In South Africa, the average consumption of pure alcohol per drinker per year is estimated to be 15–20 liters, with one in four adult male and one in ten adult female sufferers from alcohol abuse.1 And while it is not just the poor who drink excessively, given the development challenges faced by the country, it is the poor who disproportionately feel the social consequences of alcohol-related harm. A recent World Bank study found that the poorest South Africans spend more on alcohol than they do on education, health, and entertainment combined.2
Alcohol-related harm is estimated to contribute to 7 percent of the total burden of death and disability in South Africa; the global average is 4 percent. A 2011 study commissioned by the Department of Trade and Industry found that the tangible economic costs associated with alcohol abuse in South Africa were about US$4.3 billion (37.9 billion rand) in 2009, equal to 1.6 percent of gross domestic product. About half of these are direct costs, like the costs of operating roadblocks to stop drunk driving, or treating victims of alcohol-related harm in trauma units at hospitals. The rest are indirect, like the cost of a child repeating a grade at school because a drinking parent forces him to take care of younger children, or the choice by tourists not to visit South Africa for fear of violent crime.
In addition to these costs, interpersonal violence recently ranked as the second leading cause of death among males aged 15–44 years.3 Substance abuse is a key risk factor, with 53 percent of fatal and up to 73 percent of nonfatal interpersonal violence injuries testing positive for alcohol in urban areas of South Africa in 2001.4,5
Soul City
The Soul City Institute aims to improve the quality of life and health of people in South Africa by strengthening individuals, communities, and society through active citizenship and the principles of human rights, equity, and inclusion. Soul City uses a combination of prime time mass media, social media, social mobilization, and advocacy to positively affect health and other areas of development. Known as edutainment—where social and educational issues are woven into radio and television dramas—this method has been shown locally and internationally to be a powerful tool for bringing about social and behavioral change.
Phuza Wize Drink Safe Live Safe Campaign
Soul City’s Phuza Wize campaign, which means “drink wisely,” was launched in March 2010 with several aims: first, to address environmental factors that promote excessive alcohol use; second, to increase public debate around alcohol consumption and interpersonal violence; third, to challenge social norms that glamorize and encourage excessive alcohol consumption; and, fourth, to lobby for an alcohol levy that can be used to set up an independent health promotion and development foundation.
The campaign had the following components:
- Television dramas. The Soul City television drama for adults focused on the link between alcohol and violence, and role-modeled community activism to create safer social spaces. The television drama Soul Buddyz, aimed at 8- to 14-year-olds, role-modeled how children could take action to make schools alcohol-free.
- Booklets. Soul City developed several booklets. These focused on making drinking places safer and targeted different audiences—parents with information on alcohol and violence, journalists with details on alcohol advertising and marketing, and schools with a guide on developing alcohol policies.
- Soul Buddyz Clubs. This club allowed children to participate in activities at schools nationwide.
- Advocacy. This part of the program involved a campaign focused on policy change, training to build community capacity to engage with legislation, and social mobilization to support and promote community action to create safer social spaces.
The Role of Advocacy
The Drink Safe Live Safe campaign began by commissioning several pieces of research. Two of these in particular helped to shape the advocacy campaign. The first of these looked at the legal framework within which alcohol is sold and consumed in the country. It found a lack of coherent policy across all levels of government, as well as in the alcohol policy statements of several government departments. These inconsistencies resulted in almost round-the-clock sale of alcohol, as well as an increase in the number and density of outlets.
There are more than 220,000 outlets that sell alcohol in South Africa, though only about 20,000 are licensed. With only 49 inspectors nationwide, the current monitoring system is seriously deficient. Illegal outlets that are shut down generally reopen once the inspector has left. The draft National Norms and Standards has proposed an increase in the number of inspectors to 105, but the campaign believes this will still be insufficient for effectively monitoring outlets.
The majority of unlicensed outlets are in the formally blacks-only townships of the country where the population density is high, as are the rates of poverty and unemployment. These outlets are seen as job-creation opportunities by those who run them, and by many in the township whose families once relied on this income to run the home. Many others who live close to these outlets complain that they create noise, dirt, and violence, and they want government to do something.
“Government should make strict laws to shebeen [liquor store] owners to comply with the laws of selling alcohol. Police should have a list of taverns and monitor them regularly to check if they comply with the laws and whether they have license to sell alcohol,” according to one citizen interviewed as part of Soul City research. Another noted that, “We need money in taverns, but they should take responsibility not to sell liquor to young people who are underage, or students for that matter.”
A second salient piece of research analyzed the direct costs of alcohol use and misuse to the South African taxpayer in the 2009–2010 tax year. This research reviewed the direct costs of alcohol use to eight different provincial and national government departments, including health, social development, transport, and justice. As noted above, this study found total costs amount to about $4.3 billion, with half of these attributed to direct costs.
The Phuza Wize campaign argued that it is not fair for ordinary South Africans to pay for alcohol-related harm while alcohol companies take all the profit. SABMiller, one of the world’s largest alcohol companies, reported $3.2 billion dollars of revenue in 2009–2010. The extent of the disease burden created by high levels of alcohol consumption, its link to death and disability in South Africa, as well as the costs incurred also necessitate ongoing health promotion and prevention activities.
Some of these profits could go toward ongoing health promotion and prevention activities. In late 2010, the Phuza Wize campaign began to lobby for a 1 percent levy on the annual sale of alcohol to offset losses to the Treasury and the general public. The campaign argued that money raised in this way be used to establish an independent health promotion and development foundation (HPDF) similar to those found in Australia and Thailand. (In Thailand, an excise tax on alcohol and tobacco funds its health promotion foundation.) In South Africa, such a foundation would be a multidisciplinary structure providing research, advocacy, project piloting, and intersectoral collaboration to increase awareness about health interventions that improve health and save financial resources.
The experience of a Thai Health Foundation demonstrates that an HPDF not only improves health and well-being, but can also significantly reduce costs to national health insurance schemes. This linkage of the HPDF and health insurance is timely given the fact that South Africa’s insurance scheme is only now being rolled out. The scheme is being piloted with intense public and private discussions to understand and plan its various elements. Implementation is expected to take place in stages over the next 14 years.
The HPDF Network adopted the campaign to force the alcohol-producing companies to pay a levy on the sale of alcohol and for this levy to be redirected to set up a health promotion and development foundation for South Africa. This would make health promotion earn a sustainable and independent source of funding which would allow the country to determine its own priority programs. It would also have the benefit of increasing the price of alcohol, thereby reducing consumption. Finally, the government would not lose any income, as they would continue to get the same amount of tax as they’d been collecting. The HPDF Network made the decision in November 2011 to lobby for alcohol (and tobacco) taxes to be increased and for the increase to be used to set up the foundation.
While the Department of Health supports the establishment of an HPDF, it has not made explicit how it envisages the funding mechanisms or governance of the foundation. Nor has it made clear the degree to which the foundation will operate independent of the Department of Health and the government.
Phuza Wize Campaign Achievements
The campaign was conceptualized for a five-year duration with mass media, advocacy, and social mobilization components. Funding constraints resulted in curtailment of the social mobilization and mass media components of the campaign. The advocacy campaign is ongoing and has led to a range of successes, including: lending shape to the conversation on alcohol in South Africa, including the role of advertising and the need for comprehensive regulatory policy; the inclusion of Phuza Wize recommendations for safer social spaces criteria in a range of draft alcohol legislation; commitment by the government (backed up by action) to draft alcohol policies; and the inclusion of some form of levy as well as the concept of a health promotion foundation in debate over draft alcohol policies.
Soul City continues to try to raise funds to implement the social mobilization component, as this is key to ensuring that the objectives of the campaign are achieved. However, given that some aspects of social mobilization are currently being implemented in two provinces, it is anticipated that the evaluation results from these interventions will provide the necessary evidence base to galvanize more resources for the campaign.
Conclusion
Public health proponents and activists do not only view health as a human right, but they also view environments that do not promote health as harmful and legitimate targets for change. The continuing disparities in health outcomes in South Africa are a concrete manifestation of the inequity and social stratification that still exists in the country.
Universal access to health and the knowledge that can be attained through health promotion can play a crucial role in promoting development and equity. The Phuza Wize campaign continues to work to achieve the goals of a levy and a health promotion and development foundation. It is clear from our ongoing experience that making environments safer requires a multipronged approach including research to inform the strategy, legislative change, partnerships, advocacy at national and provincial government levels, community advocacy, awareness raising, and education.
