Millions of lives depend on it

Millions of lives depend on it

Mark Heywood, photo by Alon Skuy

The outgoing Deputy Chair of the South African National AIDS Council (SANAC), Mark Heywood, gives a frank assessment of the state of SANAC and what the body will need over the next five years.

Where we have come from

In August this year I stepped down as Deputy Chairperson of SANAC after occupying this position for five years, from 2007-2012. Those were the years of the first National Strategic Plan on HIV/AIDS and STIs (NSP) which was developed on the basis of scientific evidence, human rights and meaningful consultation.

The last five years have seen our country’s response to HIV break the grip of a politically-sponsored AIDS denialism that cost hundreds of thousands of lives. South Africa’s achievements since 2007 are reflected in the fact that the number of people on antiretroviral (ARV) treatment has grown from less than 200,000 in 2006 to over 1.7 million today. In the last two years alone fifteen million people have tested voluntarily for HIV. The vertical transmission of HIV from mother to child during pregnancy and birth has dropped from nearly 20% of pregnancies to 2.7%.

It is hard to believe that a decade ago a treatment programme so life-saving was the centre of a fierce political struggle and a case in the Constitutional Court!

Between 2007 and 2012 SANAC was entrusted with monitoring and advancing the NSP. The current structure of SANAC effectively came about in 2007 as a result of discussions between the then Deputy President Phumzile Mlambo-Ngcuka and the Treatment Action Campaign (TAC). It was part of the ‘peace deal’ that followed the government’s embarrassing participation in the 2006 International AIDS Conference in Canada. In the last quarter of 2006 TAC persuaded the government to delay finalising a new NSP because the draft on the table was appalling, but agreed to work to relaunch an effective AIDS Council. As a result the new structure was launched on World AIDS Day 2006. Despite many difficulties, it has grown in strength and legitimacy since then.

“it is hard to believe that a decade ago a treatment so life-saving was the centre of a fierce political struggle.”

Deeper roots

However, in late 2011 it became necessary to once again restructure SANAC in order to strengthen the council and deepen its roots in South African society. In particular, it was agreed that since major national policy debates and disagreements had been resolved the emphasis now should be on building SANAC at local and district levels.

This process is now complete. I would argue that
the key governing principles for the new SANAC should be:

  •  The accountability of representatives at all levels of the council;
  • A structure that provides maximum impact for minimum cost;
  • A council with well-defined functions whose outcomes can be clearly measured;
  • A structure that is transparent and continually open to public inspection.

With these principles in mind I want to reflect on SANAC’s strengths, weaknesses and challenges. I want to challenge the next leadership of SANAC to realise the vision of an accountable, efficient, transparent, effective and frugal institution.

In order to do this it is necessary to speak honestly.

Five crucial challenges

[box]The five years  ahead will not be the same as 2007-2012. AIDS denialism is broken and buried, and the new challenges are of a different order. The 2012-2016 NSP has a 20-year vision to eliminate new HIV infections, end AIDS- and TB-related deaths, and stop all stigma and discrimination. To realise this vision we must first and foremost nail down what we have achieved up to this point. Flowing on from this we must ask, what is the role for SANAC in future?[/box]


1 Sustaining the ARV Programme

Today 1.7 million South Africans take ARVs daily to control their HIV infection and prevent the development of AIDS. This number represents an enormous achievement. But if we are honest we must admit that the ARV programme is weak and fragile. It is not just drug stockouts — although they are a serious problem — that threaten the programme. More worrying is the poor quality of ARV services at health facilities that threatens to undermine adherence, causes preventable deaths and contributes to widespread drug resistance.

The problem is that few patients receive the necessary counselling. As a result many do not understand their medicines or appreciate the importance of adherence. The public health system does not give adequate support to people on ARVs. For example, there is little accessible information to provide treatment and prevention literacy.

For SANAC, strengthening the ARV programme and improving its quality are crucial challenges. It is not just about expanding the numbers on treatment to meet the new target of ensuring that “at least 80% of people who are eligible for treatment for HIV are receiving it”. It is also about “ensuring that at least 70% should be alive and still on treatment after five years.” To assist in this task it is vital that:

  • SANAC develops an independent monitoring capability (rather than just talking about it as it has for so many years);
  • The council has its eyes on the frontline of service delivery;
  • SANAC can pressure and assist the Department of Health (DoH) to intervene where necessary to continually improve the quality of its services.


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.



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.


Mark Heywood, SANAC Deputy Chairperson, 2007-2012