The Southern Africa TB in the Mining Sector Initiative

Tuberculosis (TB) is a significant problem in the mining industry in Southern Africa. In South Africa alone, TB rates within the mining workforce are estimated at 2,500-3,000 cases per 100,000 individuals. This incidence is 10 times the WHO threshold for a health emergency, and is also nearly three times the incidence rate in the general population.

Of the estimated 500,000 mineworkers in South Africa’s mines, approximately 40% originate from Mozambique, Swaziland, and Lesotho. Mine workers are at a higher risk of contracting TB due to prolonged exposure to silica dust, poor living conditions, and high HIV prevalence in mining communities. Furthermore, circular movement of mineworkers across provincial and national borders and a poor cross border health referral system fuel infection rates, adversely affect adherence to TB treatment, and contribute to the incidence of drug resistant strains such as multidrug resistant (MDR) and extensively drug-resistant (XDR) TB in the sub-region.

To reduce the incidence of TB in the mines, peri-mining communities and labor sending areas the World Bank (WB) has undertaken a series of studies and innovative projects, and is mobilizing stakeholders and resources. This work covers three key focus areas:

Provision of support for better analytical underpinnings for implementation of effective TB interventions: In response to requests from ministers of health and minerals and mining companies in Lesotho, Mozambique, South Africa and Swaziland, the WB has undertaken the first economic and analytical work that can contribute towards addressing the causes and challenges of the TB epidemic among miners, ex-miners and mining communities.

Harmonization of treatment protocols and funding to address the challenge: A critical function reflecting the WB’s coordinator role has been the stewardship of multi-donor funds for efficient and non-duplicative use in mining-related TB activities, as well as the signing of an agreement at the political level in 2014 to begin the process of harmonizing treatment protocols for TB across borders. The framework for the harmonized management of TB in the mining sector is now under implementation.

Innovation and collaboration:The WB is mobilizing new resources and stakeholders including national governments, development partners (the Stop TB Partnership, DFID, the Global Fund to Fight AIDS, Tuberculosis and Malaria, etc.), private sector, civil society, research institutions and ex-miners associations to tackle the drivers of TB among mineworkers: living conditions, lifestyle factors, high-risk status, and limited access.

This initiative has been catalytic in mobilizing additional resources from the Global Fund ($30 million over two years) for scaling up of effective interventions to 10 countries in the SADC region through the TIMS Project. The World Bank is also providing $120 million through the regional Southern Africa TB and Health Systems Strengthening Project in 4 countries in the SADC region: Lesotho, Mozambique, Zambia and Malawi.

The Southern Africa TB in the Mining Sector Initiative is one of the key initiatives led by the South Africa Knowledge Hub. It is an innovative multi-stakeholder effort involving government, civil society, development, and private sector partners aimed at combating TB in the mining sector in the Southern Africa region. With coordination led by the World Bank, the multi-sectoral initiative includes representatives from the Departments of Health, Mineral Resources, and, Labor of South Africa, Swaziland, Lesotho and Mozambique; development agencies (UK Department for International Development, International Organization for Migration, and Stop TB Partnership); research institutes; mining companies; ex-mineworkers’ associations; and labor unions.

The World Bank supports a number of innovative projects to help end the TB epidemic in Southern African countries, including:

The Southern Africa Tuberculosis and Health Systems Support Project 

Through the Southern Africa Tuberculosis and Health Systems Support Project, the World Bank has provided $120 million to improve coverage and quality of key TB control and occupational lung disease services in targeted geographic areas in Zambia, Lesotho, Malawi and Mozambique. The Bank is also working to strengthen regional capacity to manage the burden of TB and occupational diseases. Project partners include the Ministries of Health, Mines, Labor, the CDC, Private Sector, and Civil Society.

The project supports:

  • Innovative interventions to boost prevention, detection and treatment of TB and occupational lung diseases
  • Regional capacity strengthening to boost human resources, strengthen disease surveillance and diagnostic capacity, and mine health regulation
  • Learning and knowledge sharing at national and regional levels to share good practices, promote evidence based approaches, and support rigorous evaluations

Social mobilization of current and ex-mine workers

The Southern Africa TB in the Mines Initiative is conducting social mobilization of mineworkers and ex-mineworkers to raise their awareness on the availability of TB control services, as well as the importance of taking a Benefit Medical Examination (BME) regularly, and more generally about their rights and entitlements.  Activities are being implemented in South Africa, Lesotho, Swaziland and Mozambique and Botswana. The program has supported the Government of South Africa to track and trace 20,000 mineworkers and equip them with information. As a result, 120,000 Rand ($8,500) has been paid out in compensation to ex-mineworkers thus far.

Supporting an industry-led Public Private Partnership to improve access to TB services and community services

The private and public sector both play a role in addressing the high incidence of TB. Under the leadership of the World Bank, the District Department of Health and mining companies in the West Rand District have developed a draft compact aimed at supporting the implementation of two priority interventions: active TB case finding, and early effective TB diagnosis.

The compact lays out the broad parameters within which the parties will engage, outlines interventions for intensifying TB case finding and improving access to diagnostic services, defines implementation modalities and delineates the roles and responsibilities of the parties. However, implementation of the compact was deferred due to a lack of clarity on the integration of additional resources (from the mining companies) for community development to complement existing commitments under Social and Labour Plans, as provided in the current policy framework.

Social and Labor Plans are a regulatory condition, stipulated by the Department of Minerals (DMR). The DMR requires companies to invest in delivering social and economic benefits to the communities where they operate. Currently, the DMR is in the process of reviewing ten years of implementation of the Social and Labor Plans. The outcome of this review will inform the design of appropriate policies and strategies focused on community development priorities as well as incentives for fostering collaboration among mining companies.

Recognizing that the lack of an appropriate framework for effectively engaging mining companies in community development is a common challenge in the sub region, the program has adopted an alternative strategy of developing a framework for engaging mining companies in community development. This framework will be developed as part of the Global Fund project to promote sustainable community development in peri-mining communities.

Improved coordination and management of the TB in the mining sector response

The Bank and other stakeholders (development partners, private sector, civil society, research institutions and ex-miners associations) have continued to push for improved coordination of the sub-regional response to TB in the mining sector. This effort has been welcomed by all the countries. The Program Implementation Committee (PIC) formed in October 2013 as a governance body to support and coordinate the efforts for Lesotho, Mozambique, South Africa and Swaziland was expanded to include other SADC countries. The PIC, which meets at least once a year, provides an opportunity for partners to discuss proposed interventions and plans submitted by implementing entities to ensure that there is a multi-stakeholder priority-setting process contributing to the harmonized sub-regional response.

The PIC continues to serve as a forum for all stakeholders in the sub-region to discuss ongoing activities, address any implementation bottlenecks, and provide strategic direction for the advancement of the regional initiative.

Technical assistance to streamline compensation for occupational lung disease policies

The South Africa National Department of Health (NDoH) has requested technical support from the World Bank to help streamline the policy and regulatory instruments for compensation, as part of its effort to improve the delivery of occupational health services in the mining sector. South Africa, currently has two statutory systems for compensating occupational diseases: the Occupational Diseases in Mines and Works Act (ODMWA), and the Compensation for Occupational Injuries and Diseases Act (COIDA). The two systems are not only statutorily separate but are also administered by different state agencies—the NDOH administers ODMWA and the Department of Labour, COIDA.

It is widely acknowledged that ODMWA has significant deficiencies with respect to its definitions, scope and coverage of mineworkers and ex-mineworkers, medical assessments, compensation system financing, governance structure, claims management, and benefit structure. Thus, the compensation system under ODMWA has done little to ease the heavy burden of diseases among mineworkers, ex-mineworkers and their families. Mineworkers and ex-mineworkers face several challenges in accessing compensation, especially for occupational TB, as well as regular post-employment medical examinations essential for early detection and treatment of occupational lung diseases. 

The WB is working with the government to highlight the strengths and weaknesses of the current policy instruments, identify inconsistencies between ODMWA and other relevant legislation, and to consider international best practice in managing occupational diseases linked to the mining sector. The World Bank is working on recommendations for new legislation.

This work is bearing fruit. In May 2015, the NDOH launched Operation Ku-Riaha (Compensation) to speed up the payment of compensation to current and former miners who have submitted valid claims. The NDOH has put aside ZAR 1,500,000 to pay 1,003 of the 200,000 claims backlog that have already been certified as having a compensable occupational disease. Lessons learned from the South Africa review will guide similar reviews in emerging producer countries in the SADC region and beyond.

Creation of Mineworkers and Ex-mineworkers database

The Southern Africa TB in the Mining Sector Initiative has generated detailed information on the demographic characteristics of current and former mineworkers, as well as the availability of TB screening and treatment facilities in order to effectively coordinate and implement the regional TB response. The sub-regional mapping study that was conducted in South Africa, Lesotho, Swaziland and Mozambique was complemented with a GIS database developed with capacity to identify locations of labor sending areas and health facilities within those communities.

Health management informatics database

As part of the Global Fund-supported TB in the Mines grant (TIMS Project), an extensive mapping exercise is in process in 10 southern African countries with the aim of creating a unique health management informatics database. The 10 countries are Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe.

This exercise is being conducted by TOM-TOM, a global leader in geo-spatial mapping.  The database is mapping locations and names of all villages in southern Africa, routes used by mine workers and ex-mine workers and the nearest health facilities. It will show migration patterns linked to road networks represented dynamically on a common GPS platform.

When completed, the health management informatics database will be the first of its kind in Africa. It will facilitate evidence-based management of migration and strategic decisions on where to locate health and social interventions. It is expected to be launched in the first quarter of 2017.

Regional Health Management Information System

Work has also commenced on the development of a Regional Health Management Information System that will be a common platform that integrates national databases and is able to ensure continuity of care for mobile populations. The project is currently in a consensus building and desktop assessment phase. The regional database that will provide important health data that will be accessible across the region, thereby supporting continuity of care for patients on TB treatment. Work will progress to full design and testing in early 2017.

Cross-border referral pilots

A number of innovative approaches to improve adherence to TB treatment for mineworkers and ex-mineworkers who return home for short periods whilst on holiday have been piloted since December 2013. Previously, this group faced many challenges with inconsistent access to drugs and ineffective referral mechanisms leading to interrupted treatment and poor outcomes.

The initiative piloted an m-health-enabled intervention that allowed health workers to use mobile phone technology to follow-up with mineworkers infected with TB and to reduce the time lag between patient diagnosis and enrolment on care.

This intervention, one of the first of its kind in the mining sector, provided evidence on what works in increasing treatment adherence among mineworkers. Companies participating in this innovative pilot include Sibanye Gold and Harmony Gold Mining. A variety of incentives were used, including a briefing pack, mobile phones, SMS texts and follow up calls from mining company nurses.

Under the Global Fund TIMS Project, a cross border referral system for the 10 participating countries is being developed. This will build on the work already done and will embed a harmonized system within the National TB Programs of the countries involved.

To deliver on its goal to help end the TB epidemic in Southern African mines, the World Bank (WB) has supported a number of innovative studies through the Southern Africa TB in the mining sector initiative. Details of the current scope of the studies are:

Mapping of Mineworkers in Lesotho, South Africa and Swaziland

A mapping study was conducted in 2014 to establish geo-locations of current and former mineworkers in Lesotho, South Africa and Swaziland. The objective of the study was to identify both the geographical location of mines and the respective mineworker concentrations, together with an assessment of the proximity of health facilities to the mines and mineworker communities.

The mapping report confirmed that there is constant movement of mineworkers both within South Africa and its neighbouring countries, as well as among mines and different types of mining employment. The study further notes that the differences in types of employment and subsequent policies available to current miners makes it increasingly challenging to ensure continuum of treatment, when necessary, as well as for contact tracing of the miners’ families.

Data from the mapping study was used in the development of the proposal that helped to secure a $30 million grant from the Global Fund for the Regional TB Response to the Mining Sector involving 10 southern African countries. The 10 countries are Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe.  Findings of the mapping study were also used to inform the preparation of the WB’s Southern Africa Tuberculosis and Health Systems Support Project. Similarly, the South African government used the findings to identify suitable locations for the establishment of one-stop service centers for occupational health.

Applied ethnographic study of Southern African communities to inform healthcare delivery strategies

Dartmouth University in the USA was engaged to conduct an applied ethnographic study among ex-mineworkers in South Africa, Lesotho, Swaziland and Mozambique. The study which includes a literature review and study tools, was completed in April 2015. Field work for the ethnographic study was completed in late May. The initial report of findings reflects the following four themes:

  • There is fragmentation in administration and delivery of information and services. This results in poor communication within and across stakeholder groups. It leads to interruptions in treatment and lack of trust in care received
  • Mining is seen as a competing economic and social force, one that supports yet divides families and communities
  • Common “experiences” of invisibility leave miners, ex-miners, families, and communities isolated and disempowered; and
  • TB is widely misunderstood contributing to stigma and reduced agency