Challenge
The mining sector plays a significant role in the economic development of Southern Africa. South Africa has the third largest mining industry in the world—consisting of over 2,000 mines and contributed to about 8 percent of the country’s total GDP in 2016. The mining industry employs more than 500,000 mineworkers and has historically relied on migrant workers from rural areas and surrounding countries. While the size and labor intensity of the mining industry has created job opportunities in the region, the sector has long been associated with a high prevalence of TB and HIV/AIDS among migrant mineworkers and ex-mineworkers across national borders, ultimately resulting in a larger disease burden and the loss to follow-up of patients who migrate across health systems, contributing to the spread of multi-drug resistant TB. With 2,500-3,000 cases reported per 100,000 individuals, TB rates in the South Africa mining sector were 10 times higher than what the World Health Organization (WHO) considers as an epidemic emergency, making the sector a major “hotspot” of high TB transmission. This crisis had persisted for over 100 years due to a confluence of factors including: (i) the lack of coordination resulting from the multi-sectoral nature of addressing occupational health; (ii) poor health system performance, exacerbated by cross-border migration and; (iii) historical inequalities in access to health and other social services. Persistent TB and HIV were therefore found to be eroding the contribution of the mining sector to the economic development of the region, necessitating a rapid and comprehensive response.
Approach
Due the magnitude and complexity of TB in the mining sector in Southern Africa, a coordinated sub-regional response was critical. The World Bank implemented a package of interventions which included analytical work, convening stakeholders from public and private sector, across multiple sectors and countries, consensus-building, and implementation arrangements to address a complex problem that has persisted for over a century. The Bank’s involvement began with an assessment of the extent of the problem, leveraged its convening power to identify needs of beneficiary groups, identify solutions and consult national and global experts from in the mining industry. Analytical work was undertaken to highlight the economic impact of TB in the mining sector and identify key bottlenecks in service delivery systems. Inclusive discussions resulted in the alignment of priorities in sector and the implementation of a number of interventions to prevent and manage TB and identify and compensate mineworkers and ex-mineworkers.
Results
This comprehensive program achieved several results:
- Improved TB screening for mineworkers: From 2015 to 2017, 90% of all mineworkers were screened for TB and those found to be infected were put on treatment.
- Establishment of and increased service provision for ex-mineworkers: The establishment of the occupational health One-stop Service Center (OSSC) sites – where the full range of occupational health and social services are provided under one roof – developed national capacity to address occupational and social service delivery and enhanced access to health and other social services for mineworkers through a comprehensive approach. The OSSC provides services for accessing compensation for occupational lung diseases, pension and provident funds.
- Improved tracking and tracing of ex-mineworkers: Development and rolling out of a database in 2016 and 2017 respectively that includes both the demographic and medical information of 600,000 ex-mineworkers and 400,000 current mineworkers from 2016 to 2017. This was a landmark innovation – the first cross border disease database in the world.
- Improved compensation services for ex-mineworkers: Several generations of ex-mineworkers across Southern Africa have never been compensated for occupational lung disease they acquired while working in the mines in South Africa. Through the initiative, the Government allocated $500 million for compensation and more than 103,000 ex-mineworkers who qualified for compensation were identified and tracked.
- In addition to the above, leading gold mining companies in South Africa also committed US $117.5 million to ensure that ex-mineworkers owed compensation are paid.
- In the first year of implementation (2016), US$16.5 million was paid to beneficiaries, with 38% of payments going to ex-mineworkers in labor-sending countries.
- Improved regional coordination to fight TB in the mining sector: The signing of a Harmonized Framework in March 2014 was a historic and unprecedented achievement in the fight against TB in the mining sector in Southern Africa. Prior to the Framework, protocols for addressing TB varied greatly by country, resulting in high drop-out rates and contributing to high burdens of disease, including the rapid spread of multi drug resistant TB, in mining and labor-sending communities. The effort to align the approach of public, private, multilateral, and bilateral partners across countries around a single framework is the first example of a regional approach to comprehensive disease management and is a model for future, inclusive efforts for achieving regional universal health coverage
Bank Group Contribution
- Strong leadership and support from the World Bank President, Vice President, Country Directors, Practice Managers, and task team leader were integral to the success of the project. World Bank Group President, Jim Yong Kim, committed the Bank’s support to the initiative “to effectively follow people with TB throughout the region, we will need to improve communications, laboratories, and other elements of infrastructure, an area where we have lots of expertise. We can convene all the relevant partners and help to build a truly regional response to an epidemic that does not respect borders (2012).”
Partners
The initiative’s major thrust of $500 million came from the Government of South Africa for compensation of ex-mineworkers for occupational lung diseases. Other major partners included the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) who provided $30 million to a Principal Recipient to scale up TB prevention and treatment from 4 to 10 countries, and the UK Department for International Development (DfiD), who provided $3 million (Trust Funds) to support the regional response. The initiative established strong multi- sectoral and multi-stakeholder engagement and coalition with major stakeholders drawn from the Southern Africa Development Community (SADC) government departments of Health, Mining/Mineral Resources and Labor; private sector actors (mining companies), civil society (mining unions, ex-mine workers associations, nonprofit organizations, research institutions, development partners, (e.g. DfID, GFATM, Stop TB Partnership, International Organization of Migration, and US Centers for Centers for Disease Control and Prevention (CDC), WHO and the SADC Secretariat. The collaboration also established and convened a Program Implementation Committee (PIC) which was responsible for providing oversight and strategic direction for the Initiative in tackling the drivers of TB among mineworkers within the SADC region. The main reason for the successful results was the close collaboration with the Departments of Health and Minerals in South Africa, South Africa Chamber of Mines, leading mining companies and associations of ex-mineworkers and mining unions.
Moving Forward
Driven by the need to support economic and human capital development, the World Bank is committed to supporting countries in southern Africa to strengthen their health systems and achieve Universal Health Coverage targets. This require major commitment from governments and a range of development and technical partners. Due to the negative impact of TB on the health system, the TB in the mining sector initiative can be enhanced by: i) expanding the mandate of the Project Implementation Committee, the convening entity of the initiative, to include health system strengthening in order to establish mechanisms for collaboration on this critical issue, ii) policy dialogue with other countries in southern Africa to increase the number of countries participating in the World Bank regional project; and iii) scaling up innovations developed by the initiative such as regional health information system to track mineworkers across the region.
Beneficiaries
Vama Jele, 47, an ex-mineworker who worked in the industry for 17 years comes from a line of mineworkers in the rural Nhlangano District in Swaziland. His father was a mineworker and he has four brothers currently working in the mines in South Africa, two of whom are being treated for TB. He was deeply involved in the development of policy and expressed his gratitude for the initiative:“Thank you for the improvement to our health and our lives, individually and collectively, since 2010 when we began working with the World Bank and the South Africa Department of Health and Department of Minerals resources on TB in the Mining Sector. The different interventions, including the establishment of the One Stop Occupational Health Service Centre for service delivery for mineworkers and ex-mineworkers, changed our knowledge, increased access to health services, and provided long standing compensations including screening and treatment for TB for miners, ex-miners, their families, and communities surrounding the mining areas. The World Bank placed mineworkers and ex-mineworkers at the center of its interventions and assisted them to develop their own solutions. With the capacity I have gained, I can now advocate for the voiceless, those in the shadows of life, and those who passed away.”