NHI Bill: Welcome but flawed

By David Sanders & Louis Reynolds, People’s Health Movement South Africa

The People’s Health Movement South Africa (PHM-SA) welcomes the National Health Insurance (NHI) Bill in that it confirms Universal Health Coverage (UHC) through a single payer system as the platform for the delivery of health care. The goal of UHC is to realise the right to comprehensive health care of good quality for everyone on the basis of need, while ensuring that no one experiences financial hardship in accessing the care they need.  Comprehensive care includes promotive, preventative, curative, rehabilitative and palliative health services regardless of people’s socio-economic or health status.  The NHI should be funded through a solidarity mechanism where there is a cross-subsidy from the rich to the poor via taxation.

Although we are supportive of the principles that underpin the NHI, PHM has several reservations about whether the Bill can deliver UHC. More broadly, we remain deeply concerned about government’s ability to steer this ambitious project in the context of South Africa’s deep-seated and multi-pronged health crisis.

Administration of the NHI Fund

The Bill makes clear that the NHI Fund will be overseen by a Board of ten persons appointed or approved by the Minister. It will be the only purchaser of health services from accredited providers – public and private – and will ensure equity and efficiency in health care. A unitary system with the National Health Insurance Fund (NHIF) as the single purchaser of services allows for strategic purchasing of those services that are necessary to reach defined health goals. .

A justifiable concern, expressed by a number of analysts and based on experience of state-owned enterprises, is the potential that exists for this enormous fund to be looted.

Services free at the point of use will be provided to permanent residents while documented refugees and asylum seekers will be eligible for free emergency services, care for conditions of public health importance (presumably TB, HIV and other infectious diseases) and services for paediatric and maternal conditions.

Services not reimbursed by the fund (i.e. not part of the defined ‘package’) can be paid for through medical schemes or out-of-pocket. All users are required to be registered with a primary care provider (presumably a clinic, health centre or general practitioner) and will have to attend such a provider before being eligible for specialist care.

Services provided under NHI

The details of what services are to be funded (the benefit package) are not provided. It is hoped that the benefits package will be identical for all users of NHI-funded providers. However, the Government Gazette of July 2017 titled ‘NHI Implementation: Institutions, bodies and commissions that must be established’ describes the proposed funding arrangements for five different groups: the unemployed, the informal sector (such as taxi industry; hawkers, domestic workers), those in formal sector employment (bigger business), those in formal sector employment (small and medium size business), civil servants (including SOEs, Intelligence Agencies, Defence, Police Service). This is a concern, since it implies that there will be different packages for different groups. Although this arrangement is said to be ‘transitional’, experience from other countries shows that it is very difficult to change such benefits packages once they have been in place for any length of time. It is likely that the poorest and sickest in our country will receive the most limited package of services. If this occurs it will increase already existing inequality.

A ‘Benefits Advisory Committee’ will decide what the content of these packages will be. This important body has representation from all medical schools, provinces, private hospitals, medical schemes and the World Health Organisation (WHO) but none from civil society or labour. This will be supported by a Health Benefits Pricing Committee which also has only technocrats.

There is no room in these committees for meaningful public participation. This will bias their work and decisions towards hospital-centred specialist care and a narrow biomedical approach. It is essential to include civil society and labour on these committees.

Their proceedings should also be open and transparent, and accountable to the Minister and Parliament. In particular, they must be accountable for the reasonableness of their choices of the benefits they include in the package. The reasoning behind their choices should be open to public scrutiny, including the evidence upon which they are based and how they apply in local contexts.

Only the Stakeholder Advisory Committee, a large body that merely advises the Minister, has representation from indigenous practitioners, NGOs and civil society, although they are greatly outnumbered by representatives from professional and statutory bodies.

How will NHI purchase services?

Purchasing of services is intended to be devolved to provincial and district level hospitals and at sub-district level to contracting units for primary health care. District Health Management Offices are intended to play a coordinating role.

Justifiable concern has been expressed about whether these sub-district and district entities will have the capacity to undertake such detailed and complex activities. The mechanisms for payment of accredited service providers are vague in the Bill and it is strongly rumoured that medical schemes may be enrolled to perform this function. PHM-SA is concerned that the greater likelihood of urban and private providers being accredited than public and (especially) rural providers, holds the danger of aggravating already existing urban/rural inequity. For example, the great majority of medical specialists and therapists of various kinds are overwhelmingly located in large metros, especially in Gauteng and Western Cape. This effectively means that public tax money will be used to fund a service that will likely cater preferentially for the better-off living in urban areas.

Transitional arrangements

The Bill specifies transitional arrangements that consist of three phases extending to 2026. The current second phase will focus on establishing institutions that will form the basis for the Fund, as well as on interim purchasing of personal health care services. Phase 3, from 2022 to 2026, will establish the necessary structures and be guided by two committees – the National Tertiary Health Services Committee and the National Governing Body on Training and Development. These will be responsible for a Human Resources for Health (HRH) development plan.

PHM has two concerns about these arrangements: Firstly, an HRH plan is required urgently to ensure the development of a robust public health sector, especially at district level and below, so that the NHI can operate effectively and efficiently in formerly underserved areas. Secondly, given their unimpressive record to date in transforming health sciences education and training, it is unlikely that these structures, whose composition has been proposed to include mainly hospital-based clinicians and educators, will implement an appropriate HRH plan.

The Ministerial Advisory Committee on Health Care Benefits will be a precursor to the Benefits Advisory Committee which will advise the Minister on priority setting. Although the composition of this structure is not specified in the Bill, the 2017 gazette discussed above proposed a composition in which senior government officials and medical scheme representatives predominated. This structure too creates a concern that the emphasis will be on facility-based clinical medicine and that primary and community-level care will be marginalized, as will prevention activities.

The context: the national health crisis

While the crisis in the public health sector is front-line news today, the private sector is in a crisis of its own — a crisis of growing medical scheme unaffordability,  shrinking benefits and static or declining  membership.

The roots of the crisis lie in the systematic underdevelopment and structural inequality enforced by apartheid. Its more immediate cause is the neoliberal Growth, Employment and Redistribution (GEAR) macroeconomic policy adopted by the ANC-led government in 1996.  GEAR follows the free market fundamentalist mantra of public sector austerity, privatisation of public services and goods, trade deregulation and low corporate tax. It is failing in all 3 of its components: growth is poor, unemployment rampant, and we remain one of the most unequal countries in the world.

More than 2 decades of austerity, combined with a deepening culture of corruption, have aggravated both facets of the national health crisis. Firstly, the state has failed to address inequity in access to the social determinants of health (SDH) such as sufficient quality food, water, sanitation etc through poor service delivery and growing unemployment and income inequality, thus aggravating the burden of disease. Secondly, the tight financial constraints imposed on the public health sector by austerity, together with a growing and increasingly pervasive culture of corruption, has led to loss of posts and skills, deteriorating infrastructure, and demoralisation of staff at all levels of the system. The fact that rigid austerity was forced on the public sector in the face of the burgeoning and badly-managed HIV-AIDS pandemic of the 1990s made it all the more devastating.

Strengthening the public health sector

Before the public health sector can participate in the NHI it will need to be strengthened substantially, especially in terms of its physical infrastructure, human resource base and their skills, especially in leadership and governance. These imperatives will require strong political will and significant funds. Government has little option but to provide such funding, since the current health crisis is untenable. Although the upfront financial commitment will be large, the returns on investment are potentially even greater – as a result of savings on long-term health care, improved economic productivity of a healthier workforce, and the multiplier effect in the economy of having a larger number of employed people, especially rural women.

Financing the NHI

The Bill says very little about possible sources of funding for the NHIF, but there are no real options other than through taxation and an end to austerity budgets. PHMSA believes that progressive income tax — a surcharge added to the normal income tax at an increasing percentage — would be the best option. The principle that those who can afford it pay more, while those who need more health care receive more care, also builds social solidarity. The retrogressive recent increase in VAT adds to the tax burden of poor and working class people and exacerbates inequity in access to the social determinants of health through increased prices on some essential commodities.

There is no doubt that increases in revenue from tax are necessary to strengthen the public sector and finance the NHI. This may be difficult politically, but we believe there is room for such increases. Forslund notes that, because tax brackets have increased faster than inflation, the tax burden on the middle class and the rich has decreased substantially over the past decades. He points out that if the government had merely kept personal income tax stable since 2005/06 – by raising tax brackets strictly at the rate of inflation – personal income tax would have added more than R150 billion to the present budget. This would have made financing the NHI easier even before raising additional tax.

The alternative to tax is to borrow, which means eventually paying more and more government income towards debt servicing and away from delivering services.

Corruption

It is also essential to root out corruption. Corruption weakens the state, delegitimises taxation, destroys public services, and ruins the social fabric. Corruption thrives in dark spaces where the public and private sectors meet. Forslund argues that “as long as the public sector isn’t strong enough to provide basic services, but relies on “partnerships” and tenders, corruption will remain rampant”.

Conclusion

There have been many responses to the NHI Bill, most of them negative, many containing uncomfortable truths about the state of the health system and the extreme difficulty of fixing it. But this strengthens the case for the NHI and an equitable health system based on UHC and the principles of Primary Health Care. The state, at present, does not have the capacity to deliver it. Nor can the corporate private sector, as is shown by abundant empirical evidence in the public health literature. This places a major responsibility on civil society to give the state critical support and mobilise the public around health. It underpins PHMSA’s campaign for a “People’s NHI”.

The People’s Health Movement South Africa calls upon all citizens of South Africa and civil society to unite behind a People’s NHI to ensure that the principles of the Right to Health, Universality and Social Solidarity are adhered to throughout the implementation process. 

To join the People’s NHI Campaign, please do one of the following:

  • Dial *134*1994*333# (it’s free)
  • SMS ‘NHI’ to 31660 (standard cost SMS)
  • Visit http://bit.ly/2r22Tnl
  • Or send a PCM to 066 040 9017

Contact Person: AnneleenDeKeukelaere@secretariat@phm-sa.org

 

 

The numbers: HIV and TB in South Africa

What are the key numbers regarding the HIV and TB epidemics in South Africa? On this page we keep track of all the latest estimates from a variety of sources. This page is updated from time to time as new information becomes available. It was last updated in October 2018 with new estimates from the Thembisa model, the WHO and UNAIDS.

 1. How many people in South Africa are living with HIV?

According to outputs from the Thembisa model (version 4.1 released in 2018) there were around 7.35-million people living with HIV in South Africa in 2017. This number is likely to keep rising since the rate of new HIV infections is higher than the rate at which people with HIV are dying.

The Thembisa estimate is close to the UNAIDS estimate of 7.2-million people living with HIV in South Africa in 2017.

In his budget vote speech in May 2018 Minister of Health Dr Aaron Motsoaledi said that there are 7.1-million people who are living with HIV in South Africa.

According to the South African National HIV Prevalence, Incidence, Behaviour and Communication Survey 2017 around 7.9-million people were living with HIV in South Africa in 2017 – substantially higher than other estimates.

2.  New infections: How many people are newly infected with HIV in South Africa per year?

According to the Thembisa model there were around 275 000 new HIV infections in South Africa in 2017. The model estimates that this number peaked in 1999 at around 550 000. The model anticipates that this number will continue to fall in the coming years.

The South African National HIV Prevalence, Incidence, Behaviour and Communication Survey 2017 estimated that there was around 231 000 new HIV infections in South Africa in 2017.

The latest UNAIDS figures indicate that there were around 270 000 new HIV infections in South Africa in 2017.

All three estimates above translate to over 600 new HIV infections per day in South Africa.

3.  HIV mortality: How many people die of AIDS-related causes in South Africa per year?

According to the Thembisa model around 89 000 people in South Africa died of AIDS-related causes in 2017. This is down from a peak of around 270 000 in 2005.

The Thembisa estimate is lower than the UNAIDS estimate of around 110 000 AIDS-related deaths in South Africa in 2016. It should however be noted that these estimates have relatively wide confidence intervals and should thus only be considered to be rough estimates.

In March 2018 Statistics SA reported that HIV was indicated as the cause of death on the death notifications of 21 830 people in 2016. This number is an underestimate since death notifications do not allow for multiple causes of death to be indicated – in many cases where TB or pneumonia is written on death notifications HIV would be the underlying cause. In addition, in the Stats SA report over 57 000 deaths are categorised as “Ill-defined and unknown causes of mortality”. It seems likely that at least some of these 57 000 deaths would be because of HIV. The Statistics SA mortality and causes of death report is useful, but studies and models that use its information in combination with other sources of information are likely to produce more reliable estimates of the actual numbers of people who die of HIV and TB.

While the District Health Barometer (2015-2016) focuses on years of life lost rather than deaths per year in its burden of disease chapter, it is clear on the role of HIV in deaths, stating: “In 2000, 2005, 2010 and 2015, the three leading single causes of YLLs (years of life lost) in South Africa were HIV-related conditions, TB and  pneumonia,  with  diarrhoea  ranking  fourth  in  2000  and  sixth  in  2015,  suggesting  that  HIV-related  mortality  remains  the   leading cause of YLLs in the majority of districts in South Africa.” They also address the death reports issue, stating: “It is important to note that a large proportion of HIV deaths has been misattributed to immediate causes of death such as TB,  diarrhoeal diseases and lower respiratory infections.”

4. How many people are receiving antiretroviral therapy in South Africa?

According to the Thembisa model around 4.1-million people were receiving antiretroviral therapy in South Africa in 2017. UNAIDS estimates around 4.35-million in 2017. The South African National HIV Prevalence, Incidence, Behaviour and Communication Survey 2017 estimated that 4.4-million people were receiving HIV treatment in 2017. In Minister Motsoaledi’s 2018 budget vote speech he said that “over 4.2-million” people in South Africa are on treatment.

Whichever source you believe, there are in the region of 3-million people living with HIV in South Africa who are not receiving treatment. According to treatment guidelines all people living with HIV are eligible for treatment. Evidence from the START trial has definitively shown that it is better to start taking HIV treatment earlier rather than waiting for the immune system to weaken.

5. New TB cases: How many people contract or develop active TB in South Africa per year?

According to the 2018 WHO Global TB Report around 322 000 people fell ill with TB in South Africa in 2017. As we have explained elsewhere, in 2018 the WHO made major changes to the methodology used to estimate TB statistics in South Africa which lead to much lower estimates for a number of TB indicators. Put another way, the WHO now believes its previous estimates for South Africa to have been substantial overestimates.

A new National Tuberculosis Prevalence Survey is expected to report its first findings in 2019. The study is being conducted by the South African Medical Research Council (SAMRC), the Human Sciences Research Council (HSRC) and the National Institute for Communicable Diseases (NICD).

According to the District Health Barometer 2016-2017 only an estimated 72.8% of people in South Africa in 2016 with diagnosed TB were started on TB treatment.

6. New MDR-TB cases: How many people contract or develop MDR-TB in South Africa per year?

According to the 2018 WHO Global TB report, South Africa had around 14 000 cases of MDR- or rifampicin-resistant (RR) TB in 2017. As with other TB indicators, this number is also much lower than expected based on previous WHO estimates.

7. TB mortality: How many people die of TB in South Africa per year?

According to the 2018 WHO Global TB Report roughly 78 000 people died of TB in South Africa in 2017 – of these 56 000 were HIV positive and 22 000 were not. It should be stressed though that there is a lot of uncertainty around these numbers (as indicated by very wide confidence intervals in the WHO report).

In March 2018 Statistics SA reported that TB was indicated as the cause of death on the death notifications of 29 513 people in 2016. As explained in the HIV mortality section above, the death notification numbers reported by Statistics SA is likely an underestimate.

What are the best sources of HIV and TB numbers?

There are a number of regular reports and models that provide information on the HIV and TB epidemics in South Africa. Below we provide a list of sources together with an indication of the kind of information they provide.

  1. The Thembisa Model: The Thembisa model is a sophisticated and comprehensive mathematical model of HIV in South Africa developed by experts at the University of Cape Town. It combines and expands upon a number of earlier models, most notably the Actuarial Society of South Africa (ASSA) AIDS and Demographic model. The model is calibrated using a variety of real-world data sources and in our view provides the most reliable set of estimates relating to the HIV epidemic in South Africa. Detailed model outputs can be downloaded from the website in Excel format. Version 4.1 of the model was released in August 2018.
  2. UNAIDS: UNAIDS publishes a series of regular reports and makes estimates available on their website. They use a different model from that used by Thembisa and often come up with different estimates. Numbers in UNAIDS reports sometimes differ from numbers published on UNAIDS’s country profiles – we use the latter.
  3. HSRC household survey: Every few years the Human Sciences Research Council publishes its “National HIV Prevalence, Incidence and Behaviour Survey”. This report is based on HIV tests and interviews conducted by researchers visiting households across the country.
  4. Antenatal survey: The National Antenatal HIV Prevalence Survey is published annually by the Department of Health. It is a survey of the HIV status of pregnant women attending public health antenatal clinics. Pregnant women are one of the groups of people most likely to visit public sector clinics and as a result this survey provides one of the most complete snapshots we have of HIV prevalence.
  5. WHO Global Tuberculosis Report: Every year the WHO publishes the Global TB Report. The report contains estimates on a number of key TB indicators for South Africa and a range of other countries. Sometimes more up-to-date data is also published on the WHO’s TB site.
  6. Stats SA: Statistics South Africa annually produces its “Mortality and Causes of Death” report. As mentioned above, this report reflects only what is written on death certificates – which, while very useful, should not be interpreted as the last word on causes of death in South Africa.
  7. MRC: The South African Medical Research Council from time to time produces reports on various aspects of HIV and TB in South Africa.
  8. Government: While the South African Department of Health does not often share detailed information with the general public, important statistics are from time to time provided in speeches, press statements and answers to questions posed in parliament. The health budget vote speeches of the Minister and Deputy Minister and the State of the Nation address delivered by the President of the country usually contain some top-line numbers.
  9. SA Health Review: The SA Health Review: This annual publication of the Health Systems Trust does not track a set of indicators from year to year. It is nevertheless worth consulting since the chapters in this publication often contain rich information.
  10. OHSC: The Office for Health Standards Compliance produces reports for parliament on the state of healthcare facilities. While these reports do not specifically deal with HIV and TB, they provide useful information on the healthcare system that is supposed to form the front-line against these co-epidemics.

Provincial and district numbers

Getting reliable statistics about healthcare in provinces and districts is difficult, but there are a few places one can look.

  1. The District Health Barometer published by the Health Systems Trust is the best public source of information about the public healthcare system at district level. The 2016-2017 edition (published in January 2018 is available here.)
  2. The Thembisa Model outputs (mentioned earlier) contains provincial estimates for a wide variety of HIV-related indicators.
  3. There is provincial and district level data held by the Department of Health that is generally not released to the public.

Please let us know in the comments below if you think we’ve missed a key source or if there is a key statistic you think we should add to this page.

 

A new normal where SheDecides: What needs to happen to get there?

By Robin Gorna

I want to live in a world where every girl and every woman can decide what to do with her body, her life, and with her future. Without question.

The SheDecides manifesto (below) outlines the vision of the world I want to live in: a world which respects, upholds and promotes my fundamental rights to decide what I do with my body, the choices I make, the pleasure I have, the people I share it with, the times I use it to bring more life into the world. And the times I do not.

As an old AIDS activist, with a passion for womens rights (my activism began in 1986 and I was one of the first to write about HIV and women; my first book was published nearly a decade later, after many articles etc), I am dazzled and frustrated to see how we can make progress in many areas, and walk backwards in others.

When I started my AIDS work we were all about convening workshops, writing brochures, designing sexy campaigns, extoling the delights of Safer Sex. We promoted to young women and men – and some older ones too –  the positive joys of sex, the ways in which we needed to modify what we do to avoid HIV and other STIs, as well as pregnancy. And that consent was Queen. We’d call it integrated programming now, or comprehensive SRHR.

These are not radical notions. The underpinnings are enshrined in the Universal Declaration of Human Rights, and – as Mark Heywood & Thuthu Mbatha rightly observe in their excellent article they are bolstered by repeated declarations at United Nations and regional levels. What’s more: South Africa’s constitution has been heralded as one of the most progressive in the world. South Africa should be more than capable of creating a society where she decides. Yet the translation of good laws into policies and programmes is tough and complex, especially when sex is involved.

Mbatha & Heywood provide a rounded picture of that simplistic acronym: SRHR (sexual and reproductive health and rights). It gets flung around by professionals with few of them ever stepping back to remember that sex includes so much, including pleasure. Kudos to Heywood & Mbatha for bringing pleasure to the front of their paper and argument! They also rehearse, with great pain, the distance that must be travelled in order for South Africans to realise their rights, and enjoy good health in their sexual and reproductive lives.

Yes, activists must shoulder some blame – we have all too easily and too often collapsed into our silos – and there is much more that has brought us to this place. As a non-South African, perhaps it is not for me to comment on Pumla Dineo Gqola’s lament against “the culture of rape” that is so deeply embedded in South African society. Yet her description and analysis of the war on women’s bodies and autonomy cannot be denied: it is urgent that society tackles this perversion of culture, this abuse of the inherent goodness of sex.

Culture is society. Without tackling these enormities, these complexities, without shifting social norms, the promise and hope of the impressive South African constitution – or any brave international declarations – can not be realised. The rights of all people to enjoy their sexual rights, reproductive justice, the health and economic benefits that flow from those rights – all will remain a distant dream.

SheDecides has taken shape as a movement because it hooks into an urgent need to shift social norms, to shape a new narrative, removing the sting of historic battles and jargon and re-focusing communities and individuals on the simple story of fundamental rights: the autonomy of the body. It is an initiative designed to do what Barbara Klugman notes has been lacking: to frame these issues in ways that [catch] the public and media imagination[1]. It espouses the vision expressed by Mbatha & Heywood: All of it is connected…. SRHR can[not] be realised separately from other rights[2].

They go on to outline a plan of action, priorities that South Africa needs to work on. They remind us that the constitution provides the framework, that action is lacking, and they define an agenda to get the country back on track. It is a good one. Without doubt, tackling the rape culture and the HIV crisis are hot priorities for South Africa. And I would add in the urgency (for the 2018 short term) of getting good quality, comprehensive sexuality education (CSE) in place in every school across the country; the importance of vigilance on abortion policy (and scaling up provision of medical abortion, including by non-specialists); and emphasising (over the medium term) action on SRHR as a means to achieve Universal Health Coverage (UHC) – clearly a top priority in South Africa, and one where evidence of the linkages is already emerging.

In their agenda, Heywood & Mbatha talk about action in schools this year. Yes, PrEP, and condoms and sanitary pads – but without the knowledge, skills and resilience to understand how all of these commodities relate to my body, the self respect and resilience to choose what I do with my body, making pills and products available to young people will never be enough.

In India, where SheDecides engages through many organisations, and especially our Champion Indira Jaising (a remarkable senior advocate who has driven legal and policy change for women over the decades) there are repeated stories of girls, as young as 10, raped by family members and then forced to give birth. Why? Laws and policies exist (not perfect, but so much better than most countries) but these girls and young women simply do not know that they have had sex or that they became pregnant. There is an abject failure of the state to provide education and information. Of course the law must step in and make sure that abortion is available and easy for girls in these dreadful situations, but education, culture, social norms must also shift for that to be possible.

Currently in South Africa there have been efforts to tighten up the abortion legislation making it tougher for women and girls who choose not to continue with their pregnancies, by reducing term limits and imposing a set of conditionalities (such as a requirement for ultrasounds). The National Department of Health (NDOH) argued against the amendments[3] pointing out that WHO guidance does not support the amendments, the costs are prohibitive – and, significantly, that the amendments will add further barriers to services, and to the ability of women and girls to decide for themselves. The NDoH leadership here is important. It occurs against a backdrop – highlighted by Mbatha & Heywood – of a situation where fewer than 20% of health facilities offer abortion, and in 2010 there were some 250,000 unsafe abortions in the country. Laws must not go backwards; services must reach those in need. The promise of the constitution is not being realised, indeed it is under threat.

Vigilance on abortion services and laws is key. Globally we see a well orchestrated campaign aiming to influence the rights of girls and women to decide for ourselves. The “Opposition” failed in Ireland (by a hefty margin!) but their tactics are smart. And that is why the solidarity of global movements like SheDecides is important. It is not simply a “Pro Choice” movement – although you cannot be a Friend of SheDecides without sharing a belief in the rights of girls and women to end pregnancies that are not right for them. Nor is the movement focused solely on ending the Global Gag Rule: the pernicious re-introduction and expansion of that nasty piece of US policy sparked the creation of SheDecides. It was an immediate reaction by (mostly Northern European) politicians who turned around in January 2017 and said No: She – not He! – should decide.

The movement goes much further than that, and also stretches far beyond the ambitions of Northern donors (as an aside, I’m not convinced (m)any of those governments see SRHR as “soft” or easy rights[4]). Rather SheDecides believes, quite simply, that every woman, every girl, everywhere should have the skills, knowledge, and quality services, laws and policies in place so that she can decide for herself what happens to her body – especially in respect of her sexual and reproductive life. That means amplifying the campaigns and work of hundreds of others, all over the world. The intention is to work across silos, to bring issues, people and organisations together: to add an extra push to what is already happening, not re-invent an initiative or organisation to add to the confusion of efforts.

The movement is little over a year old. Like any infant and toddler we have stumbled and taken a few wrong steps. Yet the vision and actions needed to achieve that vision are clear. With growing numbers of Friends – now almost 50,000 around the world, with 300+ organisations and some 40 Champions driving it forward – the call is to Stand Up and Speak Out; Change the Rules and Unlock Resources. Three simple actions, which combined can lead to the new normal expressed in the manifesto. Anyone who shares the vision of the manifesto is invited to sign it, and to take action in whatever way makes sense in their community. There are already many examples, and with national movements taking off in India, Uganda, Tanzania, Kenya and beyond. National movements reflect the global shape of a Political movement with Community Support.

Why Political? Politicians have power to allocate resources and change laws and policies – and some act even before they are asked to by civil society. Indeed the first words and pledge by (then) Dutch Minster Lilianne Ploumen took many community groups my surprise.

SheDecides is political – and it is also driven by young people: the leaders of today and tomorrow. It is no accident that the extraordinary changes in Ireland – overturning long standing abortion laws – occurred under a new leader who is under 40 (and also brown and queer). He understood the power of young people’s vision for progress, of the youth vote. Our best estimate is that over two thirds of the Friends of SheDecides are young people (under 30) – also no accident. The biggest push on the first ever SheDecides Day (2 March 2018) was from young activists, organising over 50 events around the world. At the Flagship Event (in Pretoria) more than half of the 300 participants were young people, debating and co-creating future actions with their Parliamentarians and Ministers from across the East and Southern African region.

In every country there will be different priorities, different groups and leaders who are best placed to drive change. Heywood & Mbatha argue passionately that the time is now, and that other efforts will fail if these fundamental rights are not protected and promoted. I agree. There is a long tradition of South Africans drawing on the global community for solidarity, whether it has been to end apartheid or to end thousands of deaths caused by bad AIDS policy. The global SheDecides movement stands ready to participate, to stand in solidarity – as and when South Africans decide “how and when”.

WHEN SHE DECIDES

The world is better, stronger, safer.
She decides whether, when, and with whom.
To have sex.
To fall in love.
To marry.
To have children.
She has the right. 
To information, to health care, to choose.
She is free.
To feel pleasure.

To use contraception.
To access abortion safely. To decide.

Free from pressure. 
Free from harm.
Free from judgement and fear.

Because when others decide for her, she faces  violence, forced marriage, oppression.
She faces risks to her health, to her dignity, to her dreams, to her life.

When she does not decide, she cannot create the life she deserves, the family she wants, a prosperous future to call her own.
We – and you, and he, and they – are uniting. Standing together with her so she can make the decisions only she should make.

Political leadership and social momentum are coming together like never before.
But we can go further, and we can do more. From today, we fight against the fear.
We right the wrongs.
We mobilise political and financial support.
We work to make laws and policies just.
We stand up for what is right.
Together, we create the world that is better, stronger, safer.  But only if. And only when.

She. Decides. [5]

 

Robin Gorna is an AIDS activist who lived in Pretoria, working for the UK Department for International Development, from 2007. She retains strong ties to South Africa. In the early 90s she wrote “Vamps, Virgins and Victims: How can women fight AIDS”, was ED of the International AIDS Society (IAS), the Partnership for Maternal, Newborn and Child Health (PMNCH) and now co-leads the global SheDecides Support Unit.

[1] see footnote 5 in orginal paper

[2] page 6 of orginal paper

[3] Yogan Pillay, personal communication. Power Point presented, 2 May 2018

[4] page 7 of orginal paper

[5] The SheDecides Manifesto, July 2017

SA ahead of World Health Organisation in recommending new TB medicine

The Department of Health this week announced it will be making a new tuberculosis medicine available more widely than recommended by the World Health Organization (WHO). The department deserves credit for this brave decision that will both save lives and prevent many patients from suffering irreversible hearing loss.

The current WHO guidelines recommend that most people take a combination of medicines including an injectable until a change in treatment is forced by side effects

There has been substantial debate in recent years on how to best use the only two new drugs registered for the treatment of TB in the last half-a-century. Evidence for the use of these drugs have been slow in accumulating and in the generally conservative world of TB, people have opted to stick with the drugs they know, which are mainly drugs developed around the middle of the 20th century.

This conservatism in TB treatment has been particularly disturbing when it comes to the treatment of multi-drug resistant TB – that is TB for which two of the most widely used TB medicines no longer work. Even today, the WHO recommends treating people with MDR-TB with a set of old, and pretty toxic medicines. These medicines may save your life about half of the time, but they may also cause irreversible hearing loss – with studies estimating hearing loss in as many as 50% of people taking the so-called injectables (also known as aminoglycosides). Medicines in the injectable class include amikacin, capreomycin, and kanamycin.

The current WHO guidelines recommend that most people take a combination of medicines including an injectable until a change in treatment is forced by side effects. In practice, that often means that you wait until someone has some level of irreversible hearing loss, and only then do you take them off the medicines that cause the hearing loss. It should also be noted that the injectables literally refer to medicines that are injected into the body. The toll taken by months of daily, often painful, injections is surely something people should only be exposed to if it is truly essential to their health and survival.

Over the last few years many have suggested replacing the hearing loss-causing injectables with one of the two new TB medicines called bedaquiline. Bedaquiline is registered in South Africa, the United States, and a number of other countries, even though its phase III trial has not yet reported – usually drugs only get registered after phase III results are available.

Through some smaller studies, through pre-approval access, and an ambitious treatment programme in South Africa, we have learnt a lot about bedaquiline. We can say with a high level of confidence that it has a better side-effect profile than the injectables and on balance it seems likely that it is more effective than the injectables – although the latter point has not definitively been proven either way. Just this week South Africa’s Department of Health reported findings suggesting that people receiving bedaquiline were much more likely to be cured of MDR-TB and to survive the disease than people taking older medicines. We now know that bedaquiline’s impact on heart rhythms is not as clinically relevant as we feared it might be. We also now know that deaths that occurred in a phase II trial of the drug was most probably a statistical fluke. Maybe most importantly, bedaquiline is not injected and does not cause hearing loss.

Even so, as scientific evidence goes, the MDR-TB waters are still murkier than the waters in most fields of medicine. Yet, with only about half of people being cured with current treatments, waiting for the waters to clear up is not a luxury we have – we have to make the best decisions we can based on the currently available evidence. Some ongoing studies will clarify how to best use bedaquiline in the treatment of MDR-TB, but results from those studies will only start coming in in 2019, and some of the most important ones only in 2021.

It is in this context that the Department of Health’s decision this week to make bedaquiline part of the standard treatment for MDR-TB in South Africa should be seen. While the Department could probably have gotten away with waiting for the WHO to first update its guidelines, they did not. They applied their minds to the available evidence, considered the seriousness of the side effects, and made a decision that is both scientifically sound and humane. For this they deserve credit.

In February this year the Global TB Community Advisory Board and over 30 organisations wrote to the WHO urging them to update their guidelines to recommend the wider use of bedaquiline – but the response from the WHO has until now been lukewarm. New MDR-TB treatment guidelines are however expected from the WHO in the next few months. It is not a foregone conclusion that they will follow South Africa’s lead and recommend wider use of bedaquiline.

Most serious TB doctors and researchers I’ve spoken to have no doubt that if they were diagnosed with MDR-TB, they would prefer to be treated with a drug combination that includes bedaquiline and that excludes the injectables. A sober assessment of the limited evidence available supports this view – and yet the WHO has dithered and failed to update its guidelines. It is hard not to see in the WHO’s failure a reflection of the fact that poor people’s lives, and poor people’s hearing loss, is implicitly considered by many not to matter as much as those of wealthy people. Hopefully, in the year of the first UN High Level Meeting on TB, this underlying double standard in our global response to TB will be abandoned and we will start giving all patients the option of being treated with the same medicines we would choose for ourselves.

Some technical details

  • The regimen: The Department of Health’s statement this week not only indicates that bedaquiline will replace the injectables, but also that it will replace the injectables in the shortened regimen. In response to Spotlight, Department of Health Director of Communications Foster Mohale explained that the short regimen referred to is essentially that used in the STREAM stage I trial and that it contains the following medicines: Kanamycin, Moxifloxacin, Ethionamide, Clofazimine, High dose Isoniazid, Ethambutol and Pyrazinamide. We assume bedaquiline will replace Kanamycin in this regimen.
  • Timeline: Mohale told Spotlight that introduction of the new regimen will start on 1 July 2018 at “a significant number” of initiation sites that are ready and then “rapidly scale-up at sites that are not ready”.
  • Price: Mohale says the department is currently purchasing a six-month course of bedaquiline (188 tablets) for R 9950. “Between 2013 and 2015 we used a donation for 200 patients who were enrolled in the Bedaquiline Clinical Access Programme,” says Mohale. “In 2015 when we started purchasing bedaquiline the price was $ US 1000; by then 1 US $ was equal to R 9,95. The price has not increased, it has decreased from $ US 1000 to $ US 820.” Research conducted at the University of Liverpool suggests that bedaquiline can be sold profitably at a price of $98 for a six-month course.
  • Savings: Mohale claims that by introducing the shortened MDR-TB regimen the department is making huge savings on medicines and laboratory costs. “Laboratory tests that were done over a 24 months period are now done for 9 months for most patients. Also, medicines are administered for 9 months instead of 24 months, “says Mohale. “These gains will absorb the price increase due to bedaquiline.”

 

Note: Low is a member of the Global TB Community Advisory Board, which is mentioned in this article. He is writing in his personal capacity.

 

Sexual and reproductive health rights should matter to all

By Tendai Mafuma

There is overwhelming evidence that on the African continent, even in those countries where there are liberal laws, the protection and promotion of sexual and reproductive health rights has taken a back seat. In most instances, there have been express push back against the entrenchment and/or realisation of sexual and reproductive health rights.[1] Why have sexual and reproductive rights remained controversial and contested? In this article I attempt to give one of the reasons why this is.

Largely, issues relating to sexual and reproductive health are considered taboo.

The fact that not everyone is heterosexual, or that women can and should have control over their own sexuality and reproduction has often been perceived as a threat to ‘tradition’ or to the dominant patriarchal social order. Various reasons, religious and moral, are used to justify restrictions on making sexual and reproductive health education and services available, especially sexuality education and services for youth, contraception, safe abortion and condom promotion. For the longest time, people have thought of sexual and reproductive health rights as being for others, and have been seen as seeking to promote behaviours that are contrary to the boni mores (moral convictions) of the society. These perceptions can be summarised in the most generalised way as follows:

  1. Sex is for adults, or only for married people;
  2. Reproductive health is for those suffering from infertility;
  3. Abortion is for the young girl who really should not be pregnant because she had no business having sex in the first place
  4. Sexuality rights are those who do not fit within the heteronormative space; and
  5. Sexual health is for people living with HIV or for people suffering from impotence.[2]

Largely, issues relating to sexual and reproductive health are considered taboo. Parents do not want to talk to their children about them, health practitioners think that only certain people should be talking about them, teachers do not consider it their job, and governments do not want to wade into contentious issues. We hardly talk about attitudinal barriers that people living with disabilities encounter when they try to access sexual and reproductive health services. So in the end, not enough people talk about it and because of this, there is inadequate budgeting and implementation of plans to ensure the health and well-being of people. This despite evidence of the benefits that follow from the realisation of sexual and reproductive health rights.[3] For example, various sexual and reproductive health rights concerns have direct and indirect consequences on the education, particularly of young girls. These concerns include unwanted pregnancies, sexual abuse, early marriage, and HIV/AIDS and other STIs. In 2014, a survey by Statistics South Africa indicated that 473 159 girls between the ages of 12 and 19 were not attending school.  Of these learners, 18% (85 182) said that they had fallen pregnant. It is a no brainer that comprehensive sexuality education would equip young girls to make sexual and reproductive decisions in a way that does not negative impact their education.

The truth is, when we do not buy into an idea, we are not invested in it. It is very difficult to convince people to support a cause when they do not see or understand its impact in their lives, or of those closest to them. When we think that certain causes are for “others” we do not feel the need to invest as much of our energies, money, and time because we do not think that there is any benefit. Unfortunately, that has been the case with sexual and reproductive health rights. But this position is uninformed and incorrect. Sexual and reproductive health rights are for all and they matter to all. Not only because of a human rights perspective, or because of public health arguments, but in very real and personal ways.

The recent Spotlight article by Thuthukile Mbatha and Mark Heywood starts that conversation. I want to build on that conversation here.[4]

Sexuality does not matter only to those who do not fit within the heteronormative space. Sexuality lies at the core of human life, of what makes us fully human – it is the key to our capacity to contribute positively and fully to the societies we live in. The World Health Organisation defines sexuality as “…a central aspect of being human throughout life. It encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships…”. Put simply, sexuality is deeply personal, it is about understanding the sexual feelings and attractions we feel towards others. It is not just about who we happen to have sex with.[5] Despite this, sexuality has been treated either as a ‘luxury’ or as a problem which needs to be solved. Meanwhile, it concerns everyone, personally. Whether people are single, married or living in civil partnerships, living alone or with others, sexuality will be part of their personal stories.

In the same vain, sex is definitely not only for married people. Young unmarried people have sex. So instead of burying our heads in the sand and pretending that this does not happen, we need to have constructive conversations about encouraging healthy sexual behaviours. In 2014, the University of Cape Town Gender and Health Justice Research Unit conducted a study aimed at documenting and analysing the experiences and challenges faced by health care workers providing sexual and reproductive health services to teenagers aged 12 – 15 years. The study showed that many health care workers feel uncomfortable speaking to adolescents about sexuality and sexual and reproductive health. When they do, they often adopt judgmental attitudes that reflect their own moral ideas[6] about a ‘healthy’ and ‘decent’ sexuality for teenagers. The result is that adolescents often adopt unhealthy sexual behaviours due to social pressure and poor information, and often do not seek the guidance of health care workers.[7] Healthy sexual behaviours also need to be promoted even for married people.

Reproductive health and reproductive rights are not just for those seeking to have children. It is also about young girls who will undergo puberty and need sanitary products. Reproductive rights seek to ensure that those girls will experience their menses without being discriminated against in school, bullied and excluded by others for not having sanitary products. It is about ensuring that young girls are not forced into early marriages, and that even those in marriages, can have autonomy over their bodies. They are also about ensuring that women have access to safe abortions. In South Africa, reproductive health rights place an obligation on the State to ensure that it meets the needs of all people who attend to health establishments seeking reproductive health care. The State must take reasonable, legislative and other measures, within available resources to ensure that the reproductive health care needs of all in South Africa are met.

Other than contributing to the slow pace in embracing sexual and reproductive health rights, the issues discussed above have also wormed their way into service delivery at health establishments. The result is that even where the law makes provision for sexual and reproductive health rights, and places obligations on the State to provide such services, there are still impediments to accessing sexuality education and sexual and reproductive health care services.

What we need to do is to start debunking the idea that sexual and reproductive health rights only concern other people. There needs to be intentional campaigns to highlight the importance of sexual and reproductive health rights for all. A campaign that seeks to educate all, does not seek to undermine/dispute the well documented evidence that more needs to be done for invisible, marginalised and/or key populations. It simply means that even those who are neither marginalised nor vulnerable also understand why it is of import to all Knowledge of sexual and reproductive health and access to correct information, comprehensive sexuality education, sexual and reproductive health services and basic health and medical care are also crucial for reducing infant and maternal mortality in sub-Saharan Africa.

So whilst we might sometimes think that sexual and reproductive health rights do not relate to us whatsoever, we are wrong. Just because we do not understand something does not mean we are exempt from it. Everyone should be equipped to make independent sexual and reproductive decisions. We should promote sexual relationships that are mutually respectful, free of coercion, discrimination and violence, where people can enjoy their sexuality safely. And this should matter to everyone, regardless of age, race, gender and sexual orientation.

Note: Tendai Mafuma is a Legal Researcher at SECTION27. Her work mostly centres on access to quality public healthcare.

 

[1]Particularly on the African continent. For example, For example, the East African Community (EAC) Council of Health Ministers in March 2008 refused to sign the EAC Sexual and Reproductive Health and Rights strategy as they felt the „rights language‟ within the document would promote homosexuality and what they described as „other undesirable sexual practices‟ in the sub-region”. This was revealed at a Regional East African Community’s Multi-Sectoral Consultative Meeting on Sexual and Reproductive Health (held in Arusha on June 25-26, 2008). This may imply that many African leaders are struggling to understand the rationale for rights-based approaches in addressing sexual and reproductive health challenges. http://www.realising-rights.org/docs/newsletter/Why%20Realizing%20Sexual%20and%20Reproductive%20Rights%20in%20Africa%20Remains%20a%20Dream.pdf. In another instance, one of the African leaders who was negotiating, on behalf of Africans, at the global level at the Commission on Status of Women 58th Session in March 2014 is said to have said this “When we allow sexual and reproductive health to include rights, as Africans we are accepting to be influenced by western culture that of accepting persons with different sexual orientations which is not in line with our African culture”. http://femnet.org/2014/07/16/sexual-and-reproductive-health-and-rights-srhr-the-african-agenda/

[2] The list is not exhaustive.

[3] Sexual and reproductive health and rights – a crucial agenda for the post-2015 framework https://www.ippf.org/sites/default/files/report_for_web.pdf. Research has shown that realisation of sexual and reproductive health rights would result in the achievement of other development goals such as education, gender equality, the economy and broader health benefits.

[4] Thuthukile Mbatha and Mark Heywood https://www.spotlightnsp.co.za/2018/05/21/sexual-and-reproductive-health-wrongs-what-do-we-need-to-do-to-get-them-right-an-activist-perspective-part-1/. I will not venture into the human rights rationale for sexual and reproductive health rights. This article sets that out very nicely.

[5] http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/

[6] My own emphasis.

[7] http://www.ghjru.uct.ac.za/sites/default/files/image_tool/images/242/documents/Policy_Brief_1.pdf

Sexual and Reproductive Health Wrongs: What do we need to do to get them right? – An activist perspective: Part 2

By Mark Heywood and Thuthukile Mbatha, SECTION27

The latest edition of Spotlight, produced by TAC and SECTION27, is a special edition, edited by a young woman activist and SECTION27 researcher, Thuthukile Mbatha. It focusses on the state of implementation of sexual and reproductive health rights (SRHR) in South Africa. The edition illustrates that whether it be on access to termination of pregnancy, access to health services or the continued decriminalisation of sex work South Africa is failing badly in its duty to realise SRHR. In this article Mark Heywood and Thuthu Mbatha, attempt to ask, and suggest some answers to, the hard and painful questions arising from the articles in Spotlight. Why are we failing to advance – or even defend – rights issues that are central to our very being? Part 1 provided some analysis on the state of affairs. Part 2 published here makes an attempt to share some insights into what can be done. Mark and Thuthu do not pretend to have all the answers or to be authorities on the subject. This is an attempt to get an important conversation going and Spotlight will aim to publish a numbers of other opinion pieces on the subject.

Part 1 in the series ends with the statement that we have become complicit with a horrendous status quo. We kick off Part 2 with some suggestions about how we can change this.

SRHR require a struggle for power and equality.

Let’s be clear: SRHR cannot be achieved without confronting issues of power – particularly who has power and who doesn’t. Although they seem to be loved by Northern donors SRHR are not ‘soft’ or easy rights. Their realisation would have an immediate bearing on improved health and HIV prevention, but that recognition  doesn’t seem to be enough to persuade policy makers to act on them. In reality their implementation requires a challenge to men’s power in the world not only in the home, but particularly in politics and economy.

SRHR may exist in law and policy in many countries, they may be acknowledged in the SDGs, but they don’t get budgets.  This is because men dominate parliaments and men don’t take SRHR seriously. SRHR require a revolution.

SRHR require youth leadership and campaigns that prioritises young people’s well-being.

SRHRs are relevant to all people of all ages, but they are especially important for and to young people. Young people are in the phase of their lives where they are discovering the potential joy of sex and learning about their sexuality. South Africa’s Constitutional Court has recognised that:

“the majority of South African adolescents between the ages of 12 and 16 years are engaging in a variety of sexual behaviours as they begin to explore their sexuality.” Sexual experiences during adolescence, in the context of some form of intimate relationship, are “[n]ot only . . . developmentally significant, they are also developmentally normative.”

Yet despite this the law continues to deny young people access to sexual and reproductive health care services. Only last year did the Department of Basic Education (DBE) finalise a policy on HIV in schools.[1] Only in 2018 has the DBE published a very poorly written draft policy on Pregnancy in schools.[2]  Given that 59% of our population is under 30, and 17% are between the age of 15 and 24 of which nearly five million are women, this amounts to the denial of access to health care services to which they are legally entitled to a lot of people.[3]

Most women give birth before they reach the age of 30.[4] So, that’s when we most need recognition of these rights. Yet the world is mostly run by older people. For example, the average age of MPs in our National Assembly is over 50. SRHR therefore also force us to reflect upon the age and interests of the people who makes decisions and how these decisions reflect their priorities and preoccupations. They call for youth to mobilise and become much more involved in politics.

SRHR require us to recognise that experiencing sexual pleasure and freedom without risk is a right.

It is wrong to communicate and advocate for sexual and reproductive health rights as just/mainly about negative obligations and preventing harm. Young people especially pay little heed to SRHR because they are often spoken about as if they are primarily about minimising risks rather than enhancing pleasure, freedom and equality.

Another weakness in campaigns for SRHR is that they are often most spoken about by middle class people who have them; and, or, they are driven by a donor agenda that makes assumptions about the people who need them and takes little account of their real lives and needs. The people who most need SRHR are poor and marginalised. They experience multiple rights violations. There is a fight for survival, every day. They do not have the luxury to fight only for their SRHR.

Activists must start to assert SRHR as positive rights. They have been recognised in law because they are necessary to enhance human joys and freedom. They are vital for the achievement of freedom and equality, freedom particularly for women and girls, and for marginalised people and populations.

SRHR require us to join the dots between sex and struggles for equality and social justice in education and health.

Relevant SRHR at schools include access to well taught and informed life orientation programmes, that inform young people about sex, sexuality, sexual health and their rights. They should also include access to condoms, access to Pre-exposure Prophylaxis (PrEP) and voluntary medical circumcision for boys. But these rights cannot be achieved without being joined to struggles for social justice and equality in the provision of education.

Today South Africa’s basic education system fails poor learners without discrimination. Of every 100 learners who enter the education system at grade 0, fewer than 5 complete school with a qualification that admits them to University education.[5] However, girls and young women bear the main burden of this failure.[6] The denial of a quality education, the denial of knowledge and information, the denial of a safe learning environment, reduces a young woman’s power and autonomy.

Having been failed by the education system, a young woman falls into a society that further marginalises her in higher education and the economy. This disempowerment may affect a women’s ability to stand up for her SRHR. It predisposes poor women and girls towards older men (‘sugar daddies’) and in some cases sex-work, it leaves many women dependent on men and subject to domestic violence. The question for activists then is how we can integrate campaigns for SRHR into struggles for quality basic education.

A similar situation exists in relation to access to health care services. Because sex and reproduction can be affected by and impact on our health, and because the people most in need of these rights are poor, many SRHR depend upon a functional, accessible and quality public health system, a health system that has sufficient doctors and nurses, appropriate medicines and a budget to meet needs. A health system designed more with the users in mind as well as with the rights of health workers, for example the simple matter of clinic hours. Many patients complain that operating hours are solely determined by what suits healthcare workers with no consideration for what is best for those who need the services.

The issue of the right to abortion (termination of pregnancy) is an example of all that is wrong. It is also an example of the overlapping of SRHR with health and basic education rights. South Africa has a high rate of teenage pregnancy, starting at a shockingly young age.[7] The right to abortion doesn’t only exist on paper; it exists in law, and the law is explicit that a girl can seek a termination without involving her parents from the age of 12. Yet less than one in five (20%) of health facilities offer abortion. According to Marie Stopes International, 245,211 unsafe abortions were carried out in South Africa in 2010 alone.[8] SRHR would be advanced if there was a properly trained cadre of community health workers, able to play a role in community based health education on issues including sexual and reproductive health.

So the question facing human rights activists again is how SRHR can be fought for not as stand-alone rights, but as an integral part of primary health care and as an essential part of a National Health Insurance scheme? How can activists research and then educate politicians and policy makers about the personal and social cost of not respecting these rights? How can we gather the evidence to show that a sufficient and dedicated budget for SRHR would be cost-saving to the health system as well as advancing women’s rights to dignity and equality?

This is why SRHR advocacy needs well researched activism, not just slogans – however justified the slogans are. Unfortunately SRH rights are still battle-grounds and battle grounds require a battle plan.

What is to be done?

In South Africa activists have a huge advantage over our comrades in many other countries because of the legal power given to us by the Constitution and because of the entrenchment of SRHR in the Constitution, law and policy. However, no rights are ever capable of enacting themselves. They require campaigns and activism.

Before and immediately after the advent of democracy in 1994 a number of organisations fought valiantly for SRHR, initially the Women’s Health Project, Reproductive Rights Alliance and the National Coalition for Gay and Lesbian Equality. More recently the One in Nine campaign, Soul City, and others have taken forward this struggle. Social justice movements such as TAC, have taken up individual issues that overlap with SRHR, without fighting for these rights as a whole. But at best most civil society organisations have been silent and at worst many, particularly in the trade unions, have been complicit in gender based violence. Today we need to learn from and follow the lead of those who have fought in this field, but also cut a path to a much broader and more powerful activist front. SRHRs must no longer be in a silo. As I have tried to show above, they are central to social justice. We all have a responsibility to make SRHR part of our practice.

Below are some tentative suggestions about the types of campaigns that must be launched and sustained.

Make millions of people aware of their rights: The people who most need SRHR are not aware that the law and Constitution views things such as bodily autonomy and reproductive choice as fundamental rights.[9] Even the term SRHR is confusing and foreign – it is ‘NGO-talk’. To change this a massive and accessible communication campaign is needed that reaches young women and other vulnerable communities to make it clear that they are not powerless in the face of violence and to start to suggest local strategies and campaigns to advance these rights. This campaign must have scale. It cannot reach only small circles of communities. It needs to be carried through public and accessible media, like the indigenous language radio stations on the SABC which reach over 30 million people.

But linked to this a campaign is needed to educate society as a whole about SRHR, overcome misunderstandings and to engage those who think they are opposed to SRHR.

Define an agenda for SRHR: short, medium and longer term and demand action. Below are some examples of demands we should make:

In the short term (2018) we should demand:

  • A costed, budgeted national strategic plan to confront rape culture.
  • The immediate and extensive provision of PrEP to young women and girls, including through school health programmes;
  • Immediate implementation of the policy on access to condoms in schools;
  • Immediate provision of sanitary pads in every school nationally;
  • Drastically improved accesss to services for abortion.
  • Communication and mass media strategies that publicise all of the above.

In the medium term (2019-2020) we should demand:

  • The decriminalisation of sex work;
  • Implementation of the draft policy on pregnancy in schools;
  • Access to a wide range of safe contraceptives in the public health sector;
  • Extensive provision of contraceptives in schools and higher education institutions;
  • Improved access to screening, testing, diagnosis and treatment of cancers in the reproductive system;
  • Improved access to SRH services that are suitable for queer folk and health services that recognise the special needs of adolescents, LGBTQIA+ folk, pregnant teenagers and so on.

In the longer term:

  • Establishment of more shelters for gender based violence survivors;
  • Improved access to affordable breast, cervical and prostate cancer treatment in the public health sector;

Get civil society to join the dots and connect its own struggles: Civil society organisations’ greatest weakness, and the reason why we don’t often bring about lasting and systematic change, is that we don’t make enough effort to work together. NGOS and social movements have not yet worked out how to focus on ‘their’ particular issues, but at the same time reinforce others campaigns. We have not learnt how to work at the intersections of issues. Despite all the lip-service we pay to issues of gender and women’s equality, they are almost never at the centre of rights practice or advocacy. Gender and SRHR issues are on the margins unless you are an organisation  focussing on ‘woman’s rights’ or LGBTQI issues. And, as we have seen most tragically with regards to Equal Education, even the social justice sector is not immune to the plague of sexual harassment and exploitation. This is not unrelated to the fact that most of civil society, whether in the form of churches, trade unions or NGOs, is led by men and therefore – by default – reflects patriarchy and men’s agendas. Even where women lead organisations, they are not ‘allowed’ to reorient the method and focus of these organisations to take into account gender and a woman’s perspective on the approach to struggle and rights.

In the context of SRHR the biggest problem is that identified by Pumla Gqola: we treat each act of violence, whether deliberate or by omission – as if it is an individual aberration. The only weapon in our armoury seems to be outrage. Outrage is a necessary starting point, but it alone doesn’t bring change. We have to fight a system of rape by consistently demanding and campaigning for a system of rights. In the words of Pumla Gqola:

“… we need to rebuild a mass-based feminist movement, a clearer sense of who our allies in this fight really are, to return to women’s spaces as we develop new strategies and ways to speak again in our own name, to push back against the backlash that threatens to swallow us all whole.”

If this challenge is not taken up by civil society immediately, ultimately our other efforts will be unsuccessful.

The question is how and when?

[1] Url to policy on HIV in schools

[2] Url to policy on pregnancy and S27 and EELC submission

[3] https://www.indexmundi.com/south_africa/demographics_profile.html

[4] Of the 969 415 births registered in 2016, 136 996 (13,9%) were born to mothers who were between the ages of 10 and 19 years old. A large number (783 322) of the births registered in 2016 occurred to mothers between the ages of 20 and 39 years; of these, 243 148 (31%) occurred to mothers within the 20−24 years age group. A total of 34 923 (3,6%) of births registered in 2016 were to mothers in the 40−54 years age group. http://www.statssa.gov.za/?p=10524

[5] Nicholas Spaull, What Should We Be Focusing On in the Next 10 years, October 2017 https://www.dropbox.com/s/7lz256gjl3wk2sv/Penreach%20-%20Spaull%20(Oct%202017).pptx?dl=0.

[6] http://www.hsrc.ac.za/uploads/pageContent/4991/Gender%20inequalties%20in%20education%20in%20South%20Africa.pdf

[7] https://africacheck.org/reports/sa-teen-pregnancies-not-increasing-as-bbc-claimed/

[8] https://www.dailymaverick.co.za/article/2018-01-29-health-e-news-abortion-the-legal-service-performed-mostly-illegally/#.Ws7aImXBbou

[9] According to a recent study by the Foundation for Human Rights http://www.fhr.org.za/index.php/latest_news/democracy-challenged-south-africas-largest-attitudinal-survey-constitution/ only 51% of respondents were aware of the Constitution and the Bill of Rights and “as poverty levels increased, so the awareness levels decreased.” Shockingly, but perhaps not surprisingly “In response to the statement that married women are allowed to refuse to have sex with their husbands, a worrying two fifths (41%) of all respondents disagreed with this statement. Again the differences between male (44%) and female (39%) were not that stark.”

Sexual and Reproductive Health Wrongs: What do we need to do to get them right? – An activist perspective: Part 1

By Mark Heywood and Thuthu Mbatha, SECTION27

The latest edition of Spotlight, produced by TAC and SECTION27, is a special edition, edited by a young woman activist and SECTION27 researcher, Thuthukile Mbatha. It focusses on the state of implementation of sexual and reproductive health rights (SRHR) in South Africa. The edition illustrates that whether it be on access to termination of pregnancy, access to health services or the continued decriminalisation of sex work South Africa is failing badly in its duty to realise SRHR. In a two-part article, Mark Heywood and Thuthu Mbatha, attempt to ask, and suggest some answers to, the hard and painful questions arising from the articles in Spotlight. Why are we failing to advance – or even defend – rights issues that are central to our very being? Part 1, published here provides some analysis on the state of affairs. Part 2 makes an attempt to share some insights into what can be done. Mark and Thuthu do not pretend to have all the answers or to be authorities on the subject. This is an attempt to get an important conversation going and Spotlight will aim to publish a numbers of other opinion pieces on the subject.

Sexual and reproductive health is a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity. Therefore a positive approach to sexuality and reproduction should recognise the part played by pleasureable sexual relationships, trust and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right.

Guttmacher-Lancet Commission, Integrated definition of sexual and reproductive health rights, May 2018:[1]

Sex and the enjoyment of sex is universal and timeless. At some point in their life almost everybody fondles and touches and makes love. Most people know the language of sex; it is a universal language, it has its own words. Most people have felt sexual desire deep within themselves, they seek their pleasure in another’s pleasure, they relish the anticipation, the foreplay, the gathering of energy and excitement and the quiet that follows the end of a sexual encounter.

Because it is so central to human life and experience sex is celebrated in poetry, in painting, in all forms of literature, in music, in photography. Sex is associated with joy, intimacy and love. It’s a part of being human, one of our most exquisite and meaningful forms of expression. We have written about it, debated it, perfected it, for the whole of human history.

Sex and the abuse of sex is also universal and timeless. Paradoxically, because sex is so central to human experience of joy, it has a flip side. Rape has been central to slavery, colonialism and apartheid. What Pumla Dineo Gqola calls “the culture of rape” is deeply embedded in our society. Forms of sexual behaviour have also been persecuted and discriminated against. People have been marginalised and persecuted in law because of their sex, sexual orientation or sexual preferences. Even today, sex brings persecution and death. Sexual relationships are inextricably tied up with inequality between men and women as well as other genders; they become chained to issues of power, violence and exploitation.

In this context of oppression, inequality and discrimination, sex is turned into its opposite.  It becomes about coercion, powerlessness and pain. As with so many other forms of oppression that rob people of autonomy to protect their own bodies, sex becomes linked to risk of sexually transmitted diseases, like HIV, illness, physical harm and death.

Reproduction is inextricably linked to sex. It’s hard – but no longer impossible – to reproduce without having sex.  Reproduction is mostly also about joy: the joy of creation, of parenthood, of the union of two people embodied in their offspring. Healthy reproduction needs healthy bodies and minds. Giving birth should be a moment of exquisite joy for a woman – but it can also be a moment of great risk.

This means reproduction too has a dark downside. It too is meshed into inequality and unequal power relations between men and women. Girls and women are forced to get pregnant against their wishes or forced to have children against their wishes through anti-abortion laws. Some women are denied the right to have children, because of disability or stigma. For example, in some parts of the world women have been sterilised because they have HIV.

And then there’s the issue of patriarchy. In every country in the world it is predominantly men, whether as legislators or judges, who prescribe laws that proscribe women’s control over their own bodies or seek to eliminate non-conforming gender differences.

Global recognition of Sex and Rights

Safe and pleasurable sex and safe reproduction are inextricably connected to those foundational rights that most inhere within us – our dignity, our privacy, our autonomy over our bodies and decisions, our equality as men and women, our sexual identity, OUR FREEDOM. It is in recognition of the centrality of sex and reproduction to our human experience that activists fought successfully for sex and reproduction to be recognised and protected as fundamental human rights. These rights exist primarily to recognise, enhance and protect the joy of sex, our individuality, our sexuality and sexual orientation.

Today, sexual and reproductive health rights are recognised in several international Covenants. Although they were not recognised in the Universal Declaration of Human Rights, the foundational document of the United Nations, they are referred to, recognised or developed in subsequent treaties.

According to researchers the 1994 International Conference on Population and Development (ICPD), in particular, “transformed the approach from reproductive control to meet demographic targets to a more comprehensive and positive approach to sexuality and reproduction, free from coercion, discrimination and violence. ICPD forged the link between sexuality and health as human rights, where women’s agency over their own bodies and sexuality are intrinsically linked to their sexual and reproductive health.” Following this, a year later the Beijing Platform for Action “was the first declaration to embody the concept of sexual rights, and expanded the ICPD definition to cover both sexuality and reproduction by upholding the right to exercise control and make decisions concerning one’s sexuality.”[2]

Most recently the UN’s Sustainable Development Goals (SDGs), include under Goal 3, ‘Good Health and Well-Being’ the target:

“By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes”

As well as under Goal 5, ‘Gender Equality’, a commitment to:

“Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.”

Building on this the most recent significant development in international law was the publication in 2016 of General Comment No 22 on the Right to Sexual and Reproductive Health by the UN Committee on Economic Social and Cultural Rights (UNCESCR).[3] This important document spells out states’ duties in relation to SRHR, such as the right to “education on sexuality and reproduction that is comprehensive, non-discriminatory, evidence-based, scientifically accurate and age appropriate.”

The fact that there is now global recognition of SRHR is a victory for activism. It is evidence of the power of activists when organised around a common vision. It is proof of the adaptability of human rights standards as society struggles to evolve beyond conservative and oppressive ideas of sex and sexuality. Yet, in spite of these positive developments, a 2017 survey found that there is reference to sexual and reproductive health rights in the Constitutions of only 27 out of 195 countries.[4] The UNCESCR says that SRHR are “a distant goal for millions of people, especially for women and girls, throughout the world.” In May 2018 the Lancet Commision on Sexual and Reproductive Health Rights confirmed this, finding that:

At a global level … almost 4.3 billion people of reproductive age worldwide will have inadequate sexual and reproductive health services over the course of their lives and that, each year, an estimated 25 million unsafe abortions take place. Each year in developing countries, more than 30 million women do not give birth in a health facility, more than 45 million have inadequate or no antenatal care, and over 200 million women who want to avoid pregnancy are not using modern contraceptive methods. Intimate partner and non intimate partner sexual violence affects around a third of women in their lifetimes, including an estimated 29% of adolescent women aged 15-19 years who have ever had partners.

In the face of this evidence we must admit that the inability of activists to ensure the domestication and implementation of rights that we have won at an international level – rights that seem to exist on paper – is our collective failure. As we shall see, the fight for sexual and reproductive health rights is far from complete. It needs renewed commitment and a better strategy from activists and progressive governments in the world. It requires self-examination and self-criticism from within civil society and deep introspection.[5]  It is urgent, perhaps the most urgent issue we face, because it connects to so many other rights violations.

National recognition of sex and rights

In the early 1990s in South Africa a range of organisations from the women’s health movement and the National Coalition for Gay and Lesbian Equality (NCGLE) campaigned successfully to ensure that sexual and reproductive health rights were included in the new Constitution.[6] As a result, the Constitution declares that no one may be discriminated against on grounds including sex, sexual orientation, pregnancy or gender. But our Constitution goes further. It does not just include negative injunctions against discrimination: the Bill of Rights says that “equality includes the full and equal enjoyment of all rights and freedoms”.

Building on this, section 12 of our Constitution recognises that “everyone” has a right “to make decisions concerning reproduction” and to have “security in and control over their own body”. Section 27 says everyone has a right of access to “reproductive health care”.

In the context of adolescent sex and sexuality, in a very important judgment, our Constitutional Court recognised that in relation to their sexuality “children merit special protection through legislation that guards and enforces their rights and liberties.”

It is important for activists to understand that these grand rights create legal obligations, especially on the government. They ought to translate into specific policies, programmes and budgets. They ought to be evident in concrete programmes such as access to condoms in schools for prevention of teenage pregnancy and HIV; as well as access to medical technologies that can protect and enhance people’s sexual and reproductive lives.

Sexual rights and sexual wrongs in South Africa

You would think that given their growing recognition in domestic and international law, that this aspect of human rights has been placed beyond contest. If only. In reality the global crisis around sexual freedom and reproduction has never gone away. It is being exacerbated by the actions and words of ‘leaders’ like USA President Donald Trump. However, we would be mistaken to think that Trump is the problem. He is just a very visible and unapologetic manifestation of it. Across the world there is an undeclared war on sex and gender. The black American writer Ta-Nehisi Coates called the abuse of black women in the USA during slavery “rape on an industrial scale” – sadly rape on an industrial scale, particularly of black women, continues in many other parts of the world.

In South Africa there exists what Pumla Dineo Gqola insists we must call “a culture of rape”, with deep historical roots.[7] She argues that there has been an unceasing war on women’s bodies and autonomy since the start of colonialism. Today, this is reflected in statistics that reveal:

  • Very high rates of rape;[8]
  • Very high rates of sexually transmitted infections;[9]
  • Very high new HIV infections among women and girls (said to be 2000 a week); [10]
  • Very high rates of teenage pregnancy.[11]
  • Very high rates of back-street abortion; [12]

Poor implementation of policy and law have had the effect of pushing back on women’s rights. For example, in 1996 the Choice on Termination of Pregnancy Act was one of the first progressive laws to be passed by our democratic government. Yet 21 years later only a minority of public clinics offer this service – thousands of women a year are still maimed, and many die, as a result of backstreet abortions.[13] Add to this the epidemics of violence against women, girls and hate crimes perpetrated against sex workers, lesbians (so-called “corrective rape”) and other people because of gender identity or sexual orientation. Finally consider the continued marginalisation of girls and women in our education system and economy, despite the fact that the Constitution proclaims us all to be equal.

All of this violence is linked to the systematic denial, by omission and commission, of the sexual and reproductive health rights that are meant to be respected, protected, promoted and fulfilled under our Constitution and other laws.

All of this is violence on people’s bodies and minds. Consequently much of it leads to illness and trauma.

Almost all of this is preventable.

All of it is connected. Yet people pretend that SRHR can be realised separately from other rights.

In reality we are only half way even to political freedom in South Africa. We have men’s political freedom, but not women’s freedom. We have a degree of freedom for materially secure women but almost none for poor black women. Poverty, race and sex are overlapping and reinforcing oppressions. In the words of activist Naledi Chirwa, “black women can’t breathe.” [14]

So what is going wrong?

Centuries of struggles have won the recognition of human rights in policies and some laws. But their implementation is another story altogether. Worryingly, in a world of conservative men and bigots who have captured religions in order to once again enslave women, it’s clear we can’t take the rights we have on paper for granted.

The failure to “respect, protect, promote and fulfil” (the words of the Constitution) SRHR is first and foremost a failure of government. But the leadership of social justice movements and human rights NGOs cannot escape responsibility. Most trade unions, faith based organisations and NGOs do not take SRHR seriously. Our gender-neutral campaigns, our failure to advance women’s leadership in civil society, are a reflection on the prevailing patriarchy. It is not enough if an organisation says it stands for gender equality (most say we do); unless it actively seeks gender equality, women’s leadership and the realisation of SRHR then its default position is reinforcing patriarchal ‘norms’. That is a sad state of affairs.

We become complicit with a horrendous status quo.

[1] https://www.thelancet.com/commissions/sexual-and-reproductive-health-and-rights

[2] L Pizzarossa and K Perehudoff, Global Survey of National Constitutions: Mapping Constitutional Commitments to Sexual and Reproductive Health Rights, Health and Human Rights Journal, 2017. https://sites.sph.harvard.edu/hhrjournal/2017/12/global-survey-of-national-constitutions-mapping-constitutional-commitments-to-sexual-and-reproductive-health-and-rights/

[3] https://www.escr-net.org/resources/general-comment-no-22-2016-right-sexual-and-reproductive-health

[4] See footnote 2.

[5] In an important article analyzing effective (and ineffective) social justice advocacy Barbara Klugman says the following: “In the context of AIDS denialism, much of the media focus was on the conflict between the government and HIV activists, with very little attention to the lived realities of people living with HIV, nor to the high levels of sexual violence,  and cultural imperatives to have children, all of which were key determinants in the escalation of HIV. Claims regarding the need to promote sexual and reproductive rights as a key dimension to preventing HIV brought a level of complexity that this call could not contain, or, argued differently, neither AIDS activists nor reproductive rights activists were able to frame these issues in ways that caught the public and media imagination. Hence, a critical opportunity for broadening and deepeningpublic understanding and legal precedent regarding the scope of reproductive rights and women’s rights in particular, was lost. In the process, public and policy recognition of the right to treatment eclipsed the issues underlying the HIV/AIDS epidemic, in particular the lack of mutuality in sexual and reproductive relationships.” Effective social justice advocacy: a theory-of-change framework for assessing progress, Reproductive Health Matters 2011: 19(38): 146 -163.

[6] Klugman

[7] Pumla Dineo Gqola’s Rape, A South African Nightmare, MFBooks Joburg, 2015, should be mandatory reading for all social justice activists, especially men.

[8] Africa Check, Factsheet: South Africa’s Crime Statistics for 2016/2017, October 2017 http://www.africacheck.org/factsheet/southafricas-crime-statistics-201617/ 39, 828 cases of rape were reported in 2016/17, that is approximately 109 rapes per day. In addition 6,271 cases of sexual assault that were reported.

[9] South African National AIDS Council (2017) South African National Strategic Plan for HIV, TB and STIs 2017-2022. Pg.8

[10] Id at Pg.7

[11] Statistics SA, South African Demographic and Health Survey 2016, May 2017http://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf

[12] HEARD, South Africa Fact Sheet on Unsafe Abortion, May 2016 https://www.heard.org.za/wp-content/uploads/2016/06/south-africa-country-factsheet-abortion-20161.pdf.

[13] Id.

[14] https://www.marieclaire.co.za/hot-topics/naledi-chirwa-tribute-winnie-read-transcript

 

North West doctors release open letter calling for end to closure of health services

Over 70 North West doctors have released an open letter expressing their concern over the impact the ongoing labour action is having on the delivery of health services. Although they support the grievances of the protestors, the doctors said that as “care givers, we have been silent for too long. We have taken an oath to “do no harm” and in our silence, we have contributed to harm. This cannot go on as we are concerned about methods used which include closure of health care facilities that affect the health of our society.”

Read the full letter here: Letter of Concern Health Crisis NWP (iii).

8 key findings from new district health report

The Health Systems Trust last week published the latest edition of the District Health Barometer (DHB). The DHB provides a wealth of district, provincial and national level data on a wide variety of indicators. Below we have picked out eight interesting national-level findings. You can access the DHB 2016/2017 report and an associated data file by clicking here.

1. In 2016 only an estimated 72.8% of people in South Africa with diagnosed TB were started on TB treatment. The rate was slightly lower at 68% for people with TB resistant to rifampicin (one of the standard first line medicines to treat TB). The fact that around 27% of people with diagnosed TB do not start treatment timeously puts the health of these people at risk and makes it more likely that they will transmit TB in their communities.

2. According to current treatment guidelines almost all patients with both HIV and TB should be receiving antiretroviral therapy (ART). According to the DHB only 28% of people in this group received ART in 2011 (partly due to different treatment guidelines at the time). This number climbed rapidly to 90.8% in 2015 and then dropped to 88.3% in 2016. We do not know whether this drop from 2015 to 2016 is real or whether it is due to a statistical or reporting error.

3. According to the DHB the annual death rate for people with drug-resistant TB (DR-TB) is around 23%. The rate of loss to follow up is around 17% and only around 50.5% of people with DR-TB are successfully treated.

4. There has been a steady rise in the number of male condoms distributed in recent years – growing from 15.7 per male over 15 in 2011 to 47.5 in 2016.

5. The percentage of total life years lost due to non-communicable diseases (NCDs) in South Africa has risen over the last four years from 34.5% to 38.2%. This provides further evidence of the growing threat of NCDs to people living in South Africa and to the country’s healthcare system and economy.

6. In 2016/2017 only 82.3% of infants received all the required immunisations in the first year of life. This was a substantial drop from the previous two years – something the report ascribes to both vaccine shortages and poor distribution.

“During 2016/17, immunisation coverage nationally was 82.3%, almost 10 percentage points lower than the national target of  92.0%. This  was a 6.9 percentage  point  reduction  from  the  immunisation  coverage  of  89.2%  reported  in   2015/16 and lowest during the last five years. Between 2012/13 and 2014/15 there has been a general upward trend, with  immunisation  coverage  increasing  from 83.6% in 2012/13 to 89.8% in 2014/15.  The  rate  then declined slightly between 2014/15 and 2015/16 but showed a huge drop in 2016/17. The main reasons that contributed to this decline were: the global  shortage of Hexavalent that lasted approximately nine months and was resolved at a national level in October 2016; in some  provinces and/or districts the available stock was distributed equally to different areas without considering the demands  and population targets, thus painting an extremely heterogeneous picture of coverage.” – DHB

7. In 2016 there was 18 119 stillbirths in South Africa. While there is a downward trend over the last three years, the DHB also reports a downward trend in live births – which suggests that the decrease in still births is at least in part due to a reduction in the overall birth rate.

8. According to the DHB the period from 2014/2015 to 2016/2017 has seen steady reductions in the following three child-health-related indicators: Diarrhoea deaths under five years (1 514 to 886), pneumonia deaths under five years (1 411 to 1 003), and severe acute malnutrition death under five years (1 851 to 1 188). While the trend is encouraging, it is nevertheless unacceptable that over a thousand children in South Africa died of severe acute malnutrition in 2016/2017.

Steps to consider when proving PrEP in higher-education institutions

By Thuthukile Mbatha, SECTION27

1 October is set to become a memorable day in some higher-education institutions. It marks the day in 2017 that Pre-Exposure Prophylaxis (PrEP) was first rolled out at select campus health clinics as a new, highly effective HIV-prevention method. PrEP is an ARV drug combination taken to prevent infection by HIV-negative people who are at a greater risk of acquiring HIV. The two drugs in the only registered PrEP pill in South Africa are tenofovir and emptricitabine – also known under the brandname Truvada.

The provision of PrEP in South Africa occurs through various sites, these include the national health system, demonstration projects, large scale implementation initiatives (i.e. Dreams project) and the private sector. The Department of Health (NDoH) has identified seven higher education institutions that will form part of the above sites in rolling out PrEP to young people.

These institutions are the University of Free State, the University of Venda, Rhodes University, Nelson Mandela University, the University of Zululand, the University of Limpopo and Vaal University. Not all of them began rolling out PrEP on the set date; however, all these institutions were selected because they met the criteria set by the National Department of Health to assess their state of readiness to provide primary healthcare services to students.

A number of factors must be considered when determining whether an institution is fit for PrEP roll-out. These include staffing, qualification of nurses, dispensing licences and adequate storage, to name a few. The seven institutions currently providing PrEP are already dispensing antiretroviral treatment (ART) to students living with HIV, as well as other primary healthcare services, which was another prerequisite for PrEP provision. Many institutions do not offer this service for the reasons listed above, among others.

It is important for professional nurses to have a primary healthcare qualification, and also to acquire a dispensing licence. This enables them to deliver primary healthcare services, including ART and PrEP initiation. The provision of such services is usually supported by the District Department of Health office. Only the institutions that pass the assessment are considered as PrEP roll-out sites. In the institutions listed above, extensive training of clinic health personnel and peer educators was done to ensure readiness for PrEP provision and demand creation in these institutions. However, students have not yet been properly engaged, as the roll-out was introduced at what was a very busy time for students, who were preparing for exams. These institutions aim to intensify their demand-creation campaigns in the new year.

Most institutions fund the operation of their own campus health clinics; however, the Department of Health supplies them with family-planning and STI medicines. “We had to sign a memorandum of understanding with the Department of Health in order for them to supply us with PrEP,” said a health professional at one of the institutions.

“We do not have a set target number of students to provide PrEP to – every student who comes to our clinic and requests it is given it, after doing an HIV test and establishing that the student is HIV-negative,” she added.

The seven higher-education institutions that have started rolling out PrEP are an addition to the 17 demonstration sites providing PrEP that were established from June 2016. These demonstration sites include clinics for sex workers and for men who have sex with men (MSM). South Africa’s approach to PrEP roll out is focusing on targeting these ‘key population’ groups. For groups of people considered to be key populations, see www.avert.org/professionals/hiv-social-issues/key-affected-populations

Truvada (or any other tenofovir-based regimen) as PrEP is still not included in the South African Essential Drugs List (EDL). Its inclusion in the EDL would bring down the costs of PrEP, which would make it cheaper for the National Department of Health to provide sustainably to people who need it.

It is also important to note that the state of readiness for PrEP varies from institution to institution. Institutions such as the Technical and Vocational Education Training (TVET) colleges do not have campus health clinics, therefore they rely on off-campus clinics for sexual and reproductive healthcare services. The future roll-out plans should also consider such cases. A proper audit of all campus and off-campus clinics is required, so that all the issues may be addressed before the scale-up of PrEP roll-out.

Moreover, for PrEP roll-out to be effective, the inclusion of Student Representative Councils is very important, because of the power of influence they possess. It is critical to have student involvement in the entire process, to ensure a more positive uptake.