Mara Kardas-Nelson spoke to Dr Fareed Abdullah about his vision for the South African National AIDS Council.

Scheduling a time to speak with Fareed Abdullah, the new CEO of the South African National AIDS Council (SANAC), is difficult. He can spare an hour at best here or there between meetings or travel from one part of the country to another. After several e-mails back and forth between myself and his assistant, it’s decided that Fareed and I will speak on the phone, as we can’t meet in person—he’s in Johannesburg, I’m in Cape Town. On a Friday afternoon I find myself in a back corner of the office, trying to make out his words through a muffled connection.

As we speak I try to get a better idea of this new leader of the South African HIV response, but I only have his voice and his words to go on. These suggest that Fareed is measured, committed, and efficient, to the point without being blunt. Rather than giving practiced answers like so many people in positions of power, he considers my questions carefully.

A Durbanite by birth, Fareed went to medical school in his hometown before studying public health at the University of Cape Town, a city he called home for much of his early career. It was here, in the mid-1980s, that he became a pioneer of the country’s HIV/AIDS movement. Fareed worked with the South African Health Workers Congress to campaign for a more equal health system and to educate communities and union workers about HIV.

Breaking new ground

After years in the field, Fareed joined the Western Cape Department of Health in 1994. There he was responsible for, among other things, HIV and TB. In over a decade of service, he considers his proudest achievement to be the province’s antiretroviral treatment (ART) pilot project. This project — the first such government-supported programme in South Africa — was done with Médecins Sans Frontières (MSF, or Doctors Without Borders) in Khayelitsha, Cape Town.

Another significant achievement was the province-wide prevention of mother-to-child transmission (PMTCT) programme, also initially piloted with MSF in Khayelitsha. Again, it was the first in the country.  “I’m proud that we stood up to the national government policy and rolled out…[ART] for adults and children, and reached such high levels of coverage within a few years…Because the Western Cape started [PMTCT] early, we…headed off the paediatric epidemic in a way that other provinces couldn’t. This resulted in thousands and thousands of kids being born HIV-free.”

After 12 years in government, Fareed left South Africa, to work with the International AIDS Alliance, which focuses on vulnerable populations in Asia, Latin America, and Africa,. His next role was with the Global Fund to Fight AIDS, TB and Malaria, where he headed the Africa Unit.

Homecoming

Yet Fareed felt more drawn to South Africa the longer he stayed away, “I had always planned to be out of the country for three years; it [became] six years. I felt like if I didn’t come back, I would lose my connection with my country.” According to Fareed, “It was the strength and ambition of the country’s newly drafted National Strategic Plan [or NSP, the guiding document of the SANAC] that was the final pull back…When I heard what Minister [Motsoaledi] was saying about government’s policy and when I read the NSP, I felt, ‘I really want to be a part of this.’”

Fareed sees the NSP as much more than simply a set of goals on a piece of paper. In his view it is a strong and ambitious commitment from all parties. “The whole process [of drafting the NSP] was consultative, was inclusive, with a huge role for civil society, for clinicians, for technical experts, for UNAIDS…It represents the full consensus of South African society.” His experience of living in a divided country under apartheid, and his work in government at the time of Mbeki-led AIDS denialism, mean that Fareed knows how remarkable and essential it is to achieve consensus among so many players. “That by itself is a rare phenomenon,” he says. “Given our peculiar history over the last decade, it achieves its weight in gold.”

I am proud that we stood up to national government and…reached such high levels of coverage within a few years

Controversial changes

Fareed has come to SANAC at a difficult time, inheriting a structure in need of much work. The council has been plagued with problems. These have ranged from poor human resources management to administrative woes and ineffective engagement with civil society. Fareed took the brunt of criticism over SANAC’s re-structuring. The media slammed him for dismissing all of the Secretariat’s staff members during the first two months of his tenure. Some of these staffers were later re-hired by the organisation. The case was eventually taken to the Commission for Conciliation, Mediation and Arbitration.

Building a new institution

But Fareed has confidence in the new SANAC that he has helped to build. “I had to make some changes with a firm hand…My board asked me to set up a new institution, and that’s what we set about doing…. I have 18 staff on the floor now, which is twice the number we had when I arrived four months ago…There’s a lot of work to be done still, and these institutions take years to build. But as of now, the secretariat is functional, it has a working team in place, it has a budget.”

New structures for SANAC have been approved. These allow for much broader representation from provinces, stronger connection to district and local levels, and a streamlined civil society sector. Business and labour are also being encouraged to participate more meaningfully in SANAC. Such changes have generated “a critical mass that functions more effectively,” says Fareed. “We have structures that are [far] more fit for purpose, and I think they have the right people in them.”

Fareed answers my questions at length and he does not skirt around the criticisms that SANAC has faced. Yet at times he still seems very much the politician, artfully changing topic so that I hardly notice my original query has gone unanswered.

When I ask him whether it is SANAC’s job to help fundraise for struggling but essential HIV NGOs, he answers vaguely: “We’d like to facilitate the additional funding from donors and domestic sources towards all the institutions which have a critical role to play in making the NSP…a reality.” I question whether SANAC could explicitly intervene in response to bad government policies or practice — here I mention the KwaZulu-Natal TaraKLamp debacle — and he diplomatically replies, “The role of SANAC is to bring…players together to facilitate resolution of differences. In some cases, such as…the TaraKLamp, whilst SANAC can facilitate a discussion the legal responsibilities lie with the Department of Health.”

 

A community activist

Politicking aside, Fareed considers himself a community activist above all else. “My most important, formative years were as an activist for democratic change in the 1980s.” He sees the involvement of civil society as an essential part of the HIV response. “Without activism, and without a strong sense that we had to deal with [HIV] as a matter of injustice, not just [of] health care, we would not have had the big improvements we’ve had now. Without that, we would be in a very, very dark place.”

This commitment to community involvement is matched with a goal to realise the UNAIDS approach of “know your epidemic, know your response”. Together they spur SANAC’s newfound focus on strengthening district AIDS councils, and linking these with the national programme. “Only when you get down to the district level do you understand what your high transmission activities are,” Fareed explains. “In some areas it will be migrant populations, sex workers and male clients, etc., and in other areas it will be [men who have sex with men], substance abuse and drugs. If we deal with it at the national and provincial level, we don’t get it right. The district level is the right level to organise a response.”

Taking ownership of health

Fareed insists that strong community participation is key to making a success of these councils. “Part of the goal is for communities to raise their voices, and for communities to take ownership of the health system…It’s the local communities…that can raise issues of dysfunctionality in the health system, that can point out where services are not being provided, who can speak about stockouts.”

He hopes that these councils will focus on more than just HIV, but “also deal with teenage pregnancies at schools, and child-headed households, and strengthen NGOs.” This falls in line with Fareed’s view that South Africa cannot meet the NSP targets without a cohesive approach, across all sectors of society. “Dealing with the NSP on its own strips it of [its] context…[it] has to be read with the overall development plan for this country as captured in the work of the National Planning Commission.”

“SANAC is not going to build houses, but the national long term vision for housing and urban planning and economic development is critical to making our AIDS and TB response a success. The same applies to poverty and unemployment and gender relations. The short term goals, the five-year goals, of the NSP, really depend to a large extent on the overall improvement of the health system.”

As such, SANAC works closely with all relevant government departments, including health, education, and social development. The organisation aims to ensure that each government department has measurable programmes and goals that will help to meet the NSP targets, as well as further the overall development of South Africa. Regular reporting will be required  in order to monitor progress. “Over time we’d like to build a comprehensive reporting system — at least annual, but in some cases quarterly and bi-annually. Interspersed with that we’ll have more qualitative reviews.” AIDS councils will also have to report regularly to help build an monitoring and evaluation (M&E) system “from the bottom up, from the local to the district to the provincial level.”

SANAC is working closely with the Department of Health’s National Health Insurance programme. Fareed hopes that SANAC, and the strengthened district AIDS councils in particular, will assist in the DoH’s “primary health care re-engineering project.”

Fareed knows that to meet the NSP goals South Africa needs more than just strong political will and community involvement. While the country has been hailed for increasing domestic resources for HIV, and has also secured funds from key donors such as the Global Fund and PEPFAR, it will need even more to continue scaling up the HIV response.

Funding shortfalls

SANAC has already begun to tackle the funding bottlenecks between the Global Fund and the Department of Health. These problems have notoriously led to severe funding shortfalls for NGOs across the country. The council will further engage donors and the treasury to mobilise domestic and international resources.

While Fareed doesn’t see it as SANAC’s role to provide direct financial support to civil society organisations, he does hope that SANAC’s funding advocacy can marshal resources for NGOs across South Africa. He also notes that SANAC itself will need more financial support. “We don’t have all the funding that we need at this stage,” he observes. “But we certainly have enough funds that have been budgeted for and approved to do our basic work in the first year.”

“From SANAC’s point of view we want to continue with this tradition and let it grow…We want to  go beyond just paying lip service to activism, and build up real partnerships in practical programmes and important policy discussions.”

Focus on prevention

SANAC’s new CEO has plenty of ideas about how that money could be spent. While one of the key goals of the NSP is to have 80% of eligible patients on HIV treatment by 2016 (with 70% still alive and on treatment after five years), Fareed’s personal vision is focused on increasing prevention efforts. “When it comes to treatment rollout and PMTCT, the [DoH] has done an incredible job…I think SANAC’s significant value-added would be to drive prevention programmes.”

He is committed to expanding prevention programmes among key, vulnerable populations that are chronically under-served, such as sex workers and men who have sex with men [MSM]. Also targeted would be the young women who account for the majority of new infections annually. “We don’t have…a national sex worker programme to speak of…We don’t really have effective programmes for MSM in key parts of the country…We don’t really have national programmes to deal with alcohol and HIV, informal settlements and HIV. Our national road networks are key sources of infection, but we don’t have a truckers’ programme on a scale we should [have].

“We’re dealing with morbidity and mortality, and we’ve scaled up treatment, and there’s excitement about treatment as prevention. But depending on a biomedical response is not enough…you still need to deal with behaviour change, you still need primary and secondary programmes.”

Pulling together

Fareed is hopeful that the newly revamped SANAC, and an NSP that boasts measurable yet ambitious targets, will push South Africa further uphill in the battle against HIV. But his optimism is cautious. He sees success as dependent upon a cohesive response led by SANAC. For Fareed, SANAC is the glue to hold all the players together.

“I think the task will be like climbing a mountain, and we should have no illusions about the enormity of [it].” To turn around the epidemics of HIV and TB is probably one of the most difficult things that any country has to do, and we have the unfortunate distinction of being the country with the largest epidemics in the world…Everyone must pull together, row in the same direction…That’s why it’s so important for SANAC to remain strong and inclusive and… tolerant of different views.”

“The task is so big…as a country we know what it was to be disunited. We don’t…ever want to be in that place again.”

By Mara Kardas-Nelson