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Seekings and Nattrass explain why poverty persisted in South Africa after the transition to democracy in 1994. The book examines how public policies both mitigated and reproduced poverty, and explains how and why these policies were adopted. The analysis offers lessons for the study of poverty elsewhere in the world.

Abstract The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa’s public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1–7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country’s progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.

Once again, the Horn of Africa has been in the headlines. And once again the news has been bad: drought, famine, conflict, hunger, suffering and death. The finger of blame has been pointed in numerous directions: to the changing climate, to environmental degradation, to overpopulation, to geopolitics and conflict, to aid agency failures, and more. But it is not all disaster and catastrophe. Many successful development efforts at ‘the margins’ often remain hidden, informal, sometimes illegal; and rarely in line with standard development prescriptions. If we shift our gaze from the capital cities to the regional centres and their hinterlands, then a very different perspective emerges. These are the places where pastoralists live. They have for centuries struggled with drought, conflict and famine. They are resourceful, entrepreneurial and innovative peoples. Yet they have been ignored and marginalised by the states that control their territory and the development agencies who are supposed to help them. This book argues that, while we should not ignore the profound difficulties of creating secure livelihoods in the Greater Horn of Africa, there is much to be learned from development successes, large and small. This book will be of great interest to students and scholars with an interest in development studies and human geography, with a particular emphasis on Africa. It will also appeal to development policy-makers and practitioners.

Background This paper examines the effect of multi-dimensional financial development on health outcomes in sub-Saharan Africa (SSA). The study decomposes financial development into access, depth, and efficiency and tests their separate effects on health outcomes. The paper also examines the interaction effect of public health spending and financial development on health outcomes. Methods This paper is based on panel data for forty-five countries in sub-Saharan Africa (SSA) collected from the World Development Indicators (WDI) of the World Bank and the International Monetary Fund (IMF) over the period 2000–2021. This study adopts the 2-step system Generalised Method of Moments (GMM) as the estimation technique to examine the relationships among the variables. This robust approach is chosen to effectively address potential issues of endogeneity, reverse causality, and unobserved country-specific heterogeneity inherent in the relationship between financial development and health outcomes. Results The findings show that improvement in financial development measures improves health outcomes in sub-Saharan Africa (SSA). The findings further show that, in SSA, higher out-of-pocket expenses lead to worsening health outcomes. The relationship between financial development and health outcomes in sub-Saharan Africa is strongly moderated by public health financing and out-of-pocket medical expenses, suggesting important synergistic and mitigating effects. Conclusions The findings imply that financial development, public health financing, and out-of-pocket health expenditure are critical when it comes to improving health outcomes in sub-Saharan Africa. To lower infant and maternal mortality rates and raise life expectancy, policymakers must implement targeted actions to strengthen the financial system and lower household out-of-pocket medical expenses whilst increasing public health financing. These findings guide health policy formulation for the improvement of health outcomes in SSA.

African countries confront vast economic, social, and environmental challenges. Although urban issues bear upon many of these challenges, they have remained a secondary priority for governments and the international community. The growing gap between infrastructure and services already built and those needed demands a drastic change in the scale of urban financing. This book aims to begin that reexamination. It offers a broad methodological perspective and several operational avenues to bolster and modernize the financing that cities urgently require. The financing of urban investments involves several aspects of local government fiscal matters: public finance, administrative law, taxation, monitoring and controlling of subsovereign debt, urban administration and governance, and so on. It also involves other sectors, such as land management, land development, and housing. This book defines its geographic scope as two concentric circles within Africa, as described below. It also draws on other regions: the most developed or emerging countries outside the African continent that can furnish examples illuminating or adaptable to, the African context. This volume is organized into five chapters and an appendix containing eight case studies. Chapter one addresses the fundamentals. Chapter two analyzes urbanization and sectoral policies across the African continent. Chapter three is dedicated to Africa's decentralization, basic services provision, and local governance issues. Chapter four examines local governments' investment financing frameworks currently in use in Africa and new, recently emerged sources of financing. Chapter five addresses strategic and operational ideas for infrastructure and local investment financing, anticipating Africa's exceptional urban growth in the coming decades.

The book explains the social forces, forms of consciousness and structural constraints that undermined Apartheid, preserved national unity and yet, later constrained democratic sovereignty, as the imperatives of global markets clashed with the prior aspirations of the democratic revolution.

Background South Africa is composed of a two-tier healthcare system. One tier is a private healthcare system that is funded through medical insurance, and comprised of people who can afford to make monthly payments towards their medical insurance. Second tier is a government-funded public healthcare system, which covers the majority of the population. This study explored the perceived barriers and current strategies being utilised by the pharmaceutical industry to increase access to innovator medicines. Objectives The objectives of the study were to: (1) quantify and classify innovator medicines registered between 2010 and 2020 by the South African Health Products Regulatory Authority (SAHPRA); (2) identify barriers to accessing innovator medicines in South Africa through interviews with market access managers from innovator companies; and (3) explore the current market access strategies used by the pharmaceutical industry. Design This study employed a quantitative and qualitative methodology. Whereby the former involved the extraction of a list of innovator medicines from the regulator database, and the latter involved 9 semi structured interviews. Purposive sampling was conducted through pharmaceutical association member companies. The interviews included seven market access managers and two medicine managers from one of the payers in South Africa. Thematic analysis was used to interpret the data collected from the study. Results According to the regulator database during the review period, 238 innovator medicines were registered. Only 14.77% were available in the public sector in the form of tenders, whereas in the private sector (based on the products having a SEP), 76.92% were available. From the interviews six themes emerged: reimbursement of medicines, types of reimbursement, partnerships, technology, legislative challenges, and other factors (e.g., real-world evidence). Conclusion Access to innovator medicines in South Africa is a challenge, as the price of these therapies is high. Therefore, various stakeholders in the health sector must collaborate to identify and implement solutions that are locally relevant. The government needs to proactively update policies that would allow for alternative reimbursement methods to be explored.

Fresh surface water is increasingly becoming scarcer worldwide, leading to significant groundwater over-extraction. However, groundwater over-extraction could result in many environmental externalities including various land subsidence (LS) effects. LS causes the gradual reduction of the voids and the subsequent ground surface sinking. The loss of aquifer system storage capacity, owing to LS, is one such negative externality that is seldom discussed in the economic literature. In this paper, we investigate the indirect loss of the aquifer system storage capacity due to LS along with other direct LS negative externalities. We develop a dynamic economic optimization model for groundwater utilization and evaluate various policy instruments (quota systems, taxes on land sinking and aquifer storage loss, and packaging and sequencing of taxes and quotas) to prevent overexploitation externalities. The model is calibrated to South African data. We found that taxes on land sinking and aquifer system storage capacity reduction have a significant effect on withdrawals and water table levels. Taxes provide larger social welfare. In addition, under certain circumstances, quotas are preferable when it comes to supporting groundwater conservation practices. Packaging and sequencing provide the second largest social benefits.

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990-2016. The World Health Organization's (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011-2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO's 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals.

Background The population in Sub Saharan Africa (SSA) suffers poor health as manifested in high mortality rates and low life expectancy. Economic growth has consistently been shown to be a major determinant of health outcomes. However, even with good economic growth rates, it is not possible to achieve desired improvements in health outcomes. Public spending on health (PSH) has long been viewed as a potential complement to economic growth in improving health. However, the relationship between PSH and health outcomes is inconclusive and this inconclusiveness may, in part, be explained by governance-related factors which mediate the impact of the former on the latter. Little empirical work has been done in this regard on SSA. This paper investigates whether or not the quality of governance (QoG) has a modifying effect on the impact of public health spending on health outcomes, measured by under-five mortality (U5M) and life expectancy at birth (LE), in SSA. Methods Using two staged least squares regression technique on panel data from 43 countries in SSA over the period 1996–2011, we estimated the effect of public spending on health and quality of governance U5M and LE, controlling for GDP per capita and other socio-economic factors. We also interacted PSH and QoG to find out if the latter has a modifying effect on the former’s impact on U5M and LE. Results Public spending on health has a statistically significant impact in improving health outcomes. Its direct elasticity with respect to under-five mortality is between −0.09 and −0.11 while its semi-elasticity with respect to life expectancy is between 0.35 and 0.60. Allowing for indirect effect of PSH spending via interaction with quality of governance, we find that an improvement in QoG enhances the overall impact of PSH. In countries with higher quality of governance, the overall elasticity of PSH with respect to under-five mortality is between −0.17 and −0.19 while in countries with lower quality of governance, it is about −0.09. The corresponding semi elasticities with respect to life expectancy are about 6 in countries with higher QoG and about 3 in countries with lower QoG. Discussion Public spending on health improves health outcomes. Its impact is mediated by quality of governance, having the higher impact on health outcomes in countries with higher quality of governance and lower impact in countries with lower quality of governance. This may be due to increased efficiency in the use of available resources and better allocation of the same as QoG improves. Conclusion Improving QoG would improve health outcomes in SSA. The same increase in PSH is twice as effective in reducing U5M and increasing LE in countries with good QoG when compared with countries with poor QoG.