2 Rapid integration of  improved treatment and prevention tools

SANAC needs to drastically improve its ability to absorb and then implement new knowledge about HIV and TB.  At the 2012 International AIDS Society Conference we learned about the probability of pending scientific breakthroughs that would add to our armoury of HIV prevention and treatment. SANAC has four Technical Task Teams which must keep their eyes more reliably focused on developments such as these in clinical and social science. Then, SANAC as a whole, together with the DoH and other government departments, must develop the means to responsibly but rapidly act on new knowledge as it emerges.

In future SANAC must not repeat the fiasco of ‘debate’ that accompanied scientific research demonstrating the efficacy of medical male circumcision in reducing the risk of HIV infection. This research was first reported in 2007 and reflected in the NSP. But in one of SANAC’s darker episodes, the introduction of a medical male circumcision programme was delayed for two years. The programme was held hostage to the political and ideological agenda of some sitting members of SANAC that had nothing to do with our duty to uphold the NSP and prevent avoidable HIV infections.

Let’s be clear, there is no question about whether we should implement scientific knowledge in a culturally appropriate fashion. How to achieve that implementation should be the discussion for SANAC  — not whether scientific developments should be introduced at all.

3. Sufficient and sustainable financing

Central to the realisation of our AIDS response in the next five years will be securing enough sustainable funding. The 2007-2012 SANAC did little in this regard. Bodies such as the Resource Management Committee (RMC) were largely dysfunctional, and disbursements from the Global Fund to fight AIDS, TB and Malaria (GFATM) were not integrated into the national response.

Fortunately, SANAC’s weakness and lack of strategy were offset by government’s own commitment to increasing its HIV budget, which grew by more than 100% from R3.5 billion in 2007/2008 to R7.9 billion in 2011/2012. This increase accompanied a steady inflow of international funding through bodies like the President’s Emergency Fund for AIDS Relief (PEPFAR) and GFATM.

However, although funding for the continued expansion of the ARV programme is guaranteed by the government’s Mid Term Expenditure Framework (MTEF), this money does not cater for key strategic pillars of the NSP. This is particularly true of interventions around stigma and discrimination, and of education about human rights or adherence. Very worrying too is the steady retreat of the international donor community. Their support for civil society organisations such as TAC — which have been crucial in driving forward the response to HIV and securing governmental accountability — has begun to weaken.

Once established, the proposed SANAC NSP Financing Committee needs urgently to develop a fundraising and sustainability strategy for implementing the NSP. Its members need to discuss how, and from where, it will raise the billions of rand that will be required to support the social response to HIV and TB. The committee will also have to decide on what criteria to disburse these funds.

On this issue let me make one additional point:  SANAC cannot afford to allow extravagant waste or corruption to creep into its operations. In terms of financial accountability and oversight the 2007-2012 SANAC failed dismally and continues to fail. In early 2012 I resigned from the SANAC Trust. One of the reasons I gave in my resignation letter to the Deputy President was the failure to audit or account for SANAC funding or expenditure from 2007 onwards. My letter was not answered or acted upon.

4. Broad-based political leadership

The next SANAC must also question whether South Africa has really achieved the broad political leadership that is required to lead a comprehensive response to HIV and TB. Whilst no-one doubts the energy or commitment of Dr Aaron Motsoaledi, the Minister of Health, it remains unclear whether similar political leadership on HIV and TB will be shown by other ministers, premiers or mayors.

One reflection of this lack of leadership is the ongoing failure after many years to establish a functional all-party parliamentary committee on HIV and TB.

It has become a truism that the response to HIV must reach across all sectors of South African society, yet the government’s response is not truly multi-ministerial. Just a few examples are enough to illustrate this problem:
HIV and TB remain rampant in our prisons but the Department of Correctional Services (DCS) does not participate meaningfully in SANAC and neither do prisoners. The Department of Basic Education (DBE) does participate – but young people and school learners do not.  As a result, important programmes such as HIV testing and condom availability in schools have been postponed indefinitely. In another example, the Department of Trade and Industry (DTI) is developing a new policy on Intellectual property without reference to the DoH or to the concerns of civil society about issues such as patents on essential drugs for HIV or TB.

View the graphs as a pdf here

5.The structure of SANAC: self-serving or society-building?

Finally, there is the issue of the new structure and functioning of SANAC.

A 2011 mid-term review of the 2007-2011 NSP was justifiably critical of the council. Amongst other things it found that for most of 2007-2012 SANAC worked only at the national level. Many of the 17 (later 19) civil society sectors were not operational beyond the engagement of a few individuals. Their leaders were not accountable to the constituencies that they claimed to represent. Furthermore, provincial AIDS councils were weak or non-existent and were disconnected from SANAC.

Find the core

These findings show that at a national level SANAC needs to revise its terms of reference and procedural rules. Instead of trying to do everything, the council needs to identify and agree upon a core business: fundraising, policy monitoring and advice, and the development of visible communication strategies. This would call for a slimmer, more efficient and less democratic structure.  The representation of social stakeholders would remain vital but should occur at lower levels of the organisation.

Regrettably, however, it is arguable that the lengthy restructuring of SANAC lacked leadership and vision. It fell prey to vested interests and to a wider problem in South African politics: that of the individuals who sit on all sorts of committees, claiming to represent the interests of ordinary people, while in reality using their official roles to nurture their own self-interest.

In this context, SANAC’s reorganisation allowed a small number of individuals to repeatedly overturn democratically made resolutions. Furthermore, instead of discussing the critical first year of the new NSP, and how to structure the council in order to meet the plan’s ambitious outcomes, members argued and fiddled, unable to resolve largely petty issues. At the end of the process, as illustrated in the diagram on the inside back cover of this magazine, the restructuring had created a body even more bloated than its predecessor.

Despite this, the South African response to HIV cannot do without SANAC. But the dangers I have identified above call for close external monitoring of all SANAC structures. Such scrutiny would guarantee the accountability of the delegates and ensure that they truly represent the interests of their communities.

For this, there has to be an independent mechanism, a kind of ‘SANAC Watch’. If TAC does not undertake this role, another organisation must do so. Without sufficient monitoring the very purpose of SANAC would be undermined.

However, the decision to prioritise the development of SANAC through provincial, district and local AIDS councils is reason for optimism. This approach is in keeping with TAC’s own priorities which focus on the front lines of the battle against HIV and TB. But, as some reports in this issue of NSP Review show, it will not be easy for SANAC to refocus in this way. Tackling HIV and TB at a local level requires new alliances.  It also requires a constant fight for democracy on the ground, and the prioritisation of budgets to meet local needs. This is a whole new struggle.

Conclusion

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Over the years, many of us in civil society have fought for a functional SANAC – not because we like to sit on committees but because South Africa needs an effective advocacy body to lead and coordinate the country’s HIV and TB response. We need a forum where civil society can convey its experience to government, and where government can report and account for its actions to civil society. We still need this body. But we also need to integrate the HIV and TB response with policies and plans that tackle South Africa’s legacy of poverty, gender inequality and underdevelopment.

Millions of lives depend on it.

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Mark Heywood, SANAC Deputy Chairperson, 2007-2012