What are the factors and who are the actors that determine whether migrants obtain legal residency in Germany and South Africa? What does being an irregular migrant mean in terms of gaining formal access to public healthcare in the two countries? It is not only in the enactment of laws designed to regulate immigration and the rights of migrants that state sovereignty is evident, but also in policy implementation procedures and their results. This research study widens what has hitherto been a purely Western focus on these questions by comparing and contrasting the implementation of policies in Germany and South Africa. This comparison demonstrates the factors that decisively influence the ability of states to achieve conformity between legal regulations and policy implementation results, for example, the quality of laws and policies, available resources, municipal commitment, and the cooperation networks of governmental and non-governmental actors.