Rebecca Surender

The ideas, practicalities, and challenges of establishing effective social protection in Africa are steadily, if somewhat slowly, gaining notice in both policy-making forums and mainstream social policy analysis. The world’s second largest and populous continent, Africa is also its poorest region, with chronic poverty, vulnerabilities, and preventable hardship. Despite some significant developments in social welfare interventions and outcomes since the turn of the century, the policy agenda and dynamics in most countries remain complex and tenuous, arguably more so than other lower and middle income (LMIC) regions. This special edition contributes to a critical analysis of the challenges and opportunities facing social protection systems in Africa. It also seeks to examine the extent to which the staple explanatory concepts of welfare dynamics in the northern and western hemispheres – the role of actors, ideas, and institutions – need to be modified or adapted when analysing welfare dynamics in Africa. The focus is on Sub-Saharan Africa (SSA) rather than the more diverse and heterogeneous Middle East and North Africa (MENA) region. While, it is important to acknowledge that SSA nations are also distinct and varied; nevertheless, they share important characteristics in terms of historical contexts, average incomes, development outcomes, and most relevant for the purpose of this analysis, social policy strategies, and challenges.

Social polices of developing countries are frequently determined by forces outside their national borders, via international governance organizations and development institutions. In this context, most analysis has focused on the transfer of funds and ideas from North to South and on ‘Western’ actors. Increasingly, however, attention is turning to a set of new agents, the so-called BRICS—Brazil, Russia, India, China, and South Africa—distinguished by fast-growing economies and escalating influence on global social development. This chapter addresses their South-South cooperation practices and their influence on global social policy and governance debates, processes, and structures. It argues that while it is too early to make definitive prescriptions about what it means for the conditions, processes, and politics of global social policy, it is clear that the BRICS group has begun to significantly impact the architecture and discourses of global governance as well as on the quantity and nature of aid to developing countries.

Effective use of proven treatments for high blood pressure, a preventable health risk, is challenging for many patients. Prompts via mobile phone SMS-text messaging may improve adherence to clinic visits and treatment, though more research is needed on impact and patient perceptions of such support interventions, especially in low-resource settings. An individually-randomised controlled trial in a primary care clinic in Cape Town (2012–14), tested the effect of an adherence support intervention delivered via SMS-texts, on blood pressure control and adherence to medication, for hypertensive patients. (Trial registration: ClinicalTrials.gov NCT02019823). We report on a qualitative evaluation that explored the trial participants’ experiences and responses to the SMS-text messages, and identified barriers and facilitators to delivering adherence support via patients’ own mobile phones. Two focus groups and fifteen individual interviews were conducted. We used comparative and thematic analysis approaches to identify themes and triangulated our analysis amongst three researchers. Most participants were comfortable with the technology of using SMS-text messages. Messages were experienced as acceptable, relevant and useful to a broad range of participants. The SMS-content, the respectful tone and the delivery (timing of reminders and frequency) and the relational aspect of trial participation (feeling cared for) were all highly valued. A subgroup who benefitted the most, were those who had been struggling with adherence due to high levels of personal stress. The intervention appeared to coincide with their readiness for change, and provided practical and emotional support for improving adherence behaviour. Change may have been facilitated through increased acknowledgement of their health status and attitudinal change towards greater self-responsibility. Complex interaction of psycho-social stressors and health service problems were reported as broader challenges to adherence behaviours. Adherence support for treatment of raised blood pressure, delivered via SMS-text message on the patient’s own phone, was found to be acceptable, relevant and helpful, even for those who already had their own reminder systems in place. Our findings begin to identify for whom and what core elements of the SMS-text message intervention appear to work best in a low-resource operational setting, issues that future research should explore in greater depth.

To address problems of inadequate public health services, escalating private healthcare costs and widening health inequalities, the South Africa (SA) Government has launched a bold new proposal to introduce a universal, comprehensive and integrated system for all SAs; National Health Insurance. Though attention has been devoted to the economics of universal coverage less attention has been paid to other potential challenges, in particular the important role played by the clinicians tasked with implementing the reforms. However, historical and comparative analysis reveals that whenever health systems undergo radical reform, the medical profession is instrumental in determining its nature and outcomes. Moreover, early indications suggest many SA private general practitioners (GPs) are opposed to the measures—and it is not yet known whether they will comply with the proposals. This study therefore analyses the dynamics and potential success of the reforms by directly examining the perceptions of the SA medical profession, in particular private-sector GPs. It draws on a conceptual framework which argues that understanding human motivation and behaviour is essential for the successful design of social policy. Seventy-six interviews were conducted with clinicians in the Eastern Cape Province in 2012. The findings suggest that the SA government will face significant challenges in garnering the support of private GPs. Concerns revolved around remuneration, state control, increased workload, clinical autonomy and diminished quality of care and working conditions. Although there were as yet few signs of mobilization or agency by private clinicians in the policy process, the findings suggests that it will be important for the government to directly address their concerns in order to ensure a stable transition and successful implementation of the reforms.

China’s role as an emerging donor and its conceptualization of social policy in Africa has generated polarized reactions in the West. Many argue its ‘productivist’ approach is driven less by notions of citizenship and social rights, and more in terms of accumulation functions. Social investment is justified for broader economic development goals in contrast to current safety-net or ‘welfarist’ models of Western donors. While some international organizations perceive the Chinese approach as antithetical to Western goals and practice, others welcome it as an opportunity to develop new ideas about social development.This qualitative research explores to what extent and in which direction Chinese aid to Africa is influencing Western ideas about welfare policy in developing countries. The study comprises a systematic review of Sino-African and Western policy documents and in-depth interviews with senior Chinese, Western and African stakeholders. It investigates how social policy is conceptualized by those involved in Chinese aid to Africa, to what extent this differs from traditional Western approaches, and what it means for Western social development policy. The implications for understanding the drivers of global policy development and links between the economic and social dimensions of welfare are explored.

Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa‘s child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal). This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18–24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt. Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6). Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children’s rights, more efforts are needed to improve and ease access to this cash transfer program.

Sino-African cooperation embraces not only trade and foreign direct investment, but a ‘social dimension’ also, including expenditure on health and education. However, the ‘Chinese approach of social welfare appears to be mediated under a different set of normative premises, institutional actors, and policy mechanisms from traditional development partners. Based on in-depth elite interviews, and a systematic content analysis of key policy documents, this research examines both the nature and implications of the emerging Chinese “social policy model” in Africa. Located within global social policy discourses and focusing on the role of policy actors, the analysis investigates how welfare and social policy is conceptualized in China-Africa development aid cooperation. The study explores the implications for our understanding of traditional debates concerning the drivers of social policy development, as well as the extent to which these ideas represent a new policy paradigm or merely repeat earlier debates.