A vision without a plan: In-depth analysis of SA’s new HIV and TB plan

Crowds gather for a “Good Governance” week hosted by the Public Protector’s Office in Vosloorus. It’s set up to allow the community to air its grievances.

By Marcus Low

On 11 May 2017 South Africa’s National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 was finally published after multiple delays. The NSP is meant to coordinate and guide a coherent response from government, business, organised labour and civil society to the HIV and TB epidemics in South Africa.

That such a master plan is of critical importance seems obvious. There are still around 270 000 new HIV infections in South Africa per year. According to what is written on death reports, TB is the number one killer in the country. If death reports are combined with other sources of information, experts conclude that HIV is the number one killer in South Africa – with around 150 000 deaths per year. Meanwhile, rates of drug-resistant forms of TB are increasing at alarming rates and reports from the Office of Health Standards Compliance (OHSC) and others paint a picture of a healthcare system that is often severely dysfunctional.

It may not make the headlines as it used to, but HIV and TB remain at crisis levels in South Africa. The NSP should be judged by the seriousness, ambition, and realism with which it addresses this crisis. With that guiding principle, we will start by considering the context in which the NSP is to be implemented. After that we will evaluate the content of the NSP in a number of key areas. Then, we will try to map some potential ways forward.

The NSP and the realities of our public healthcare system

In November 2016 the Business Day newspaper obtained data from the OHSC showing that only 89 of 1427 inspected clinics and hospitals met the OHSC’s 70% pass mark. Not one of 53 clinics inspected in the Free State obtained a pass mark. In all 9 provinces in the   country, the average performance outcome of district hospitals inspected fell below the pass mark. Some of this data was later presented to parliament and eventually published in a devastating report.

While the establishment of the OHSC is certainly one of the most notable achievements under Dr Aaron Motsoaledi’s tenure as Health Minister, it is deeply concerning that the data was only made available after Business Day had filed a request in terms of the Promotion of Access to Information Act (PAIA). The affair does however highlight the tendency from government and government-linked entities to sweep healthcare system problems under the carpet – as is arguably also done in the NSP.

While the OHSC data provides probably the most compelling evidence of widespread dysfunction in the healthcare system, there is no shortage of other red lights. From the Life Esidemini tragedy in Gauteng where at least 94 people died, to the unconscionable decay in cancer services in KwaZulu-Natal, to a Treatment Action Campaign (TAC) survey that found only 15 of 158 clinics across seven provinces had sufficient TB control measures in place, to the reports of the Stop Stockouts Project, to the terrible conditions in the Free State healthcare system and a collapsing roof at Charlotte Maxeke Hospital in Gauteng, there can be no doubt that there is widespread dysfunction in the public healthcare system in South Africa.

It is in the context of this widespread dysfunction that the NSP is to be implemented. Yet, when one reads the NSP one finds no recognition of this crisis, nor of the fact that the failure to engage with this crisis may render the NSP essentially unworkable. As argued in a recent TAC and SECTION27 media statement: “This is an NSP that seems reasonable when considered in the abstract, but that risks falling apart when confronted by the realities of the public healthcare system in South Africa and the political context in which this healthcare system exists.”

Underlying the dysfunction in our healthcare system are at least two key factors, a lack of funding and a political crisis that is undermining the public service. The funding crisis in relation to healthcare is most obvious in what amounts to the freezing of posts – something for which the recent health budget offered no relief. The OHSC report was also clear on this, stating that “indeed budget constraints has had direct impact on adequate funding of vacant clinical and allied professional  posts, inadequate  infrastructure and maintenance budget, medical equipment, medical supplies,  consumables including pharmaceuticals have been reported but there is no funding available.” Though the final NSP touches on the lack of funding, it does not go into much detail on this or on the accompanying human resource crisis and certainly does not connect the dots to make a powerful case for increased funding as one would have hoped it would.

On the political side, the NSP is even further removed from the realities of the fraught context it is to function in. The NSP justifies its own vagueness by arguing that it will be up to provinces to develop implementation plans. While this seems fine in principle, the reality is that this model has failed badly over the last five years since most provinces simply do not engage meaningfully with either the NSP or AIDS councils. There is no evidence in the new NSP that this failure has been reflected on with any seriousness and we thus seem doomed to repeat the same pattern of national-level policies or strategies being sent to provinces to die. One would at the very least liked to have seen annual provincial-level targets on all key indicators highlighted in the NSP and clear guidance for provinces as to which interventions to prioritise given resource constraints.

This dynamic of the breakdown between national and provinces of course cannot be disconnected from our wider politics and the culture of cadre deployment, corruption, and capture that has come to dominate public discourse in South Africa. Essentially, too many MECs for health are still untouchable because of their loyalties to particular factions within the ruling party. In addition to this ongoing accountability deficit, South Africa’s political crisis has also lead to rating agency downgrades and a recessionary economy which seems set to further shrink an already insufficient health budget. It may have been too much to expect the NSP to make an explicit statement on South Africa’s political crisis, but it could certainly have more forcefully and concretely made the case for the good and transparent governance of provincial healthcare systems and for greater political accountability.

HIV prevention in the NSP

One of the most remarked upon short-comings in the NSP is the very low targets set for pre-exposure prophylaxis (PrEP) in the final NSP – 18 000 people receiving PrEP by 2019, and 85 000 people by 2022. These low targets are particularly disappointing given that earlier drafts of the NSP contained much higher targets. Draft 1 of the NSP set a target of 1.4 million, including “200 000 young women ages 20-24, 500 000 adolescents of both sexes, 450 000 sex workers, 175 000 MSM and 60 000 people who inject drugs”. The 1.4. million target may or may not have been a good target – we never saw a specific justification for it – but at least it was ambitious.

The NSP sets a target of reducing new HIV infections to under 100 000 per year by 2022. This is a very ambitious target given that the rate is currently around 270 000. While substantial reductions seem likely (Thembisa model outputs published last year projected around 170 000 by 2022), getting as low as 100 000 would require aggressive use of all available interventions. An important  modelling study by Dr Leigh Johnson and colleagues published in June last year, suggested that while not the most important factor in HIV prevention, PrEP aimed at youth and the general population may nevertheless have an important role to play in reducing new infections – incidentally, PrEP in sex workers was projected to have less impact on overall infection rates, although a moral case could still be made for providing PrEP to sex workers. In addition, as pointed out by Professor Linda-Gail Bekker in a plenary at the recent SA AIDS conference, one of the risks of limiting PrEP to sex workers is that it socially stigmatises PrEP, making later expansion of the programme difficult. Either way, the low PrEP targets in the NSP are baffling.

As former SANAC CEO Dr Fareed Abdullah  has been quoted as saying at the closing of the recent SA AIDS Conference, the “toolbox” provided in the NSP “doesn’t match the impact that we’re looking for”.

To have a chance of getting down to 100 000 new HIV infections per year by 2022 would require aggressively using all tools at our disposal. This will, amongst others, require a renewed focus on condom distribution and correct condom use and a drive to conduct more safe and voluntary medical male circumcisions. The NSP sets a target of 700 000 VMMCs performed in 2016/2017, reducing by 50 000 in each subsequent year. It sets a target of distributing 850 million male condoms per year and 40 million female condoms. These may or may not be good targets – it is hard to tell since the NSP provides no motivation for these specific numbers. It is also of interest that the NSP’s somewhat weak recommendations on access to condoms at schools has been superseded by a much stronger policy from the Department of Basic Education.

The study by Johnson and colleagues is particularly valuable for thinking about the NSP since it weighs up in a sophisticated way the relative impact different interventions (such as condoms, PrEP and VMMC) could be anticipated to have on the rate of new HIV infections. In a conclusion that might be surprising to some, they found that for the purposes of reducing new HIV infections the “most important epidemiological parameter to target will be the infectiousness of patients receiving ART”. They explained that this will mean “promoting adherence interventions such as adherence clubs, patient supporters, and SMS contact”. In other words, the most important intervention for reducing new infections is helping people already on treatment to stay on treatment and become and remain virally suppressed. The NSP’s distinction between prevention (goal 1) and treatment (goal 2) is thus somewhat problematic since the most important prevention intervention is not in the prevention section.

Either way, the NSP does generally say the right things regarding viral suppression, although there are some puzzling elements. For example, a sensible target is set to “ensure that 90% of all patients receiving antiretroviral therapy are virologically suppressed”. But then the NSP also says that “at least 90% of all ART patients will receive viral load testing in accordance with clinical guidelines compared to the 52% to 75% who do so now”. Though the current rates quoted are shockingly low, the 90% target for viral load coverage by 2022 is unacceptably low. Surely every single person who is receiving ART can also be offered a viral load test given that these are by definition people who are already interacting with the healthcare system. Getting one viral load test per year is not optional, it has been part of local and WHO guidelines for some time and a basic part of decent quality of care. In addition, the guidelines recommend viral load tests for all people on ART, not just 90% of people on ART. Of course, and as recognised in the NSP, adherence and viral suppression will depend on much more than just viral load testing.

The NSP and workers in the healthcare system

There is a welcome recognition in the NSP that we need “strategies to strengthen adherence to treatment and care” and that “adherence is a key element of reaching the 90-90-90 targets”. In broad terms the right things are said about the employment of community healthcare workers, primary healthcare nurses, and other types of healthcare workers. There seems to be at least a conceptual understanding that the success of the NSP will depend on the people employed in the healthcare system.

In fact, the NSP at times seems positively utopian in its outlook, as for example in this quotation:

“All people living with one or more of the three diseases covered by this NSP will have access to differentiated service delivery, including facilities that are friendly and suitable for children, adolescents, young people, men, people with disabilities and survivors of sexual assault. Services provided will be people-centred, integrated and comprehensive in scope. They will not only address HIV, TB and STIs, but also non-communicable diseases and other health conditions experienced by individuals, including access to palliative care. Services will include treatment and support for functional limitations or disabilities that people living with HIV and TB may increasingly experience as they age. People with HIV and TB will have access to age-appropriate psychosocial and treatment adherence, counselling and support, mental health screening and treatment.”

While ambition is welcome, the NSP generally fails to provide a realistic road-map as to how these ideal conditions will be reached – especially given the current state of the public healthcare system as reflected in the OHSC report. While the rough costing that was provided in the final NSP provides some indication that at least some attempt has been made to connect the dots in terms of cost, the costings are still too general and avoids critical issues like the employment of CHWs. It is alarming that even with the current costings – that we suspect may exclude some human resource costs – the NSP is underfunded by more than R6 billion per year.

It is also notable that the NSP never specifies the numbers of CHWs and other healthcare workers that would be needed to implement the plan. Side-stepping a critical issue like this brings into question the plausibility of the entire NSP. This is particularly disappointing since plans to fund an expanded CHW programme have recently been turned down at the Medium Term Expenditure Committee (the committee that makes decisions relating to what programmes are included in the budget). Unfortunately, there is very little in the NSP that would strengthen the Department of Health’s hand when going back to MTEC on this issue. Then again, apart from some high level comments, the pedestrian way in which CHW policy has progressed over the last decade suggests that the Department of Health itself has little appetite for an expanded CHW programme.

Good news on HIV testing

The NSP sets a target of 10 million people receiving an HIV test every year. This will be achieved through an ambitious programme described as follows:

“A new national HIV testing effort to find the remaining people who don’t know their status and those who become newly infected will be strategically focused on optimising testing yield. Testing will be decentralised and expanded testing services will be delivered in and outside health facilities, e.g. in workplaces and community settings. Specific efforts will be made to close testing gaps for men, children, adolescents, young people, key and vulnerable populations and other groups that are not currently accessing HIV testing at sufficient levels. The importance of at least annual HIV testing will be emphasised, especially for young people. Self-screening will be rolled out as part of the strategy to expand HIV testing and to close testing gaps. A major push will be made to ensure 100% birth testing of newborns exposed to HIV and of provider-initiated counselling of mothers and testing for all children up to 18 months to identify those that have acquired HIV through breastfeeding. All children of HIV positive parents will be tested for HIV. Every person that is tested for HIV will also be screened for other STIs as well as for TB.”

In our view the vision set out here is exactly what is needed in terms of HIV testing. The critical question however is whether we will see the necessary political will to drive this campaign – for example by taking it to workplaces and through ensuring sufficient funding for HIV self-testing and making sure referral networks are functional and easy to use for people who test positive. Fortunately, if we do the right things, the prospects are good in as far as HIV testing goes. While Johnson and colleagues’ model shows low likelihoods of reaching the second and third 90s, they project that South Africa is on course to reach the first 90 (90% of people with HIV know their status) by 2020.

As an aside, it is concerning that the NSP is inconsistent on whether the 90-90-90 targets in South Africa are to be met by 2020 or 2022. On page 15 under Goal 1, it states that in order to achieve the objective, it must prioritise “Achieving 90-90-90 by 2020 for HIV and TB” and it also includes an explanation as to why 2020 was the adopted timeline for South Africa. However, later, on page 19, it states; “To reach the 90-90-90 HIV target by March 2022, the end of the period that this NSP covers…” and later, “As this NSP covers the years 2017-2022, Goal 2 objectives and activities aim to reach the 90-90-90 target by 2022…” To further confuse things, a recent Bhekisisa news article quotes Deputy Director General of Health Yogan Pillay as saying that “by 2025, the health department aims to have 90% of all people diagnosed with HIV on treatment” (the second 90).

Moving these targets back to 2022 or 2025 would constitute a significant retreat from the ambitious 2020 goals set by UNAIDS.

Two thirds of a TB plan

Like much of the NSP, the TB sections are superficially very good. There is for example a commitment to rapidly implement new treatments and diagnostics. This could be particularly important given that changes to diagnostic tests and algorithms and further changes to the treatment regimens for drug-resistant forms of TB and for latent TB are likely within the period of this NSP. Given South Africa’s good track record regarding the introduction of new TB diagnostics (e.g. Gene Xpert) and treatments (e.g. bedaquiline), we can expect this aspect at least to go well.

The more difficult thing to fix in our TB response is ensuring that many more people get screened and tested so as to get people on to treatment quicker and to reduce the time that people are infectious. As in other areas, the NSP’s stated intent here is spot-on:

“Every person who is tested for HIV must also be screened for TB, as must all TB contacts. Tracing of TB contacts is especially urgent for DR-TB and will be prioritised. This Plan envisages intensified TB case-finding in key populations, including household contacts of people with TB disease, healthcare workers, inmates, and people living in informal settlements. People with diabetes and every child contact of an adult TB patient will be screened. All patients suspected to have TB will receive appropriate diagnostics, including GeneXpert MTB/RIF as an initial diagnostic and rapid confirmation of results.”

If this vision could be fully realised, it could have a dramatic impact on TB in South Africa. Again though, such a screening drive will be extremely labour intensive and require thousands of community healthcare workers and other healthcare workers to implement. The reality however is that there is an HR and funding crisis across the healthcare system and as yet no clear policy on the employment of CHWs. The NSP should have made it clear that its ambitious TB screening plans are fully dependent on certain human resource requirements being met – and then gone on to precisely outline and cost those human resource requirements. As it is, we have a great vision, but not much of a plan of how to realise that vision.

Decriminalisation of sex work

Earlier drafts of the new NSP, as well as South Africa’s previous NSP,  contained some, though insufficient, language on the decriminalisation of sex work. Even that language was eventually stripped from the new NSP. This is somewhat hard to understand given that the SANAC Sex Worker HIV Plan launched last year took a progressive position on the rights of sex workers and seemed to set a course toward decriminalisation. During the NSP development process, there was very strong support for the inclusion of a recommendation on decriminalisation from a number of civil society groups, including Sonke Gender Justice, SWEAT, Sisonke, and the Treatment Action Campaign. No explanation has been provided to these groups as to why decriminalisation was cut from the NSP at the last minute.

The removal of sex work from the NSP is likely one of the clearest examples of how the governance crisis at SANAC impacted the NSP. Under Dr Fareed Abdullah’s leadership SANAC has in recent years taken very progressive positions on decriminalisation – supported by a number of civil society organisations and by the published evidence on sex work and HIV. However, with his removal as CEO and from the NSP drafting team, one of the most outspoken and influential supporters of decriminalisation was side-lined. It is after his departure that decriminalisation was completely removed from the NSP. Spotlight sources also report that civil society representatives who were part of the drafting team did not oppose the removal of decriminalisation – despite the views of the civil society organisations above being known to them.

Better use of data

If the NSP’s ambitions regarding the better collection and use of data are met by 2022 South Africa’s healthcare system would have taken a significant step forward. Firstly, the NSP commits to the implementation of a unique patient identifier, which is welcome even though it is long overdue. This means patients will have their records stored electronically and these records could then be accessed at any healthcare facility. This should make it much easier for people to move between clinics or for people leaving correctional facilities to transition to clinics on the outside. Ensuring that this network is secure and that confidential patient information is not leaked will be a significant challenge – but not a reason not to implement the system.

Secondly, the NSP imagines routine and efficient data collection across the healthcare system. Having more geographically specific but, where appropriate, personally deidentified, data should help to spot trouble areas and better target interventions. If such data is routinely made available to AIDS councils, hospital boards and clinic committees, it could help inform more effective problem-solving. If shared publicly, which the NSP unfortunately does not explicitly suggest, it could make it easier for people to hold local healthcare managers accountable.

It is telling that with this focus on data, the NSP does not make more of the data already being generated by the OHSC. This data already provides very useful insights on the state of the healthcare system in specific districts and specific facilities. More explicitly integrating the OHSC data into NSP-related monitoring would have helped to more effectively root the NSP in the reality of our struggling healthcare system. In addition, there may be a cautionary lesson for NSP-related data in the fact that OHSC data only became public after a PAIA request. In an unrelated case, Spotlight recently also had to file a PAIA request to access information held by the Department of Health. While the data revolution picture painted by the NSP is promising, it will come up against a deeply ingrained culture at the Department of Health whereby most bad news is buried.

The way forward

How one responds to the NSP is at least in part a question of strategy. While hardly anyone would be entirely happy with the plan, most people should find at least some elements they could agree with. How one weighs up those positive elements against the various flaws in the plan will likely depend on who you are and what your interests are.

The most convincing argument for rejecting the NSP is that made by TAC and SECTION27 – that the NSP is fundamentally flawed and unimplementable since it does not take the current state of South Africa’s public healthcare system into account. In late March, the two groups said that they could not accept the NSP in the form it was then (referring to the then draft of the NSP and a summary document). The two groups said that they would only endorse the NSP if certain conditions were met. The conditions were as follows:

1. If an addendum to the NSP is developed and published that provides detailed and realistic guidance to provinces and districts on NSP implementation. This must include provincial sub-targets on all key NSP targets and introducing smarter indicators as outlined by Doctors without Borders (MSF).
2. If an addendum to the NSP is published setting out all the HR requirements for the various interventions and how this increased HR capacity is to be funded. This must include a budgeted and quantified plan and policy on community healthcare workers. Without such a plan we cannot endorse the NSP since we cannot endorse an unrealistic NSP.
3. If all of the key interventions in the NSP are costed and funding sources identified.
4. If all provincial AIDS councils are chaired by their respective provincial Premiers and if all provinces produce realistic, costed and fully-funded implementation plans.

these conditions have not been met so far – although some progress was made in the final NSP on condition 3. A key decision for activists is whether or not to hold out for all these conditions to be met, or to accept a flawed NSP and try to make the best of it.

A rejection of the NSP will be a step too far for some people or organisations or may not make strategic sense for some. In such a case, one way forward is to identify some of the positive elements in the NSP and to advocate for their implementation. It could, for example, be very important to pressure and hold government accountable for implementing the HCT campaign envisaged in the NSP or to use the NSP to advocate for the rapid introduction of new TB diagnostics and treatments. As described above, there are quite a number of positive commitments in the NSP that can be used to hold government accountable and to drive implementation.

Another possible position is simply to accept that the NSP has only limited influence since most key decisions regarding HIV and TB are ultimately made by government irrespective of what is written in the NSP. One could for example decide to ignore the NSP and simply attempt to engage with government directly as needed on specific policy issues. The difficulty with such a position is that one would essentially be forfeiting the good things that are included in the NSP. The NSP is after all endorsed by cabinet and as such presents official government policy – and in theory at least, such policy commitments are binding.

Finally, one cannot divorce the NSP from the structures of AIDS councils from local, district, provincial, to national level. Unfortunately AIDS councils across the country have mostly – with a few exceptions – been dysfunctional. The ongoing governance crisis at SANAC itself is particularly alarming and there is a real question as to whether SANAC should continue to exist in its current form. It is possible though that a radically reformed SANAC could help save the NSP by filling in the gaps and bringing together the right people. (Spotlight will soon be publishing an article on the crisis at SANAC and the potential for reform. The issues at SANAC are too complex to discuss fully in one article together with the NSP.)

• Thank you to Kristanna Peris and Sasha Stevenson for help with this article. Thank you also to the many others who have shared their views and analysis of the NSP in recent weeks and months. I take sole responsibility for all errors in this article.

Note: Spotlight is a joint publication of SECTION27 and the Treatment Action Campaign. The Spotlight editorial team does however have substantial editorial independence – which it guards jealously.