Editorial: Three months to get it right

By Anso Thom and Marcus Low

Delays at the South African National AIDS Council (SANAC) has meant that the new NSP (National Strategic Plan) will now only be ready in March 2017. While the delay itself is not of any great concern, the kind of plan that will be produced by an unsettled SANAC and a weakened, unrepresentative civil society is concerning and brings into question the very idea of SANAC and the NSP. Already we are hearing rumours of a back-track on various things contained in draft zero of the NSP – including a back-track on the recommendation to decriminalize sex work.

There is a risk that over the next three months an NSP will take shape that will lack many of the targets and deadlines it needs to make an impact. It is understandable that government doesn’t want what they see as an external plan to interfere with their internal plans. But civil society should not accept this. We need leaders who can stand up to government, when needed work with them, but ultimately demand we do better on key issues such as sex work, condoms in schools, active case-finding for TB and community healthcare workers. Unfortunately, from what we’re hearing, civil society is capitulating on these issues without much of a fight.

Even though many critical issues will be mentioned in the eventual NSP, mere mentions are not enough. We need plans, timelines and budgets. We need an NSP that is highly focused and concrete. The decriminalization of sex work, for example, has been on the agenda for years – but simply having it on the agenda is not enough. We need to have a roadmap from where we are now to an actual amendment in our laws. Without such a roadmap, we do not in fact have a plan.

Similarly, setting targets for providing more people with HIV treatment and helping people adhere to treatment is all good and well, but targets are not a plan. How do we improve treatment adherence? Do we need to employ more community healthcare workers to provide adherence support and to trace patients who default? We think we should. How do we provide differentiated care through adherence clubs, if we don’t pay people to run those adherence clubs? How do we ensure there are no drug stockouts which endanger trust in the health system. How do we build a Medicines Control Council that can cope with the workload or registering new drugs and investigation unlawful treatment and activities? These are the issues the NSP must map out in detail and force action on. It should make the case so clearly and convincingly that the Department of Health and treasury has no option but to fund it.

In the same way, we can say whatever nice things we wish about active case-finding for TB (possibly the most critical TB intervention we are not implementing), but if we don’t map out what that means in the real world then it will be just an another aspirational target. The NSP has to make it explicit that we can’t do active case-finding without people and that we need to train and pay people to start doing active case-finding. In two words Community Health Workers.

Another critical area on which the new NSP must move the dial is HIV and pregnancy prevention in schools. We need a programme that is explicit about the right to comprehensive sex education and the right to access condoms – the latter being a right in terms of the right to access healthcare services. But again there appears to be no clear plan on the table on how we get from here to there.

If the new NSP doesn’t deliver on these critical issues with detailed timelines and budgets then it will be hard for us to support it. As has become clear in recent issues of Spotlight (previously NSP Review), our HIV and TB response is at code red. Our public healthcare system is in crisis. We need a plan that deals with this emergency seriously and based on the best available evidence. Anything less is not good enough.

A difficult political environment

The development of the new NSP comes at a very difficult time in South Africa’s history. Amid the Public Protector’s State Capture Report, the various scandals relating to the Gupta family, spurious charges against Finance Minister Pravin Gordhan and widespread calls for President Jacob Zuma to stand down, Deputy President and SANAC chair Cyril Ramaphosa has had a lot on his plate. In this fraught political context the new NSP has hardly elicited the national conversation or leadership that is needed – that it is needed is clear from the fact that around seven million people in South Africa now live with HIV and tens of thousands still die of tuberculosis every year.

To some extent, our HIV and TB response is also falling victim to the wider crisis in our politics. It is thus very encouraging that Health Minister Dr Aaron Motsoaledi and deputy Minister Joe Phaahla took a public stand against corruption when late in October they publically declared their support for Minister Gordhan. The spurious charges against Minister Gordhan have since been withdrawn. We trust that these leaders will not lose their jobs or be victimised for having taken this correct and principled stance. We will watch closely.

While the fight against corruption and state capture in South Africa is urgent and critical, the development of the new NSP is also critical. We urge the Deputy President, the Minister of Health, the rest of the national cabinet and all provincial cabinets to engage with both these urgent issues. Just like corruption, HIV and TB impacts the lives of millions of people in this country.

While the big picture politics are deeply concerning, there are also some signs that all is not what it should be at SANAC. The position of SANAC CEO Dr Fareed Abdullah was recently advertised amid rumours of a campaign to replace him with a person more compliant to the whims of some in government. Whether there is any veracity to these rumours we do not know, but it has reached us from various sources.

What is clear though is that in the current political context we need SANAC to be stronger than ever. Abdullah has done well in steering SANAC over the last five years and much of what concerns us at SANAC is beyond his control. Removing him now will threaten operational continuity at SANAC – something we cannot afford.

Civil society leadership crisis

While operational continuity is critical at SANAC, we urgently need new energy and ideas on the political side. This political energy has to come from civil society leaders at SANAC. Many people we have spoken to have expressed their disappointment with the failure of the current civil society representatives to raise critical issues impacting on ordinary people living with HIV and/or TB over the last five years. There is a strong feeling that SANAC needs a civil society sector that is fully representative, that speaks with the voices of the marginalized, speaks with the voices of the poor and that the only way in which this can happen is if the current civil society is disbanded.

The new NSP provides an opportunity to make a clean start where we avoid the pit-falls of the past and ensure that people living with HIV and TB in South Africa feel they are properly represented. One way to avoid these pit-falls is to set some guidelines of what we expect from our civil society representatives.

To start with, we should insist that civil society leaders must represent constituencies and not just themselves (academics and other technical experts can of course contribute in their personal capacities to technical questions). Ideally, we want people who have been elected by affected people and who must account back to those people on what they have or have not done at SANAC.

Secondly, we should insist on transparency regarding the financial affairs of all civil society representatives. Where people represent NGOs, the finances of those NGOs should be open for public scrutiny – as is the case with all NGOs. If people do business with government, then that potential conflict of interest should be disclosed.

Looking back, there is much to be proud of, but what lies ahead is what matters now and what we do in the next three months will set the course of the next five years.