Chapter 19
GLOBAL AND REGIONAL HEALTH
Usuf Chikte, Ritika Tiwari, Precious Matsoso, Yogan Pillay, Robert (Bob) Fryatt, Lindiwe Makubalo
Introduction
This chapter provides an overview of the global health context and main health issues facing the African region and the rest of the world. The overview includes the main actors and institutions that influence health in South Africa, and those which South Africa influences globally. The responsibilities for the health of the people of South Africa are laid out in the South African Constitution and in the National Health Act, no 61, 20031. Whilst most of the provisions of both these require accountability within South Africa, it is common currency that the health of people within the country is influenced by factors beyond the borders of the country, both in terms of the determinants of health and in interventions to improve health. Global health transcends national borders and links people and other living species together beyond states, continents or regions, making particular health problems central for the whole world, within the context of security imperatives and humanitarian values2
Global health landscape
Over the last three decades, the global health landscape has undergone rapid transformation in terms of the disease focus, health actors, funding and architectural arrangements. One of the significant features of the current health landscape has been a major epidemiological and demographic transition with increased life expectancy giving rise to growing and aging populations. At a policy level the Sustainable Development Goals (SDGs) or Agenda 2030 introduced, at a level of health and wellness, aspirations targeting Universal Health Coverage (UHC) through Primary Health Care (PHC). The World Health Organization (WHO) has translated this aspiration to the Triple Billion programme targets on protection from emergencies, healthier lifestyles and prevention3 Emerging diseases and outbreaks have become more dominant, posing major threats which are accompanied by significant social, public health and economic consequences.
The period under review in this chapter has been characterised by the rise in global public health threats. Ebola emerged as a global threat to public health in 2015 and continues to be a threat in the African region. In 2019, an unprecedented pandemic, COVID-19, shook the world and brought the entire globe almost to a standstill. COVID-19 spread across 215 countries and territories claiming lives, with dire social, economic and health consequences as well as laying bare the fragility of health systems, and the worlds’ ability to produce and distribute countermeasures against COVID-19. The shortcomings of international instruments and mechanisms to respond to widescale epidemics and pandemics were laid bare. The COVID-19 pandemic also generated a greater cooperation between scientists, institutions and agencies to find rapid solutions, underscoring the need to intensify and invest in research and development with the view to understand rapidly the new variants and embark on a race to discover a vaccine, therapeutics, appropriate diagnostics tools and public health prevention measures with calls for greater investments in these areas. South Africa played a major political role during this period and contributed significantly through sharing information and discoveries and collaborating on the scientific front. The COVID-19 pandemic has reiterated the value of international cooperation and collaboration. When the World Health Assembly convened in May 2020, member states passed a resolution emphasising the need for solidarity, resource redistribution, and collective action4.
South Africa’s role in the multilateral system for global health
The global health institutional system has seen expansion over the past few decades in the form of a continued increase in both the number and diversity of actors5-7. The increasing number of health agencies has its pros and cons. Concerns have been raised that non-multilateral agencies could weaken the multilateral approach and undermine the more democratic approach to global policy-making. However, the interactions between global health actors are influenced by the actors themselves, the internal arrangements within the system, and external forces, such as actors and arrangements from other important global policy domains8. Multilateralism is an important tool for ensuring inclusive global policy. Organisations such as the WHO have provided low- and middle-income countries an opportunity to participate in framing global health policy and to some extent influence the flow of resources. During this period, South Africa played an important role in the global multilateral system.
During the period under review, South Africa as a member of the Foreign Policy and Global Health Group led resolution on UHC to the United Nations General Assembly. In addition, South Africa co-chaired the Health Employment and Economic Growth initiative, led by the WHO, International Labour Organization and Organisation for Economic Co-operation and Development. South Africa served on the WHO Executive Board for a three-year term and chaired for a year. This was during the most crucial time of WHO reform. South Africa played a stewardship role in the Stop TB initiative as its chair, in the BRICS initiative advocating for the combatting of TB in 2016. The Stop TB Partnership has been key in advocating for an enhanced response to the global burden of tuberculosis. The Stop TB Partnership represents a coalition of over 1 600 government, civil society and donor organisations and is currently hosted by the United Nations Office for Project Services and was previously hosted by the WHO. South Africa led the resolution of the United Nations General Assembly for the convening of a High-Level Meeting on TB in September 2018 as part of the Global Health and Foreign Policy member countries which included Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand. The significant role played by South Africa as the G20 member was led by President Ramaphosa with its role as founding member of the WHO Access to COVID-19 Tools Accelerator (ACT-A) initiative, and as a member of the G77 which strongly advocated for stopping TB. The South African Health Minister co-chaired the Facilitation Council with Norway, guiding the work of ACT-A, leading to the establishment of the Manufacturing Task Force on vaccines, which has been instrumental in advancing negotiations on technology transfer to Africa and other developing countries.
Assuming African Union chairpersonship in 2020 was a significant development as it placed the country in the forefront of COVID-19 activities globally and on the continent. In 2020 South Africa chaired the African Union Commission and initiated and supported programmes on COVID-19 such as the AVAT Africa Vaccine Acquisition Platform9, the development of the Africa Taskforce for Novel Coronavirus (AFTCOM), African Medicines Supplies Platform (AMSP) COVID-19 Response Fund, and envoys led to the President being nominated COVID-Champion by African Union heads of states in 2021.
South Africa and health diplomacy
South Africa made several other significant contributions to global initiatives. Largely led and guided by the South African Mission to the UN, South Africa was able to contribute to the framing of declarations and global policy resolutions on an extensive list of critical areas. This included antimicrobial resistance, the Global Vaccine Action Plan, primary health care, neglected tropical diseases, Ending TB, maternal, infant and young child nutrition, and initiating and leading negotiations on Ebola which led to a significant global response. South Africa also played a significant role on the International Health Regulations (IHR), establishing the WHO Emergencies programme, and chairing the Independent Oversight and Advisory Committee (IOAC) for the WHO Emergency Programme. In 2020 South Africa in collaboration with India proposed and has been negotiating for a waiver on some provisions of the Trade Related Aspects of Intellectual Property Rights (TRIPS
agreement) for preventing and containing COVID-19. South Africa also represented Africa on the UNITAID Board, the Global Fund Board, the IHR Committee, and other key initiatives.
In addition to this diplomacy and advocacy, South Africa has continued to be a significant contributor to the research, science and technical developments through science institutions and contributions by South African scientists on a large number of technical advisory groups and committees.
Case Study: Regional Agenda Shaping – The Role of Communities, Civil Society and Non-Governmental Organisations in South Africa for HIV Advocacy and Health Delivery
Civil Society in South Africa has also been a major influence and inspiration to many areas of health. Perhaps most important has been its influence in tackling HIV. In 2006, international and African scientists and politicians gathered to identify and discuss the main drivers of the HIV epidemic in Southern Africa, which led to the identification of key drivers which included multiple concurrent sexual partnerships, gender power inequities, high population mobility, and cultural norms and belief systems10. The consensus among scholars about the main drivers is that the social context in high-prevalence communities in South Africa plays a major role in the way in which sexual risk-taking is configured in the country.
Historically, the role of communities in places with people living with HIV (PLHIV) and peers in service delivery, research and drug development, as well as groups responsible for advocacy, social and political accountability, resource mobilisation and social and human rights protection have also been recognised as some of the crucial drivers for HIV. Their leadership and engagement have contributed significantly to improved outcomes in access to HIV treatment, prevention, and support and care services around the world. Their continued and expanded role is especially important for the future success of HIV responses in sub-Saharan Africa, where the HIV burden remains the greatest. The lessons learned from the leadership and involvement of communities of PLHIV and peers in the HIV response hold value beyond HIV responses. The models and approaches they have efficiently and effectively utilised have relevant applications in addressing shortfalls in health systems in the COVID-19 era, as well as broader, more integrated health challenges as countries move to develop and operationalise UHC11
Specific initiatives of regional importance
Public–Private Partnerships for Health
Public–private partnerships in health offer significant opportunities for strengthening health care systems, especially in Africa where the health financing gap is a major issue. The development and implementation of the Bioko Island Malaria Elimination Project is a case in point. Loss in productivity through absenteeism as well as high health costs motivated this 15-year project. This partnership between the government of Equatorial Guinea and three private sector partners (Marathon Oil Corporation, Noble Energy and Atlantic Methanol Production Company) has been reported to have reduced the prevalence of malaria by 75%. The results have been substantial, with 1 000 infected mosquito bites per capita annually in 2004, down to three bites per capita in 2018. Lessons learned from this example include acknowledging the challenges caused by different management and operational styles between partners that can cause conflict, continuity of funding, and different expectations of potential outcomes and responsibilities. In addition, a potential weakness on the part of governments is the development of national health plans without considering or including the participation of the private sector in the process, thus ignoring the symbiotic role companies can play in bolstering the services offered by the public health system14
African Continental Free Trade Area (AfCFTA)
In an increasingly interconnected world, the AfCFTA agreement will play an important role in facilitating trade of health products and medicines on the continent, including through reduced tariffs among member countries and will cover policy areas such as trade facilitation and services, as well as regulatory measures with reference to sanitary standards and technical barriers to trade. In general, the agreement is expected to create the largest free trade area in the world measured by the number of countries participating. AfCFTA can lift an additional 30 million people from extreme poverty (1.5% of the continent’s population) and 68 million people from moderate poverty15. The pact aims to connect 1.3 billion people across 55 countries with a combined gross domestic product (GDP) valued at US$3.4 trillion16. With the global economy in turmoil due to the COVID-19 pandemic, the creation of the vast AfCFTA regional market is a major opportunity to help African countries diversify their exports, accelerate growth, and attract foreign direct investment15
Human Rights and International Justice
South Africa is party to international laws and agreements such as the United Nations Convention on the Rights of Persons with Disabilities53. In 2018, almost 600 000 children with disabilities remained out of school. Most children with disabilities attend specialised schools or classes. Children with psychosocial disabilities are frequently placed in poorly regulated special service centres, based on long-term institutionalisation, often located far from their families and communities, and lack properly trained staff. No legislation exists to give full effect to the right to inclusive education for all children with disabilities. Across South Africa, a high number of cases continued to be reported of corporal punishment, violence, abuse, neglect and inequality involving children with disabilities, especially children with autism spectrum disorder and children with psychosocial and/or intellectual disabilities, by teachers and peers in schools and school hostels17
As in previous years, the government has still not implemented key aspects of the 2001 national policy to provide inclusive education for all children with disabilities, nor adopted legislation to guarantee the right to inclusive education. However, the government continued to implement the Screening, Identification, Assessment and Support (SIAS) policy designed to ensure that children with disabilities are provided full support when accessing education. The majority of the government’s limited budget for learners with disabilities continued to be allocated to special schools rather than to inclusive education17.
International development assistance within South Africa
Historically, during the transition to democracy, the international community supported President Mandela’s nation-building process by channelling all development assistance via the new democratic government. The first years of the democratic dispensation saw the establishment of the Reconstruction and Development Programme (RDP), with a dedicated ministry under the presidency. Through the use of the fiscus and extra budgetary resources from donors and the private sector, the government constructed low-cost housing and extended access to water and electricity to millions of poor18 Management of foreign aid was led by the RDP Ministry under the presidency, but under President Mbeki this was shifted to the National Treasury and managed by the International Development Cooperation unit in the Budget Office. Official development assistance (ODA) from donors was now aligned to government priorities, and used in a more strategic way to support development planning, apparatus building and public policy. As attention shifted to state building, less funding went to civil society, causing a gradual non-governmental organisation (NGO) crisis over the next years with many organisations obliged to shut down.
South Africa was never an aid-dependent country, as ODA never exceeded 1% of the government’s own budget. Technical support, however, continued and was used primarily to address the capacity gaps in the government and improve delivery of services. South Africa has to a large extent received funding and technical support through multilateral sources, mostly the WHO. Much of development assistance was therefore provided through bilateral engagements in the form of resources, capacity development, exposure visits, dialogue, and knowledge exchange with other countries. An important global debate at present is the extent to which upper-middle-income countries such as South Africa can expect development assistance. Increasingly, upper-middle-income countries are not receiving assistance. This was evident, for instance, during the COVID-19 pandemic, when South Africa was one of the few countries in Africa that did not qualify for support from COVID-19 Vaccines Global Access (COVAX) to purchase vaccines and had to purchase from domestic resources. Most middle-income countries, South Africa included19 nevertheless have high poverty rates and a weak capacity of the public service to deliver appropriate services, which thus justified donor engagement. It is also argued that COVID-19 and the measures that were put in place have had a significant impact on most economies. At the same time, South Africa has been fortunate as it attracted many donors because of its strong macro-economic stability and a world-class public financial management system18.
In the past, South Africa had a major national human resource deficit and this was addressed with the import of technical skills – engineers, doctors, teachers, and other specialised personnel from Europe and North America, as well as from Cuba, Iran, Uganda and other African countries with higher levels of education18. Prior to democracy, most development assistance from foreign donors would flow via civil society, churches, student organisations and the private sector20. Major institutions that acted as conduits of foreign aid included the Kagiso Trust, Urban Foundation, Gerald Foundation, Rural Foundation, Cofuka Steps, Joint Education Trust, South African Chamber of Commerce, and the United Democratic Front18
Today, South Africa’s largest donors include the United States, the European Union, Germany, the United Kingdom, France, Netherlands, Belgium, various Nordic countries, and United Nations programmes and funds18. The ODA is provided through a mixture of budget support (provided through the RDP Fund), technical cooperation and concessionary loans. The bulk of foreign aid goes to the health and education sector, where South Africa still has major deficits and the largest HIV-infected population in the world21
Significant amounts of US funding (mostly from the United States President’s Emergency Plan for AIDS Relief or PEPFAR, the US Centres for Disease Control and Prevention, and other HIV-related funds) are channelled largely through NGOs, research centres, universities and public entities18. The collaboration of the NDoH with the US government resulted in the development of important programmes such as the ‘Dreams programme’22, which uses a multisectoral approach to prevent HIV/AIDS among adolescent girls and young women and their male sex partners.
Whilst South Africa is not a recipient country because of its middle-income status, GAVI receives a modest contribution from South Africa as a donor country. From 2020, GAVI’s mandate as a member of the ACT-A means that South Africa now indirectly benefits from GAVI through the COVAX facility negotiation.
Conclusions and way forward
South Africa has been shaped by, and is actively shaping the world through global trends on the determinants of health, and formal collaborations with global and regional institutions. The influence of South Africa in the response to COVID-19 in the region exemplifies this – with the President’s role in the African Union, the pivotal role of South African scientists in tracking and researching interventions, and the breakthrough in planning for the mRNA COVID-19 vaccine production in the country. South Africa needs to continue to examine and expand on its role in the region and globally, both to improve the health of the people of South Africa, and to play its role in improving health globally. The country is constantly striving for the betterment, harmonisation and coordination of Africa’s global health system with investment through sustainable financing initiatives and ensuring that aid goals are continuously aligned with the regional health needs and priorities. At the same time, there is a critical need to develop thought leadership for effective decision-making, for implementation of the most appropriate global health programmes, and for strengthening global health initiatives to enhance regional alliances and efficient functioning at a governmental level.
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