced by healthcare providers in delivering health promotion to migrants.

6. Interpretation: Themes were interpreted in relation to the study objectives, four-tier health systems model, and the broader health system context.

To enhance trustworthiness, we applied qualitative standards, including investigator triangulation, an audit trail of coding decisions, and maintaining close engagement with the data through both manual and software-assisted coding [24], [25]. This approach ensured analytical rigor while minimizing decontextualization of meaning [18]. The lead researcher, a trained sociologist and demographer with over a decade of experience in health research, conducted the interviews and led the analysis. Their prior engagement with migrant health and healthcare systems in Botswana provided contextual sensitivity while acknowledging the potential for bias. The co-researchers, also trained in demography and anthropology, independently reviewed and coded transcripts to challenge assumptions and enhance analytical depth. Reflexive discussions among the team helped maintain objectivity throughout the research process.

Ethical considerations

All respondents received an interview guide and informed consent form. Ethical considerations included informed consent from all participants, who were assured of the right to withdraw from the study at any point without penalty. Written informed consent was obtained from all participants prior to their interviews. The interviews were audio recorded with the consent of the participants. The confidentiality of participants was protected through anonymization of transcripts and secure data storage. This study was approved by the University of Botswana (Institutional Research Board; Clinical Trial Number: HDPME 13/18/1) and the Ministry of Health Research Committee, which is Health Research and Development Committee (HRDC).

Results

This study aimed to explore the experiences and challenges faced by healthcare providers in delivering healthcare services to migrants in Botswana. The findings revealed several interrelated themes that reflect the complexity of providing care in this context. These include: (1) challenges in accessing health due to individual-level factors such as legal status, payment, language, and system knowledge; (2) healthcare workers’ attitudes; (3) Healthcare facility factors, including lack of resources and unclear guidelines; and (4) Policy and regulatory issues that influence provider decisions and migrant eligibility. The themes are organized using a four-tier health system framework to illustrate the multi-level challenges that healthcare providers face.

Twenty healthcare providers participated in the study. Detailed socio-demographic characteristics are presented in Table 1. As shown in the table, most participants are female and aged between 25 and 49 years. The majority hold a diploma qualification, while a smaller proportion have degrees. Work experience varies, with most participants having between four and eleven years in service. The study also includes a mix of roles, such as nurses, midwives, doctors, and coordinators, providing diverse perspectives on healthcare delivery.

Table 1.

Demographic characteristics of the participants

Participant ID	Sex	Age range	Number years Worked	Educational level
1. Nurse in charge, clinic 1	Female	40–49	12	Diploma
2. Nurse, clinic 3	Female	25–35	4	Degree
3. Nurse, clinic 1	Female	25–35	4	Degree
4. Nurse, clinic 2	Female	35–45	7	Diploma
5. Nurse, clinic 3	Female	35–45	8	Diploma
6. Doctor, clinic 4	Male	30–35	8	Degree
7. Midwife, clinic 5	Female	40–49	10	Diploma
8. Doctor, clinic 6	Male	35–45	8	Degree
9. Nurse, clinic 4	Male	25–35	3	Diploma
10. Midwife clinic 7	Female	30–35	7	Degree
11. Nurse, clinic 6	Female	35–45	6	Diploma
12. Midwife, clinic 7	Female	40–49	11	Diploma
13. Nurse, clinic 8	Female	40–49	10	Diploma
14. Nurse, clinic 2	Female	25–35	4	Diploma
15. Nurse, clinic 8	Female	30–35	7	Diploma
16. District coordinator	Male	40–49	11	Degree
17. Nurse, clinic 9	Female	40–49	10	Diploma
18. ARV Coordinator, clinic 10	Male	40–49	11	Degree
19. Nurse, clinic 2	Female	25–35	4	Diploma
20. ARV Coordinator	Female	40–49	10	Degree

Challenges in healthcare provision

Table 2 organizes the main challenges health workers face when caring for migrants, structured according to a four-tier health system model. This model provides insight into the factors that influence healthcare at every level, from individual interactions to broader systemic influences.

Table 2.

Challenges faced by healthcare workers in providing healthcare to migrants: a four-level model analysis

Themes	Level	Explanation
Challenges in Accessing Health	Individual Factors	Refers to individual challenges faced by migrants, such as proper documentation, legal status, payment barriers, language barriers, and familiarity with the healthcare system. Includes issues like referral barriers and lack of transport that hinder access to health services.
Healthcare Worker Attitudes	Healthcare Worker Factors	Encompasses healthcare workers’ attitudes towards migrants, including perceptions of migrants as “tricky” or difficult to understand, their knowledge of services available to migrants, the balance between professional ethics and work ethics, and the degree of discretion exercised in providing care.
Healthcare Facility Factors	Interaction Factors	Examines the relationship between healthcare workers and the workplace, focusing on health governance, resource availability, and institutional support that can either facilitate or hinder care delivery to migrants.
Policy and Regulation	Political and Economic Factors	Addresses the influence of the broader political and economic environment, including policies, laws, and regulations that define migrant patients’ eligibility for healthcare and shape the operational context of healthcare delivery.
Challenges in Tracking Next of Kin	Interaction Factors	Refers to difficulties healthcare workers face in identifying and contacting the next of kin of migrant patients, which can complicate care and communication during treatment.

Challenges in accessing health (Individual Factors)

This level represents the personal challenges that migrants face and that directly impact their access to health services. Migrants often face document problems, legal restrictions, language barriers and unfamiliarity with the healthcare system. Health system challenges such as referral barriers and lack of transportation also limit their access to necessary care. These barriers create an environment in which health workers must manage complex individual needs and systemic constraints to ensure appropriate care.

Language barriers

Several participants stated that the biggest challenge in dealing with migrants was the problem of the language barrier. The reason for this is that migrants generally do not understand the national language of healthcare workers. Another problem is that migrants may also be cared for by a healthcare provider who does not speak English, which also complicates communication between the two parties. One of the participants said: “The difficulty for migrants in accessing the services is that they face a language barrier, some migrants do not fully understand Setswana and they may be cared for by a nurse who does not speak English well, so there is always a problem, especially when they consult the doctor, and then it looks like the administration is not completed, but the problem is the language barrier (Interview 14: registered nurse).

Another respondent expressed the same opinion:

“We cannot communicate with most migrants in English. Therefore, sometimes it is difficult for us to help them when there is no one to interpret Ndebele or Shona because we do not have interpreters in the clinic” (Interview 2: registered nurse).

The challenges of language as a barrier lead to communication problems that can result in migrants not correctly following the instructions given to them. The lack of interpreters for healthcare workers was also seen as a further obstacle. Healthcare workers tend to only give migrant patients the medications they will then see what to do. One of them said: Most migrants do not follow instructions, and the language barrier can also be a problem. O moneela hela o tla bona gore o tswa jang kwa pele (You just give to the migrant, he/she will see what to do). (Interview 11: registered nurse).

Payment barriers

Payment barriers are a big challenge that migrant face, which also affects how health care is provided to migrants. In other words, healthcare workers face difficult decisions regarding fulfilling their professional responsibilities while following policies. Participants further highlighted that migrants face challenges when revenue collectors are around because they insist that they pay for services. Thus, migrants that are unable to pay for healthcare services are not assisted.

A respondent mentioned, “

Migrants experience difficulties when revenue collectors are present. They are often required to pay and subjected to further investigation until payment is made. If they fail to pay, they face even more challenges. Those who can afford to pay are discharged, but if they cannot pay, no action is taken on their case. In some instances, even if they pass away, they remain in the facility without any intervention or pressure to settle the payment (Interview 8: Registered Nurse).

Participants were of the view that payment barriers affect migrants’ healthcare access. However, for those who can pay, the payment process is often lengthy because migrant patients are typically referred from clinics to go and pay at the referral hospital. The lack of revenue collectors contributes to lengthy payment barriers. One of the participants stated, the lack of revenue collectors in our clinic is a challenge for payment purposes for migrants who have to go to the referral hospital to pay. Thus, a revenue collector should be hired. You return a patient or refer him/her to the referral hospital to pay” (Interview 11: Registered Nurse).

Another respondent said,

“The difficulty we face when giving migrants healthcare services is the barrier of payment, imagine someone coming to the clinic and being sent back to pay at a referral hospital and then coming back again to access the services, so if someone is as far as Block 14 clinic and they are sent to the referral hospital then they find a queue, this is a problem” (Interview 9: Registered Nurse).

Participants also mentioned that the lengthy payment process was worsened by the system used in the referral hospital, which is always down/not working most of the time. They also highlighted that information about payment for healthcare services is often different from that of hospitals and clinics. Participants also discussed that they often made suggestions in meetings that revenue collectors should be hired in clinics to deal with payment issues. On a different note, participants mentioned that some migrants often lack the funds to make payments for registration, transportation, and healthcare. Pregnant migrant women face challenges in paying for antenatal care.

Lack of knowledge of the healthcare system on the part of the migrant

Healthcare workers mentioned that migrants lacked knowledge about the health system and also about the type of health services offered in health facilities. This is a concern for participants as migrants only know about the type of health services offered at the health facility and sometimes find that the health facility does not provide the service they are looking for. One of the participants said: “Lack of knowledge of the healthcare system is a problem because, firstly, they don’t know exactly the services offered by the Extension 66 clinic, they just know that it is a clinic and they can go there whenever they want need it.” We help them and can tell them that we do not provide Child Welfare Clinic services, ANC services, or delivery services. You won’t determine until you get here. This lack of knowledge is a problem for them because they do not use the services most of the time. (Interview 2: registered nurse).

Lack of knowledge about health services offered in the health sector is a challenge for migrants as they are only told what is expected of them in order to receive medical care. One of the participants said, “I think lack of knowledge about the health services could be a challenge, but again, when everyone arrives at the clinic, when they enter the clinic, they will learn what to do, they will know, they have to pay an amount that is 20 pula or 50 pula, they always find their way to the clinic”. (Interview 19: Doctor). Participants also felt that a lack of knowledge about the healthcare system could lead to migrants feeling that healthcare workers are unwilling to help them.

Challenges related to referrals

Healthcare workers face significant referral challenges when dealing with migrant patients, as migrants are often unfamiliar with the referral process and the specific services available in different healthcare facilities. Hospital administrators expect a patient to pay first before they can be assisted, and they even expect the healthcare provider who brought the patient to pay. This lack of understanding often leads to migrants seeking treatment in clinics that cannot meet their needs, creating frustration for both patients and healthcare providers.

A registered nurse explained, “Migrants don’t know the specific services offered by clinics like Extension 66. They might assume they can get any service here, but then find out we don’t offer things like ANC or Child Welfare services.” (Interview 2).

Another participant highlighted the importance of guidance, noting that, “When migrants arrive at the facility, there should be someone to help them navigate– like a consultation advisor– to direct them to the right wards or services.” (Interview 14).

This lack of system knowledge can also lead to misinterpretations, as migrants may feel neglected or believe healthcare workers are unwilling to assist. A midwife commented, “When a migrant doesn’t understand the system, they might feel that you’re refusing to provide care, not realizing it’s an issue of available services.” (Interview 10).

These reflections suggest that clear, accessible information and guidance for migrants on referral procedures and service availability could improve their healthcare experience and reduce barriers to appropriate care.

Healthcare worker attitudes (Healthcare worker Factors)

Health workers’ attitudes and perceptions towards migrants can influence the quality and extent of care provided. Some healthcare workers perceive migrants as “tricky” or challenging, which may stem from communication barriers or cultural misunderstandings. In addition, healthcare workers lack knowledge about the healthcare services to which migrants are entitled and conflicts between professional ethics and workplace policies may arise. This level reflects the influence of healthcare workers’ knowledge, discretion and perceptions on patient care. One of the participants said: “The difficulties that migrants face in accessing health services at this clinic are, in my opinion, due to the attitude of the caregivers and most of them are out of fear that they do not have the right documents and do not have the financial means to pay.” (Interview 12: Registered Nurse). Another respondent mentioned that healthcare workers mistreat migrants; Healthcare provider mistreat patients. Participants also discussed that the lack of access to migrants is due to the attitudes of healthcare workers, especially when a migrant patient does not have the correct documents/is an undocumented migrant.

One of the participants said: Since we as an institution have not provided the service and I have not, the attitude problem arises when we say someone is undocumented and I will not do it or provide the service but they come, that means someone is not allowed to offer a service and you ask yourself, colleague, they will tell you that I did not offer it because he or she did not have the papers, it is a question of attitude. (Interview 1: registered nurse).

Healthcare facility factors (Interaction factors)

This level is about the interaction between health workers and the health facilities in which they work. Key factors include the availability of resources, support for health care providers, and institutional policies regarding the treatment of migrants. Facilities with limited resources or unclear policies on migrant health care create an environment in which health workers face greater challenges in providing consistent and equitable care. Furthermore, the difficulty of identifying next of kin of migrant patients complicates patient management and continuity of care. Difficulties in locating next of kin have been cited as a challenge for healthcare workers in providing services to migrants. When a patient is seriously ill, healthcare workers face the challenge of determining who to consult. On the other hand, it is usually difficult for healthcare workers to correctly record patients’ medical history at home. Participants also discussed the challenges of not having contact details, such as the patient’s whereabouts, and how this could impact continuity of care.

One respondent said: “The challenges one experiences; Lack of relatives in cases where a migrant patient is on the ground. (Interview 2: registered nurse). The Participants also shared the same opinion: “The biggest difficulty in dealing with migrants is the language barrier, and the second is the question of next of kin. For example, if I am treating a patient and I want further information or the patient’s medical history, and the patient is not communicating due to his condition, then you will find that the problem is that the family or the people you can help are not in the country but at home, where the patient comes from and it becomes difficult to help the patient. Sometimes I want the patient to receive more and continuous care at home, but then that person doesn’t have a home, maybe he/she works, he/she is a maid and stays in the home Where he/she works, it means that he/she is at the Continuity of care at home in terms of support is lacking as all relatives are at home, so the question of next of kin is an issue”. (Interview 7: registered nurse).

Another respondent said; “It is difficult to identify migrants’ next of kin when we refer them because they sometimes do not provide their contact information”. (Interview 6: registered nurse). Participants also highlighted that migrants are difficult, leading to a lack of trust between healthcare workers and migrant patients. Healthcare workers are typically unsure whether immigrant patients will report health problems when seeking medical care.

Policy and regulation (Political and economic Factors)

In the broadest sense, the political and economic context shapes the experiences of healthcare workers by defining migrant patients’ eligibility for healthcare through policies, laws and regulations. National policies that limit migrants’ access to health care or are unclear about entitlements pose ethical and logistical challenges for health workers. The broader regulatory environment thus directly influences the extent to which health workers can support the health needs of migrants. Most participants felt that migrants face challenges in accessing healthcare due to policies that exclude them. They stressed that the guidelines stipulate that migrants must pay for treatment at public health facilities. However, the guidelines are also silent on what to do if a migrant patient cannot pay.

One of the healthcare workers said: “Our policy–the provision of services to migrants or access to healthcare– is that the foreigners should pay.” In cases where he/she cannot pay, he/she is silent; he/she should pay or nothing else. Sometimes we offer his or her discretion; I can give the service to the patient or deny the service, but for us as nurses, we know that we should provide the services regardless of race, colour or background. It is our plaque, but these policymakers don’t come to us to tell us what to do, so we continue to offer our services. (Interview 13: registered nurse).

Another added:

“We need to harmonize things because we really need to know what to do when and where, how we have a problem, there are guidelines in terms of whether we want to charge the migrants money, and now we’ve fallen into the nurses’ trap.” In between, we are the ones who see these people. If you’re not careful, you can sometimes get into trouble; you never know how the authorities will react. They come to us to ask us about this topic. They were shocked that we took care of migrants 12 times without paying and ended up delivering them without paying. When we asked them what to do, they had not told us what to do. The authorities should provide clear guidelines and instructions on the steps to take. Healthcare services should be paid as agreed upon, but it must be clear what steps to take when dealing with non-citizens, how the patient should pay, and when we tell them to go and pay. Policymakers are failing us. We must provide services to all people, including migrants. (Interview 6: registered nurse).

Another respondent stated the following:

Failure to provide a particular form of healthcare, e.g. ARVs is a painful situation for healthcare workers, but we refer to the guidelines. The lack of antiretroviral drugs for migrants can cause stress and illness for healthcare workers, but we are trying to be strong. We live with all these problems and are used to re amogela seemo (we accept the situations), o nna moko o thata (to be tough). It is beyond our control that you may become ill or have stress-related problems. Participants also mentioned that they face challenges when providing ARVs to migrants. They also emphasized that not providing ARVs to migrants as healthcare workers is a difficult and painful process for them, which can lead to stress on them (Interview 15: registered nurse).

Discussion

This study explored healthcare providers’ experiences in delivering care to migrants in Botswana, focusing on their perceptions, attitudes, and the challenges they encounter. The findings highlighted several barriers, including referral issues, payment constraints, language difficulties, healthcare provider attitudes, and exclusionary policies, as well as broader systemic challenges such as transportation limitations and healthcare system knowledge gaps among migrants. These findings provide critical insights into the complexities of healthcare delivery in the context of migration.

Healthcare providers in this study reported challenges when referring migrant patients to specialized services, especially due to the lack of official documentation and payment requirements in advance. These barriers reflect systemic inefficiencies that disrupt the continuity of care, which is reflected in other studies worldwide. For example, Newbold (2011) [26], Suphanchaimat et al. (2015) [8] and Matlin et al. (2019) [27] reported similar referral challenges in Canada, Thailand and South Africa, where bureaucratic hurdles and financial restrictions delay timely care. In Botswana, the lack of a clear transfer path for undocumented migrants tightens these problems and underlines the need for extensive guidelines that ensure fair access to transfer services. The requirement for upfront payments further restricts migrants’ access to healthcare, as observed in this study. Respondents noted that migrants often miss necessary care due to their inability to pay, which aligns with findings from Jayaweera (2020) [28] and Doctors of the World (2019) [29]. These studies emphasize that financial barriers not only limit healthcare access but also create ethical dilemmas for healthcare providers tasked with balancing care delivery and institutional policies. The current system in Botswana reflects global trends and suggests that urgent policy reforms are needed to address economic disparities in access to healthcare.

Language emerged as a critical barrier, with healthcare providers struggling to communicate effectively with migrant patients due to the absence of professional interpreters. This finding aligns with research of Posselt et al. (2017) [30], Jensen et al. (2013) [31], Ahmed et al. (2013) [32] and Jayaweera (2020) [28], which have highlighted the detrimental impact of language barriers on patient satisfaction and health outcomes. The lack of interpreter services in Botswana reflects a broader trend in resource-limited settings, where language barriers often lead to misdiagnoses and increased mistrust. Addressing this challenge requires investments in interpreter services and cultural competency training for healthcare workers. Negative attitudes towards migrant patients, described by respondents, mirror findings from Matlin et al. (2019) [27] in South Africa, where xenophobia among healthcare providers has been termed “medical xenophobia [33]. Such attitudes not only compromise patient trust but also highlight systemic biases within healthcare systems.

In Botswana, these attitudes may be exacerbated by limited training in cultural competence and the lack of institutional support for managing diverse patient populations. Interventions to address these issues must prioritize empathy training and policy frameworks that promote inclusivity. Respondents also identified exclusionary health policies as significant barriers to migrant healthcare access. Policies that require official documentation or restrict services to citizens disproportionately affect migrant populations, as demonstrated in study from Costa Rica [29]. In Botswana, such policies not only undermine health equity but also increase the burden on healthcare providers, who are often left navigating these restrictions while attempting to deliver care. Policymakers must consider revising these frameworks to align with international human rights standards and promote universal healthcare access. Other systemic challenges identified in this study include transportation barriers, difficulties locating next of kin, and a lack of knowledge among migrants about the healthcare system. These findings align with research by Priebe et al. (2011) [34] and Berg and Smaland (2011) [35], who reported similar challenges in resource-limited settings. Migrants’ limited understanding of healthcare systems often results in delays in seeking care, further complicating their health outcomes. To address this, public health campaigns that educate migrants about available services and their rights are essential.

These findings carry several implications for healthcare providers, facilities, and national health policy. For healthcare providers, there is a clear need for targeted training programs that enhance cultural competence, language proficiency, and empathetic service delivery to better manage increasingly diverse patient populations. At the facility level, investments in supportive infrastructure such as interpreter services and strengthened referral systems can significantly improve care quality and reduce the access barriers faced by migrant patients. From a policy perspective, there is a pressing need for inclusive health policies that actively address economic, linguistic, and systemic obstacles. Such policies should aim to ensure equitable access to healthcare for all individuals, regardless of migration status.

Limitations of the study

The findings of this study may not be generalizable to all healthcare providers in Botswana, as the research primarily focused on healthcare facilities in urban settings and a specific group of providers (nurses). As a result, the experiences of healthcare workers in rural areas or those in different professional roles, such as doctors and community health workers, may not be adequately captured. Additionally, the study’s context-specific nature means that the results may not be applicable to other African countries with distinct healthcare policies and migrant populations. The study relies on self-reported perceptions and experiences, which introduces the potential for social desirability bias, where healthcare providers may be inclined to present themselves in a more favorable light, possibly underreporting negative attitudes towards migrants. Recall bias may also affect the accuracy of responses, particularly if participants have infrequent interactions with migrant patients.

Although the sample size of 20 participants may appear small by quantitative standards, it is consistent with qualitative research principles that prioritize depth and richness of data over breadth. The number of interviews conducted was sufficient to reach data saturation and allowed for an in-depth exploration of the healthcare providers’ experiences. However, as the study was limited to providers working in public urban clinics, the findings may not reflect the perspectives of healthcare workers in private healthcare settings or rural areas. This may limit the transferability of the findings to other contexts within the country.

Conclusion

This study highlights the multifaceted challenges healthcare providers face in delivering care to migrants in Botswana, including systemic, policy-related, and attitudinal barriers. Addressing these issues requires a comprehensive approach that integrates healthcare system reforms, provider training, and inclusive policy frameworks. Future research should explore the long-term impact of such interventions on both healthcare delivery and migrant health outcomes.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

ARV

Antiretroviral

DHMT

District Management Team

HIV

Human Immune Virus

IOM

International Office of Migration

Author contributions

GB came up with the idea for the study. GB conducted the analysis with guidance from TG and DSR.GB also prepared figure 1 with input from TG and DSR. GB wrote the initial draft of the manuscript, and TG and DSR reviewed it. All the authors read and approved the final version.

Funding

No funding was sourced to conduct the study.

Data availability

Data would be provided upon request.

Declarations

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

Ethical approval and consent to participate

Consent to participate in the study was sought from all participants. All methods were performed in accordance with relevant guidelines and regulations at University of Botswana. Approval for this study was obtained from the University of Botswana (Institutional Research Board) and the Health Research and Development Committee (HDPME 13/18/1).

Source

Adapted from Reid et al., (2005)