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

By Marcus Low

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

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

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

The NSP and the realities of our public healthcare system

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

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

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

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

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

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

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

HIV prevention in the NSP

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

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

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

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

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

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

The NSP and workers in the healthcare system

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

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

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

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

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

Good news on HIV testing

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

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

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

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

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

Two thirds of a TB plan

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

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

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

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

Decriminalisation of sex work

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

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

Better use of data

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

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

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

The way forward

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

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

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

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

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

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

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

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

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

Full NSP finally published

After substantial delays the final version of South Africa’s National Strategic Plan (NSP) for HIV, Tuberculosis and STIs 2017 – 2022 was finally published on the website of the South African National AIDS Council (SANAC) on the 11th of May 2017. While the plan was officially launched on the 31st of March 2017, only a summary of the NSP was available at the time. The March 31st date was itself a week after the previous publication date given by SANAC – which was World TB Day (March 24th). The original publication date given for the NSP was December 1, 2016.

The NSP is a long and relatively unfocussed document. It contains over 100 pages and a number of tables. It starts with a poem, acknowledgements from the Director General of Health, a foreword from the Deputy President, a preface from the Minister of Health, and a message from the vice-chairperson of SANAC.

As we have previously reported, the content and the process of the development of this NSP has been unusually controversial. A number of organisations and the previous SANAC CEO have been publicly critical of the NSP and certain ommissions from it – with the Treatment Action Campaign and SECTION27 going as far as to say they can’t endorse the plan in its current form. Yet, according to the Deputy President, “the Plan is inclusive, both in the process of its development and in the range of its priorities”. A similar claim is made by the SANAC vice-chairperson who writes that “the SANAC community has spoken through the NSP”.

In the coming weeks Spotlight will continue to explore these contrasting views on the NSP and its development. We will also seek to publish opinion pieces on the NSP from a wide range of people.

What is in the NSP?

Below we provide a short summary of some of the key elements of the NSP. Note, however, that this does not include an analysis of what has been left out of the NSP – an issue that some contributors will write about for Spotlight in the coming weeks.

At the core of the NSP are eight goals. They are as follows:

  1. Accelerate prevention to reduce new HIV and TB infections and STIs
  2. Reduce morbidity and mortality by providing HIV, TB and STI treatment, care and adherence support for all
  3. Reach all key and vulnerable populations with customised and targeted interventions
  4. Address the social and structural drivers of HIV, TB and STIs, and link these efforts to the NDP
  5. Ground the response to HIV, TB and STIs in human rights principles and approaches
  6. Promote leadership and shared accountability for a sustainable response to HIV, TB and STIs
  7. Mobilise resources to support the achievement of NSP goals and ensure a sustainable response
  8. Strengthen strategic information to drive progress towards achievement of the NSP goals

In addition to these eight goals, the NSP also identifies five “critical enablers”:

  1. Focus on social and behaviour change communication to ensure social mobilisation and increasing awareness
  2. Build strong social systems, including strengthening families and communities, to decrease risks of transmission and to mitigate the impact of the epidemics
  3. Effectively integrate HIV,TB and STI interventions and services
  4. Strengthen procurement and supply chain systems
  5. Ensure that the human resources required are sufficient in number and mix, trained and located where they are needed.

The NSP also contains a range of targets that South Africa should aim to meet by 2022. Below we have made a selection of what we think are some of the most notable targets:

  • Reduce new HIV infections to less than 100 000 by 2022
  • Reduce TB incidence by at least 30%, from 834/100,000 population in 2015 to less than 584/100,000 by 2022
  • Implement the 90-90-90 strategy for HIV (90% of all people living with HIV know their HIV status. 90% of all people with diagnosed HIV infection receive sustained antiretroviral therapy. 90% of all people receiving antiretroviral therapy are virally suppressed.)
  • Implement the 90-90-90 strategy for TB (Find 90% of all TB cases and place them on appropriate treatment. Find at least 90% of the TB cases in key populations (the most vulnerable including people living with HIV with low CD4 counts, under-served, at-risk) and place them on appropriate treatment. Successfully treat at least 90% of those diagnosed with DS DS TB and 75% of those with DR TB.)

Do we have the money and the political will?

The NSP gives civil society a useful tool with which to advocate for certain programmes or policy changes. The NSP e.g. commits to an ambitious new HIV testing campaign. Civil society can use the NSP to ensure that such a testing campaign gets fully funded and is properly implemented.

A welcome addition to the final version of the NSP is some rough costing estimates. These underline that implementation of the NSP is by no means guaranteed. As stated in the NSP: “Although it appears that there will be funding shortfalls in certain programme areas if all the interventions articulated in the NSP are implemented, it is difficult to estimate the magnitude of potential financial gaps without further robust analysis. Accordingly, “it is recommended in the NSP “that a systematic funding gap analysis be undertaken for the NSP that presents estimated funding shortfalls by sub-programme.”

Below we quote some of the most encouraging sections of the NSP. If the money can be found and if all the commitments made in these sections are met, South Africa’s HIV and TB response should be in a good state come 2022.

On HIV testing:

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

On HIV treatment:

“Increase antiretroviral treatment coverage from 53% to 81%: The 90-90-90 approach demands that at least 81% of people living with HIV receive antiretroviral therapy by 2020.To achieve this target, South Africa will fully implement its Test and Treat approach, focusing on rapid treatment initiation for adults and children, with treatment starting on the same day as diagnosis for those ready to do so. Roll-out of superior regimens will be prioritised as safer, more effective antiretroviral medicines, such as dolutegravir, become available. Concerted efforts will be made to further simplify regimens for children and ensure access to third-line adult and paediatric regimens. The implementation of differentiated service delivery models for people-centred care will be accelerated to support early and sustained treatment. The Central Chronic Medicines Dispensing and Distribution Programme will be expanded, supplying three month ARV drug refills and supplying to alternative pick up points or clubs. Improved tracking of mother-infant pairs will be undertaken to ensure ongoing access to care. Clear guidelines will be developed to support community-based workers to optimise their role in health facilities and in communities and households, as part of the differentiated care strategy to support achievement of the 90-90-90 targets.”

On HIV viral load testing:

“Ensure that 90% of all patients receiving antiretroviral therapy are virological suppressed: At least 90% of all ART patients will receive viral load testing in accordance with clinical guidelines compared to the 52% to 75% who do so now.”

On TB treatment:

“In order for drug-susceptible TB cure rates to move from 83% to at least 90%, and for drug-resistant TB cure rates to improve from 48% to at least 75%, in addition to strengthening adherence, priority will be given to early detection, early initiation on treatment after diagnosis, and the rapid introduction of new drugs as they are approved. Examples include bedaquiline, delamanid, pretomanid and other new, novel, and shorter options for XDR-TB.”

Let our Actions Count: SA National Strategic Plan for HIV, TB & STIs 2017-2020

This is the fourth National Strategic Plan (NSP) that South Africa has adopted to guide its response to HIV, Tuberculosis and sexually
transmitted infections. Viewed together, the plans set out in the NSP provide insight into the path we have travelled as a nation to
overcome one of the most devastating human challenges of our time.
They show how our response to HIV, TB and STIs has evolved over the last two decades as we have come to understand the nature and
impact of the epidemics with regard to the factors that contribute to their spread, and the interventions that work best in reducing
infection, morbidity and mortality.
This NSP is a clear demonstration of the outstanding progress we have made. It is also a stark reminder of how far we still need to go.

Download here

TAC survey highlights poor infection control in clinics

By Marcus Low

Tuberculosis (TB) infection control measures in some South African public sector clinics fall woefully short. This is according to an infection control survey that was published by the Treatment Action Campaign (TAC) ahead of World TB Day (23 March 2017).

While the survey has some limitations, and is by no means an exhaustive survey of clinics in South Africa, it nevertheless provides compelling evidence that we have an infection control problem at a number of public sector clinics. Given that poor infection control at clinics may be a significant contributor to TB transmission in South Africa, this is a red flag that should be taken seriously.

How was the survey conducted?

TAC branch members across seven of South Africa’s nine provinces were trained on a TB infection control questionnaire. Delegations from TAC branches then went to their local clinics to fill in the questionnaire. They reported their findings back to the TAC national office where the findings were captured.

The questionnaire contained seven questions relating to TB infection control measures that should be in place at clinics. Each question was simply given a “yes” or “no” answer. It was designed in such a way that “yes” answers in each case indicated correct infection control procedures. In other words, the more “yes” answers a clinic got, the better.

What did the survey find?

As part of their media release, TAC published an Excel file with the data they collected. This file contains details of the 158 clinics that were surveyed and how each of seven questions were answered in relation to these clinics. Below we present some additional analysis we conducted of the data provided by TAC. (For those interested in exploring the data, we have done some data cleaning and saved it as a CSV file that can be downloaded here.)

While TAC rated each clinic red, orange, or green – the data can also be represented as a score out of 7 for each clinic – where each yes answer adds 1 point to the score. Thus clinics that score 7/7 are rated green, 5/7 or 6/7 are rated orange, and 4/7 or less are rated red.

Scores by province

ProvinceNumber of clinics surveyedMean score out of 7
Western Cape 15 4.67
Eastern Cape253.52
Free State193.16

The above table shows the mean score of the clinics surveyed in each province. We should stress though that these are not representative samples and the findings cannot be generalised to entire provinces. The mean scores in some provinces are also so close together that we should not read anything into the fact that e.g. Mpumalanga is above Gauteng, or that Free State is above Limpopo. It does seem significant however that the clinics that were surveyed in the Western Cape tended to do substantially better than clinics surveyed in other provinces.

No clinics in the North West province and the Northern Cape were surveyed. Of the seven provinces surveyed, Mpumalanga is somewhat over-represented with 39 out of the 158 clinics – most other provinces had around 20 clinics surveyed.

Results by question

This table shows the total NO and YES answers to the seven questions. In each case YES indicates correct infection control measures. Only question 1 and 3 received more than 50% YES answers. Question 5 received exactly 50% YES answers.

QuestionsAnswered NOAnswered YES
1. Are the windows open?22136
2. Is there enough room in the waiting area?9266
3. Are there posters telling you to cover your mouth when coughing or sneezing?6494
4. Are you seen within 30 minutes of arriving at the clinic?10157
5. Are people in the clinic waiting area asked if they have TB symptoms? 7979
6. Are people who are coughing separated from those who are not?10553
7. Are people who cough a lot or who may have TB given tissues or TB masks?11642

The TB infection control measure on which clinics did the best was keeping the windows open in the waiting area. Second best was having posters up on the walls telling people to cover their mouths when coughing or sneezing. However, apart from opening windows and having posters on the walls most clinics did very poorly at TB infection control.

It is also notable that on the cross-cutting question as to whether people are seen within 30 minutes, only 57 of the 158 clinics got “yes” answers. Long waiting times becomes a more important risk factor when other infection control measures are not in place because people are exposed for longer periods. The mean score in clinics with less than 30-minute waiting times was 5.1 compared to only 2.3 in clinics with longer waiting times – in other words, the clinics where people waited longer tended to be clinics where the risk of TB infection were already substantially higher.

How much did clinic scores vary?

Only 15 of the 158 clinics in the survey got “green” ratings. 31 were rated “orange” and 112 were rated “red”. The mean rating for all clinics surveyed was 3.34/7 and the median was 3/7.

Measuring up to the task of tackling HIV and TB in the new NSP

By Julia Hill

What gets measured gets done and, ideally, gets improved. As the South African National AIDS Council (SANAC) nears completion of the next National Strategic Plan (NSP) on HIV, TB, and STIs (2017-2022), lofty ambitions for positive outcomes are in place. However, what provinces and districts are expected to measure in order to track implementation and incremental steps toward these goals is—at this point—completely absent from the NSP.

Correctly, the NSP aims to achieve substantial reductions in HIV infections to fewer than 100,000 per annum by 2022, and reach UNAIDS 90-90-90 targets by 2020 for HIV testing, retention in care, and viral suppression. Biomedical and social service approaches to HIV prevention are also prominent, including tackling the national epidemic of sexual violence. On the TB front, the NSP similarly seeks to close the gaps in prevention, diagnosis, treatment initiation, and treatment success, and specifically notes the special attention that must be paid toward bringing the drug-resistant TB (DR-TB) epidemic under control.[i] The wish-list of goals in the NSP leaves out very little. But these targets are expected outcomes—and outcomes do not evolve from a programmatic void.

The resulting pie-in-the-sky document makes it difficult for communities most affected by HIV and TB to hold to account AIDS Council governance structures and government departments. National success depends on smaller programmatic successes at district, sub-district, and service provision level. Monitoring and evaluation (M&E) standards must therefore be put in place at these system levels to ensure people are able to access services intended to lead to achievement.

For example, the intention to put half a million adolescents on PrEP by 2022 is overdue and welcome. But where is the breakdown for what districts are expected to contribute to that national total? High-burden districts like King Cetshwayo (formerly uThungulu) in KwaZulu-Natal have HIV incidence rates among adolescent girls that skyrocket to 6.2% by age 19[ii] –far exceeding the WHO threshold for PrEP eligibility. These districts should have very specific targets for the number of adolescents that should start and be retained on PrEP. But districts and sub-districts should also have ambitious targets in place for the proportion of schools offering HIV testing services and referrals to preventative services such as PrEP, or for the proportion of facilities implementing youth-friendly services—such as staying open after-hours on some days of the week. It is through monitoring these types of indicators that we can ensure that districts are offering services that put them on track to meet targets.

At the 21 February 2017 consultation on Draft 1 of the NSP, interested parties were invited to participate in shaping indicators and targets for the provincial implementation plans. A long list of possible indicators was shared with this group. Some indicators were intended to be aggregated at the national level to measure major outcomes—such as the number of people on antiretroviral therapy—but a number of process indicators were also proposed that, if well-designed, could be used to measure programmatic implementation progress down to the sub-district level.

It was not clear if provinces were required to report on any of these process indicators, or if they are merely expected to select those they find interesting or convenient. Outcomes of this meeting were—to our knowledge—never published online or shared, making it extremely difficult for provinces to incorporate programmes and M&E support into their implementation plans.

However, it is not too late for provinces and high-burden districts to be offered guidance on what to prioritize. Not everything must be done everywhere, but certainly a bare minimum must be universally required across the country, and high-burden districts must be required to implement additional interventions beyond the minimum.

So what type of interventions should be prioritized as the essential minimum required from all districts, and implemented with urgency in high-burden districts? At Doctors Without Borders (MSF), our short-list includes the following:

  • Proportion of sub-districts offering a package of school-based services (including HIV testing, TB and STI screening, pregnancy tests, condoms, and referrals for PrEP, VMMC, and referral to further HIV/TB services) in 100% of schools – Target 80% of sub-districts by 2019; ≥90% by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of PrEP courses distributed to adolescents and youth – National target of 200 000 adolescents and 75 000 women age 20-24 initiated on PrEP by 2019; 500 000 adolescents and 200 000 women age 20-24 by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of free HIV self-testing kits distributed in public sector – National target of 3 million tests per year by 2019; 10 million per year by 2022
  • Proportion of sub-districts with primary health care (PHC) facilities (including community health centres (CHC)) offering essential services for sexual violence survivors (forensic examination, PEP, emergency contraception, psychological counseling, social assessment), linked into interdepartmental referral network for more advanced services – Target 100% of designated PEP facilities in all HIV high-burden sub-districts capacitated by 2020; 100% of all sub-districts with minimum one facility by 2022
  • Proportion of CHC/district hospitals and PHC facilities in high-burden settings providing comprehensive DR-TB services (diagnosis, treatment initiation, continued management –Target 100% of PHC facilities in high-burden settings; target minimum one facility per sub-district in lower-burden settings. Total of 800 facilities by 2019; total of 1000 facilities by 2022.
  • Proportion of PHC facilities not providing 3-month ART refills to stable ART patients – Target <5% of facilities by 2019; 0% of facilities by 2022.
  • Proportion of PHC facilities per sub-district achieving ratio of one lay health worker: 800 people within community (with 25% of lay workers facility-based; 75% community-based – Target 80% of facilities by 2019; 100% by 2022.
  • Proportion of treatment sites (including community pick-up points serviced by Central Chronic Medicine Dispensing and Distribution) experiencing stock outs of ARV or TB meds –  Target: <10% by 2019; <5% by 2022.
  • Proportion of PHC facilities in HIV high-burden districts and CHC in all districts offering after-hours/Saturday services for ART initiation and/or ART refill collection – Target 75% by 2019; 90% by 2022.

This approach will require strengthening data capturing and M&E systems, and the public must have access to data if those responsible for action are to be held to account. It is mandatory to invest in requiring and measuring programmes if we are to avoid frittering away the next five years. When sub-districts receive specific guidance, they are inclined to implement it—this is evident in the massive uptick in numbers enrolled on HIV treatment, or registered to receive their medicines at community pick-up points. And if government departments or other stakeholders do not implement programmes, or do not run them well, then a robust M&E system makes it obvious where intensified efforts should be directed to improve the quality and availability of HIV and TB services.

South Africa knows what it wants to accomplish in reducing the national burden of HIV and TB over the next five years. The major question remaining is whether or not it will measure up to the task before it.

Julia Hill is Deputy Head of Mission, Doctors Without Borders/Médecins Sans Frontières South Africa

[i] SANAC. Draft 2: South African National Strategic Plan on HIV, TB and STIs 2017-2022. Accessed 27 March 2017. Available at: http://sanac.org.za/wp-content/uploads/2017/03/NSP-Draft-2_24-February-2017.pdf

[ii] Grebe E, Huerga H, van Cutsem G, Welte A. (2016) “Cross-sectionally estimated age-specific HIV incidence among young women in a rural district of KwaZulu-Natal, South Africa” presented at the 21st International AIDS Conference. July 18-22 (2016), Durban, South Africa.

The Achilles Heel of the new NSP: Accountability and Equity

By Russell Rensburg

As we move towards the release of South Africa’s latest National Strategic Plan for HIV/AIDS, TB and STI’s it is important to celebrate the successes achieved since the end of AIDS denialism and the introduction of a revitalised AIDS response in 2006. Getting there and sustaining the response has required significant political will and herculean effort to harness the combined energy of all sectors. The results are undeniable: we have seen over 3 million people initiated on treatment (something almost inconceivable at the start of the journey), the near elimination of mother to child transmission.

Successes aside, significant challenges remain: our performance on TB is less than spectacular and the rate of new infections among key populations—such as young woman, men who have sex with men and commercial sex workers—remains unacceptably high.  We are almost there, but not quite.

The new NSP, which is deeply rooted in the global AIDS movement, heralds the end of AIDS by 2030. This belief is premised on the 90 90 90 strategy, which a lot like the offside rule in football, is deceptively simple but often difficult to explain. All things considered, the goal is to test 90 % of people, initiate 90% of those who test positive on treatment, and ensure that at least 90 % of those on treatment have suppressed viral loads, which will lower the risks of HIV transmission and prevent new infections. The idea is well articulated in the new NSP which proposes several innovative strategies to realise these goals. Some strategies target key populations, those directed at young women and girls, and strategies aimed at high transmission districts.

So, we have a good plan in hand? Not quite, we are afraid.

What makes a good plan is a plan that promotes equity and a plan that is informed by the people most affected. A good plan is a plan that we know will be implemented due to robust accountability mechanisms. These in our view are the Achilles’ heels of the new NSP.

Community consultation

There are complaints from different sectors as to the integrity of the consultation process. As with our own submission, there are allegations that the input of critical stakeholders, most especially community groups, have not been taken sufficiently into account. It would strengthen the plan’s standing if it could make fully transparent the consultation process and how key concerns have been addressed; or if not, why not.

Crumbling rural Building Blocks

Our second major concern regards the feasibility of the plan. Don’t get us wrong, we  am not advocating for a less ambitious plan – but for a realistic, equitable plan.  The World Health Organisation in their framework for strengthening health systems identifies six building blocks that are essential to a truly functional health system. These building blocks include leadership, human resources for health, service delivery platforms, sustainable financing, medical technologies and health information system. Looking at the plan through this lens, the feasibility of the new strategic plan is indeed exposed. To illustrate the challenge that lies ahead, it may be useful to reflect on a few of these concerning the goals presented in the NSP.

For instance, the NSP recommends a rapid expansion of the country’s treatment program by focusing on high-risk groups with the hope to more than double the number of people on treatment. Logically, it follows that the expansion in treatment will require concurrent investment in improving the functionality of the district health system. The reality, however, is that the NSP kicks off at a time when resources for health are diminishing, a weak currency is contributing to significant increases in drug prices, and there is a deepening crisis in human resources because resources are insufficient to meet basic HR needs. The system is close to collapse.

The picture is particularly bleak in rural areas where more than 40% of our population currently reside. Rural facilities, which have always struggled to attract health professionals, are further threatened by staffing moratoria. Infrastructure problems and neglect and the lack of investment in dignified and family-friendly accommodation for rural health care workers are other disenablers for the recruitment and retention of health care workers so critical to implementation of the NSP in the rural areas. Investment in HR is being channelled to larger urban centres, placing at risk millions of rural woman and girls who continued to be left behind.

The Role of SANAC

This brings us to the very critical role of the South African National AIDS Council (SANAC). Against the above context, it is obvious that SANAC needs to ensure that the NSP speaks to these rural realities for if not, it is a plan doomed to fail on Government’s mandate to plan and deliver for all who live in South Africa. Secondly, SANAC ought to advocate robustly for these rural realities to be turned around: for strong, firm building blocks to be put in place and for these to be protected in rural South Africa. Beyond more nurses, doctors and pharmacists in rural areas, what we need are sufficient community health workers to reach the most impoverished communities at household level; and Clinical Associates to upscale the Medical Male Circumcision drive and to support the minimal numbers of doctors in many small rural hospitals at the brink of collapse.

While the NSP continues to advocate for a multi-sectoral response that includes all stakeholders, it provides little guidance on how the various sectors will interact nor does it provide an accountability framework against which the custodians of SANAC can be assessed. This is particularly important when you consider that beyond the development of the NSP, SANAC has little influence on how the strategy is implemented. What is required is a strong SANAC that has the support of all stakeholders. A strong SANAC that can lead, direct and accelerate the response. We fear SANAC in its current state does not meet this muster.

To ensure the success of this NSP urgent attention to the governance and accountability frameworks are needed. As a start, the current leadership vacuum has to be addressed. Secondly, there should be a robust review of existing governance structures at national provincial and district levels. Finally, it is time for fresh elections of all SANAC office bearers, ensuring that we have the right people in place with the courage and commitment to coordinate and oversee the implementation of an equitable NSP that brings quality HIV and TB services to all.

Russell Rensburg – RHAP Programme Manager: Health Systems and Policy

Prisons and the New NSP: Nobody left behind?

by  Ariane Nevin[1] and Thulani Ndlovu[2]

Evidence has shown that prisons are a key battleground in the fight against HIV and TB. Prison populations are transient, and inmates are released back into their communities, taking with them all of the infections and unhealthy behaviours learned in prison. This means that any HIV and TB plan that doesn’t address the drivers of HIV and TB in prisons will fall woefully short of achieving its goals. And sadly, the latest draft of the NSP, with its inadequate prison-focused interventions, looks set to do just that.

The first draft of the NSP, released in November 2016, was cause for some jubilation for prisoners’ rights activists, for the first time including inmates as an HIV key population and incorporating important human rights language and interventions for prisons. However, we may have celebrated too soon, as two drafts later, following a far from transparent or inclusive political process, the prison-focused language has been markedly stripped down.

Although inmates remain a key population for both HIV and TB, and recipients of a core package of services targeting key populations, the NSP is missing interventions directed at addressing the causes of the TB and HIV epidemics in prisons: insufficient infection control, non-implementation of the Policy to Prevent Sexual Abuse of Inmates, dismal levels of overcrowding , inadequate ventilation, and insufficient re-integration support or linkage to care for ex-inmates upon release, to list but a few.

The latest draft includes as an objective, ‘Train correctional and detention centre staff regarding the prevention and health care needs and human rights of detainees and inmates living with or at risk of HIV and TB.’ However, sexual violence and overcrowding in prisons, which are key drivers of HIV and TB respectively, do not feature in any objectives. Surely any plan directed at training correctional centre staff on the prevention of HIV should look first to existing policies, of which the Policy to Prevent Sexual Abuse of Inmates is an excellent one. Why not include the implementation of this policy as an objective? Likewise, if we are to reduce TB infection rates, the plan should at the very least include amongst its objectives a strategy to reduce overcrowding.

The Departments of Correctional Services and Health receive plenty of money to fund their TB and HIV response, which they are using to test and screen inmates. However, they can counsel and screen as much as they like; until plans are developed and fully implemented to address the drivers of the epidemics, attempts to contain and beat them back will continue to have minimal impact.

International donors need to push DCS for a more comprehensive approach, greater transparency and better data. We cannot continue simply to roll out treatment blindly. If we are going to win this fight, we need to cut off these diseases at the knees.

Inmates and ex-inmates would have been the most qualified to suggest effective strategies for preventing TB and HIV in prisons, and effective support for reintegration of ex-inmates into their communities. However,  the inclusion of key populations in NSP consultations was made difficult, if not impossible by SANAC’s dismal organisation and planning that left important participants stranded and ultimately not consulted. Not only this, but the processes through which provisions are included or left out was entirely opaque, leaving stakeholders frustrated and in the dark, and SANAC, unaccountable.

So, what should the targets be?

  • Full implementation of the DCS Policy to Prevent Sexual Abuse of Inmates in DCS Facilities: Sexual abuse is prevalent in prisons, and is a recognised driver of the spread of HIV inside prisons. Unless urgent steps are taken to detect, prevent and respond to sexual violence in prison, transmission of HIV will continue.
  • Full implementation of a TB infection control policy: Prevention is better than cure and raising awareness among inmates that windows should be left open is not adequate. Steps need to be taken to decrease overcrowding, to ensure that cells have sufficient cross-ventilation and to allow inmates to spend more time spent outside of their cells. The NSP must set more concrete targets in this regard.
  • Urgent steps need to be taken to address extreme overcrowding in prisons: TB and HIV infection control policies will continue to have limited impact until overcrowding is decreased. Studies show that implementation of national cell occupancy recommendations could reduce TB transmission risk by 30%. The NSP must set concrete and measurable targets in this regard and map out a clear and workable strategy to eliminate overcrowding as soon as possible.
  • An effective prison oversight body with sufficient independence and powers to investigate and refer complaints needs to be established to replace the Judicial Inspectorate for Correctional Services: this will ensure that DCS policies are adhered to, and their obligations met. It will also provide a safe avenue through which inmates may submit complaints. Improved linkage to care between prisons and communities, and support groups for ex-inmates: Inmates need to receive counseling, a copy of their medical file and a referral to a clinic accessible to their community to enable adherence to treatment once they leave prison. They also need ongoing support to avoid re-offending. These services are currently lacking. In order for this to happen simple systems need to be put in place, and the DCS, DOH and DSD need to work together to ensure that there is no loss to care in the transition between incarceration and freedom.
  • An effective collaboration in real time between the DCS and NDOH to ensure that new NSP policies, like Universal Test and Treat and condom distribution are implemented with no delay.

We hope that the final NSP 2017-2022 will take heed of this advice, and look forward to an NSP that is actually strategic and truly leaves nobody behind.

[1] Sonke Gender Justice

[2] Zonk’izizwe Odds Development

Towards a workable plan

By Vuyokazi Gonyela, SECTION27

A key ingredient to ensuring our response to the AIDS and TB epidemics is effective, is having a workable plan. To that end, consultants and experts are working furiously to make sure South Africa has a new National Strategic Plan (NSP) to take us through to 2022.

But we know what is said about South Africa and our plans and policies: Full marks for great plans and policies; fail for implementation. The involvement of civil society is a critical component of a

The involvement of civil society is a critical component of a workable plan.
The involvement of civil society is a critical component of a workable plan.

workable plan. Established civil society structures already exist within the various AIDS councils at national, provincial and municipal (local or community) level but there is an unequal distribution of resources from the councils to these structures, which, in turn, means they struggle to get work done and to participate meaningfully in processes.

South Africa’s response to the HIV/AIDS, TB and Sexually Transmitted Infections (STI) epidemics requires coordination and leadership from various accountability structures, including the South African National AIDS Council (SANAC). This body hosts the National Civil Society Forum (CSF), which monitors progress on the implementation of the NSP and holds government accountable on behalf of the users and practitioners in the health-care system.

Theoretically, national structures that manage the HIV/AIDS TB and STI response should function in a manner that provides both leadership and support to provincial and local structures. But, provincial and local bodies need to be just as empowered to hold the government accountable – even more so – on behalf of the health-care users on the ground.

Despite this theoretical commitment to the development and strengthening of provincial structures, little has been done to provide these structures with the resources and authority that they need.

In provinces like the Eastern Cape, the struggles and difficulties are clearly visible. The province has struggled to implement strategies to respond to HIV/AIDS, which has left the community at a great disadvantage. Among the factors that impact negatively on the work to be done, is poor leadership. In the Eastern Cape, for example, the former elected CSF chairperson was last seen in 2015. This critical position was left unattended because the leader had other interests that compromised, not only the forum, but the entire provincial mandate.

The intervention campaign and strategies also need to adapt and respond to new data. Recent statistics indicate that the prevalence of HIV/AIDS has shifted from adolescents to young women and girls: the stats show about 2,363 new infections weekly in South Africa, with AYWG accounting for almost 1,750 of these infections.

The goal to end HIV/AIDS by 2030 is far from being realised, particularly because there is little investment in developing young leaders and creating more active citizens. They have a big role to pay and are central in our response to HIV if we truly want to deliver on the rhetoric of ending AIDS.

A further concern is that women are grossly under-represented within provincial leadership sectors tackling HIV. Across the nine provinces, the leadership is mainly dominated by men. Provincial CSF chairpersons sit on the Provincial Councils on AIDS as co-chairpersons; seven of the nine provincial chairs are male. The Eastern Cape took a bold stand in September 2016 and elected the first woman as a CSF chairperson. No attention is paid to this.

The voices of many women are suppressed in their households, communities and in leadership structures. Provincial AIDS structures need to take the lead, transform themselves, and support capacity-building female leadership as a critical investment, not only for the provinces but for the country. Nothing less will do.

Communities in crisis

By Treatment Action Campaign

The Treatment Action Campaign has shared the following stories with Spotlight from their provincial operations in KwaZulu-Natal, Limpopo, Mpumalanga and the Free State. Elsewhere in this issue of Spotlight we take an in-depth look at Gauteng – which is therefore not included here.

France, KwaZulu-Natal

Branch members go door to door in France to find out how people in the community cope without a clinic.

The community of France in KwaZulu-Natal does not have a clinic. A mobile clinic comes to the community just once a month. But most people don’t use it; some don’t even know about it. Instead they travel by taxi to other clinics – if they can find the money. Sometimes they must lie about where they live in order to see a nurse, or they simply go without medicines and health services altogether. Only certain community caregivers can deliver medicines to patients, if they have an ID, and if the patient is being treated at the mobile clinic. The rest, however ill, have to collect medicines themselves. It seems people are defaulting on ARVs, TB treatment and other chronic medicines as a result. We can never have #treatment4all – or #EndTB – when people can’t even get to the clinic. TAC members have asked the people of France how only having a mobile clinic affects them. The resounding response is that once a month is not enough. To resolve service deficiencies such as this one, which keep the dual epidemics burning, health system challenges must be addressed in the National Health Department’s test-and-treat plan and within the new National Strategic Plan on HIV, TB and STIs. Otherwise we are doomed.  #FranceNeedsAClinic.

Khujwana, Limpopo

Within a few hours of walking door to door through the streets of Khujwana it is clear there is a major problem. Every home has a story to tell – a story of frustration and suffering, a story of failure.

While the local clinic looks functional, even ‘pleasant’, from the outside with its solid infrastructure and garden, inside it s a totally different matter. Many patients report ongoing stockouts and shortages of their medicines. They wait for hours before being seen by anyone – there is a shortage of nurses and no doctors ever come. Some go to other clinics altogether. People report incidences of nurses treating them badly, being rude or, worse, negligent. Mothers report the indignity of having been mistreated, or unattended to, in the midst of labour. Khujwana Clinic is failing the people and the community it is meant to serve. Tired of this situation, the community is mobilising. Testimonies from community members who try to use the clinic are being gathered. Local stakeholders are coming together to draw attention to the major shortcomings. All they want is a clinic that can give them the health-care services they need. They are clear: They will continue to escalate this issue until they #FixKhujwanaClinic.

Boekenhouthoek, Mpumalanga

The local TAC branch in Boekenhouthoek receives ongoing complaints about the local clinic. People

In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.
In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.

report waiting for long periods of time, with or without being seen. There aren’t enough nurses stationed in the clinic exacerbating this issue. The clinic is too small, and people wait outside while waiting to be seen. The clinic is faced with regular stockouts and shortages of medicines meaning people are often sent home empty handed. Some community members choose to go to different clinics altogether. A luxury that many of those unemployed people who live in the area cannot afford. Traditional leaders confirm these conditions, from personal experience. One woman spoke of never receiving a TB diagnosis, months after taking a test. One man spoke of misdiagnosis. Another had never been told he had HIV, yet had been prescribed ARVs for more than four years with serious side effects. People reported of nurses being rude to them in moments of severe vulnerability. The TAC Boekenhouthoek branch is monitoring the clinic and gathering information from residents about the challenges they face. How can we reach #treatment4all if clinics run out of medicines? Or if people don’t want to use them because of the lengthy waits and poor service? The reality is that the dysfunction in our health-care system will stop the new HIV guidelines on test-and-treat from being a success. We need significant investment into stronger systems in order to respond to the HIV and TB epidemics. #BetterBoekenClinic

Phuthaditjhaba, Free State

Members of the TAC in Phuthaditjhaba have reported serious problems at Manapo Hospital that are putting people’s right to access health care in serious jeopardy. This report followed a strike by frustrated, overburdened staff members, including doctors, nurses, physiotherapists, porters, cleaners, and kitchen staff, who claimed to have not received pay for significant amounts of overtime since 2015. TAC members investigated the hospital and spoke to many patients entering and exiting the facility. Reports of long waiting times, a lack of nurses, doctors, and other staff being stretched beyond their capacity, and medicine shortages, were common.

After being stabbed in the forehead, one teenager reported not seeing a doctor after seven days of waiting. Another teenager had been stabbed in the upper chest four days earlier. He was also still waiting to see a doctor. A woman with a homemade sling and swollen wrist left the hospital in pain to return to the clinic. One man, falling in and out of consciousness, was told to return to casualty with a referral letter. Outside the hospital, visibly injured patients could be seen wandering the grounds in their pyjamas. After taking a rest on the grass, one young man with bandages across his face struggled to stand up and had to be assisted by two other patients to get onto his feet before limping back inside. Portable toilets remain outside the hospital after a water crisis the month before. It is unclear whether the water shortages continue. A TAC member helped a man with crutches who struggled to climb up the metal steps to enter the toilet. If urgent action is not taken to turn around this crisis, the TAC will be forced yet again to embark on a campaign of civil disobedience in order to save the lives of those reliant on the failing public health-care system. #FSHealthCrisis





Rich province, poor health care

By Ufrieda Ho

In money terms, Gauteng’s health budget looks plump and healthy at R37,4 billion for the 2016-2017 financial year – R2.07 billion more than the previous financial year. It represents a sizeable portion of the province’s overall budget. On the surface, this is money that could make a significant contribution to improving the health outcomes for the province’s patients.

But, even though it’s South Africa’s richest province, Gauteng is under pressure from a growing metropolis and is not future-proofing fast enough for its evolving needs. There are challenges of rapid urbanisation, with high migrant numbers and community members who are transient and difficult to track medically. The province also has to plan for accelerated environmental degradation, overcrowding, job shortages, limited resources and the yawning gap between the haves and have-nots.

The divisions are evident in data from Stats SA’s General Household Survey of 2015, which was released in June this year. For example, Gauteng is home to the highest percentage of medical aid members in the country at 27.7 percent, but this still leaves 70 percent of the population reliant on that R37,4 billion to be spend wisely and effectively.

The Gauteng Department of Health has its own hurdles to overcome, including proving that it is fit to govern. After being placed under administration in 2013, the department finally achieved an unqualified audit from the Auditor General for its financial management this year.

But the health issues continue to be a challenge in the province. On-going staff shortages, overworked staff, unreliable ambulance services, staff who don’t treat patients with dignity, and a disconnect between policy and plans and the reality on the ground. Increasingly, bureaucracy replaces communication, and there are more reference numbers and records of complaint than actual solutions or firm plans on how problems can be rectified.

In addition, a tangled web of social failings impact on the health-care challenges. There’s high unemployment and competition for scarce resources. Public works shortfalls mean infrastructure in hospitals and clinics is not upgraded or maintained. And the high cost of commuting, or lack of proper roads in new developments, represent very real barriers to accessing health care for many patients. The protracted drought in southern Africa has also made food security a great cause for concern among the most vulnerable people in the province.

It is a most distressing trend that already weak health-care standards are slipping further and that there are clear losses in areas where gains had previously been achieved. For Gauteng TAC leaders Portia Serote and Sibongile Tshabalala, these include noticeable deterioration in the way TB is being managed in many of the province’s clinics and hospitals.

Serote, who works mainly in the East Rand districts, says many basic good care and oversight practices are simply not adhered to.

‛We can walk into clinics and see people not using masks. Patients are all mixed up in the same small facilities – so you can see XDR and MDR patients with TB patients. There is no infection control, or the UV lights (that help limit the spread of infection) are not working,’ says Serote.

She says the TAC has had to step up its own outreach programmes after discovering in a spot sampling exercise recently, that out of 60 people, 10 had TB and three had MDR-TB.

Another growing concern, says Tshabalala, is the high number of ARV defaulters that they are noticing. Tshabalala says the target of getting patients to undetectable viral loads is slipping.

‛We did a workshop and survey in Orange Farm earlier this year and found that people default because they can’t afford the taxi fare to get to a clinic, and it’s too far to walk. They also have to wake up by 4 am to get to a clinic or hospital if they want to get help that day. There is a benchmark for waiting of 180 minutes, which is just too long,’ says Tshabalala.

The facilities that people rely on have no privacy, are often cramped and have not been properly maintained. Serote says she’s visited clinics where nurses have brought curtains from their homes so patients can have some privacy and dignity during their consultations.

And, Serote says, mental health patients are falling through the cracks in the province. The TAC has seen an increase in the number of patients who simply walk out of hospitals in hospital pyjamas, completely unnoticed, sometimes for days.

‛The nurses were just unaware in Pholosong in Tsakane, when a man who was mentally ill just got up from his hospital bed and left. He was living in really terrible conditions and that’s where we found him, still in his hospital clothes, but the nurses didn’t know anything,’ she says.

Both Serote and Tshabalala acknowledge the nurses are under immense pressure themselves. ‛Nurses are not just nurses; they are counsellors, they’re cleaners – they are expected to do everything. The Department of Health thinks that a benchmark of one nurse to every 40 patients is not being overworked, and very often the nurses see even more people than that,’ says Serote.

Even for a thriving economic hub like Gauteng, prosperity is shared by only a few. Money can buy many things, it seems, but clearly it can’t buy solutions that are inclusive, innovative or impactful for a health-care system that needs just these.