Background
Methods
Document reviews
Key informant interviews
Results
Organisation | Number |
---|---|
Professional associations | 4 |
Universities & research institutions | 8 |
Non-governmental organisations | 7 |
Health financiers | 1 |
Departments of health - national, provincial & local | 5 |
Other government departments | 12 |
Industry | 4 |
Media | 2 |
Consulting firms | 1 |
Total | 44 |
Policy context
Post-apartheid period
Risk Factors targeted | Specific policies |
---|---|
Tobacco smoking | 1993-Tobacco Products Control Act 21 |
1994-Tobacco Products Control Regulations | |
1999-Tobacco Products Control Amendment Act 23 | |
2000-Tobacco Products Control Amendment | |
2007-Tobacco Products Control Amendment Act 25 | |
2008-Tobacco Products Control Amendment Act 28 | |
2011-Tobacco Products Control Amendment- regulations | |
Alcohol Abuse | 1989-Liquor Products Act 60 |
2003-National Liquor Act 59 | |
2004-National Liquor Regulations | |
2008-Western Cape Liquor Act; 2013 – Gauteng Liquor Act | |
2013-National Drug Masterplan (2013–2017) | |
Unhealthy diets | 2009-National School Nutrition policy |
2011-Regulations relating to trans-fat in foodstuffs | |
2013-Food and Nutrition Security Policy by Department of Agriculture | |
2015-Strategy for Tackling Obesity | |
2013-Salt Reduction Regulations | |
Physical inactivity | 1996-Schools Act 84 |
1998-National Sports and Recreation Act | |
2011-Promotion of Physical Activity in Older Persons | |
2012–2016-National Strategic Plan for NCDs |
Political will
The burden of NCDs
The NCD policies
Policy on alcohol and substance abuse
Substance abuse, including Nyaope or wunga (a street drug that has been widespread in South Africa from 2010), was associated with depression and crime, while banning advertising of alcohol was seen as a way of changing the image of alcohol (binge drinking and alcoholism) from being glamourous to categorising it as an illness:“We normally speak about substance abuse in three tiers[:] … Demand Reduction [that involves] education …, Supply Reduction [that involves the] South African police service [,] the department of justice [and the] South African Breweries …, and Harm Reduction [that is related to treatment and involves] the department of Health [and] the department of social department” (Study participant _1).
Alcohol control policies tend to focus more on the regulation of alcohol production and distribution. Consequently, priority is given to addressing trade and industry concerns rather than public health issues [7]. Nevertheless, policy formulation and implementation has been more successful in tobacco smoking.“When [a study of 14 drugs] compared harm to the user [and] … harm to others, alcohol was actually number 1. So the harm to others is actually worse than … cocaine, crack cocaine and crystal meth” (Study participant _42).
Tobacco control policy
The main drivers of this change of policy were the Left and the Tobacco Action Group (the Heart Foundation, The Cancer Association of South Africa (CANSA) and the Council against Smoking). Through the Amendment of the Tobacco Products Control Act (1999) that was passed after the 1997 ANC conference, advertisements of tobacco products and tobacco smoking in public buildings were banned. The Act also provided for the allocation of smoke-free zones [7]. This was not without opposition from the tobacco industry, the media, the Democratic Alliance (DA) and (surprisingly) the Pan African Congress (PAC):“A new Health Minister Dr Nkosazana Zuma … was prepared to do things that were [in line with] international best practice” (Study participant _40).
The Tobacco Action Group responded to claims about potential job losses, harm to the economy and freedom of speech:“The industry obviously did not want the legislation at all and they opposed everything and anything the government said … the SABC [South African Broadcasting Corporation] was worried about loss of advertising and revenues. We had … big media houses going to parliament and saying [that] if you ban tobacco advertising…they will close down. Then … the Freedom of Expression Institute opposed the legislation … but the courts found that the ban on advertising was constitutional” (Study participant _40).
Some organisations argued that they were excluded in policy formulation, and that regulations and/or tax increases would raise their costs, reduce their market share and reduce their profits. Notwithstanding these objections, the regulations resulted in the reduction in tobacco smoking by 22% between 1999 and 2009, especially among the youth [5, 10]. Nevertheless, South Africa still has one of the highest smoking rates in Africa [5, 10]. Although the policies passed since 2000 changed practice, continuing problems with smoking have compelled the DOH to “revise[e] its regulations to enforce plain packaging and clean air regulations, regulate e-cigarettes, and increase taxes to revitalise efforts to reduce tobacco use” ([5], p. 1). The government resolved that, for a healthy nation, tobacco controls should be accompanied by tackling the lack of physical activity and unhealthy diets.“Journalists were even telling us that … pro-legislation [accounts] would not be published by the newspaper editors because their own interests were different and [they] policed every story we told … One of the concerns was to make sure that [there was protection of] the main victims of secondary smoking … [that is,] women … [Moreover,] advertising … [was] banned to protect everybody but particularly … to make sure that younger women didn’t think smoking was clever, smart and glamorous … [the] tobacco industry was targeting younger women with their advertising” (Study participant _40).
Policy on physical inactivity
Programmes introduced to tackle physical inactivity that is a major risk factor for NCDs, include:“Too many people are getting up in the morning, getting into their car or into a taxi right outside their house … if you want people to ride bicycles you have to create the [safe] environment [including policing] for people to ride bicycles. You try and ride a bicycle in Pretoria, you gonna get knocked over … [what is required are] physical planners [who ensure that the building of roads is accompanied by] lane[s] for bicycles [and walking]” (Study participant _9).
“Sport and recreation … to address (hypertension, high blood pressure) NCDs in elderly people … the Golden games [have subsequently been ‘appropriated’ by] the National Department of Social Development” (Study participant _44).
Policy on unhealthy diets
By 2011, the Minister for Health began to prepare the country for the salt reduction regulations, arguing that “reducing salt intake in just bread only would save close to 6500 lives per annum” ([20], p. 2). By 2013, the Salt Reduction Regulations were adopted as an intervention for tackling hypertension [7, 31]. Too much salt intake is associated with hypertension, and “in South Africa hypertension is [also] - - - the major cause of kidney disease” (Study participant_4). Given that legislation is in place, it remains to be seen how successful the implementation will be:“We believe that if you teach a person what and how to eat, they will hold onto that till [they] grow old, and old grannies will continue to teach the next generation as well” (Study participant _14).
In 2016, the national treasury drew up proposals for the taxation of sugar-sweetened beverages [32, 33]. The proposals for taxing sugar-sweetened beverages were not only debated by the national treasury and DOH, but stakeholders from civil society organisations, industry, research and academics also participated in the drafting and refinement of the taxation regime [7, 34].“The companies [had] until 2016 for the first target [for reducing salt] and then to 2019 for the second target … if you do it gradually, then people don’t even know they are tasting anything different and they get used to it” (Study participant _9).
The taxation of sugar-sweetened drinks aims to “cut the number of obese people by 220,000 in 3 years” [4]. With this in mind, the Minister for Finance (2017) assured the country that the sugar tax would be implemented [36]. However, funds for implementing large-scale programmes to prevent and control NCDs are inadequate.“We need to explain to the public that even though they don’t feel sick, they are sick. They are seriously obese and they are on the brink of developing diabetes, they have got high blood pressure but they don’t feel sick yet … Also educate teachers in high schools … [and make children aware] of the long-term risks of being physically inactive … [and incorporate healthy lifestyles into] the curriculum in schools” (Study participant _18).
Challenges in implementing NCD policies
Funding priorities focusing on infectious diseases
To ensure the success of NCD policies, funding must also be linked with community participation vis-a-vis multi-sectoral action:“[Funding is concentrated on] T.B., malaria, HIV … there is a problem with prioritizing disease, [particularly] if you look at kidney disease per se” (Study participant_4).
While emphasis was placed on people owning the policies, there was also concern that policies were not well co-ordinated.“If the government can give out a million for a few seconds advert on TV, the government can give out money for full studies that are community based, that involve people to change … We have to include community involvement … even the communication strategy needs to focus on the people” (Study participant _31).
Lack of multi-sectoral action
In addition, multi-sectoral action can only be successful if data problems are addressed.“[Prevention of NCDs] is more at a company level. For instance…TB is an occupational disease … we support companies but with NCDs - - - we just leave it to the company” (Study participant _26).
Lack of data
Meeting the NCD reduction targets requires consistent and comparable data to identify patterns and trends, and thus inform policy on how NCD risk factors can be monitored and controlled. Non-disclosure of data and non-cooperation of stakeholders in the implementation process poses problems to policy.“The baseline data that is used to set the target are sometimes questionable because of data collection. We get our information from the district health information system DHIS that is how the district health data is collected … from [the] clinic level to national level. There is a lot of data problems in that system due to incorrect data and so on” (Study participant _12).
Interference from industry
At a time of growing youth unemployment, such threats were sufficient to put pressure on the government to withdraw the Bill. Delaying tactics involved asking the government to embark on further research on the impact of alcohol advertising:“They [the industry] said to us, alright take us to court … one of their high people [did] admit that they had been duping us … they were prepared to go to court but at the same time saying that warning labels have not [had] impact on drinking. This is what they say, so I ask if there is absolutely no impact why so scared?” (Study participant _9).
On a different but related matter concerning the government’s efforts to limit sodium levels, Hoffman and Lee observed that: “industry’s opposition to government intervention lay not only in the political debate of the encroaching powers of a ‘nanny state’ government, but also in the practicality of the proposed measures” ([37], p. 8). The food industry tried different tactics to resist and circumvent the regulations:“a request for more research and we also know that most of it is because the alcohol industry is gonna do whatever it can to ensure that there’s a delay in the public discussions on this and the implementation of the alcohol [advertising] ban. They see that of all the policies … as the biggest threat to the industry” (Study participant _42).
“Things like bread, they said this is the limit, after this our bread is going to collapse … We do not actually believe that it’s not possible for them to find something else at that point. So we have given them a challenge … [and said to them that] we have given you a long time to work this out and it got very complicated because in the United Kingdom they managed to bake bread at lower levels [of salt]. They said wheat is different … There is sort of international food safety regulation. It does not include things like salt. We said, of course it must include things like salt; it makes your food unsafe. So, there’s a whole shift that needs to take place and it is taking place” (Study participant _9).