HIV and tuberculosis (TB) remain at crisis levels in South Africa. Every year, modelling suggests that about 270000 people acquire HIV and TB remains the leading cause of death, according to Statistics South Africa.
Reports from the Office of Health Standards Compliance and members of the activist organisation the Treatment Action Campaign paint a picture of a public healthcare system that is often so severely dysfunctional that it hinders the implementation of HIV and TB programmes. The lack of TB infection control in many clinics and hospitals is an obvious example.
The public healthcare system has fallen prey to the same corruption and cadre deployment that has crippled much of the public service.
It is with this in mind that South Africa’s new national strategic plan for HIV and TB, launched on Friday, should have been developed. But there is no indication that the realities on the ground have been translated on to paper in the document.
The new national strategic plan for HIV and TB is a plan that seems reasonable when considered in the abstract, but that risks falling apart when confronted by the realities of the public healthcare system and political context.
The strategy, on a superficial level, says many of the right things. It recognises the need for a new HIV counselling and testing campaign more than six years after the country’s most recent such drive kicked off. The document also acknowledges that we need to use new TB drugs and diagnostics quickly and efficiently while doing more to find new cases.
Wish lists are welcome, but they’re of little value without plans to implement them.
The country’s latest plan to tackle the twin epidemics fails in four ways: It reinforces a lack of accountability, avoids dealing with the shortage of health workers as well as the cost and sustainability of the HIV and TB response. Finally, it pays little but lip service to some of the today’s most pressing issues, including how we will get condoms into schools and the decriminalisation of sex work into law.
One of our public healthcare system’s most fundamental problems is a lack of accountability: policies set at a national level go unimplemented in provinces and poor management at the provincial or district level often comes without consequences.
A critical flaw in the national HIV and TB plan is that it shifts all the responsibility for its implementation to provinces. This is to be supported in principle, but the strategy provides little guidance to provinces on how to do this or how this will be measured. And we know what remains unmeasured may never get done.
Second, much of what the plan proposes will require increases in human resources, including goals such as doing more to find new TB cases and putting millions more on antiretrovirals. Community health workers play a vital role in tracing some of those most at risk of TB, including those who have been in close contact with TB patients. They also do much of the counselling to ensure that people who start HIV treatment stay on the life-saving medication.
It is a disgrace that over the last 10 years, we have made almost no progress on the employment of community healthcare workers — an area in which this new national plan also fails.
A more serious document would have connected the dots, spelling out the substantial human resource requirements of its proposed interventions. Had it done so, we would be in a better position to plan not only how to recruit the right people to get the job done but also to lobby for the money to pay them.
The national strategic plan hardly makes mention of what proposed interventions may cost or if we have the resources to fund them. As it stands, many of the plan’s interventions may end up unfunded and thus unimplemented.
Data from the Human Sciences Research Council’s latest HIV household survey tells us that almost a quarter of new HIV infections occur in women aged 15 to 24. And yet condoms remain conspicuously absent from the one place where many youths spend the much of their time: schools.
South Africa’s next HIV and TB plan includes the provision of condoms as part of school programming but the language is weak and, as is the case with much of the strategy, lacks concrete steps to implement this.
We cannot talk seriously of reducing HIV infections in women and girls if we fail to provide easy access to condoms. Ensuring the provision of both condoms and comprehensive sex education in schools should have been front and centre in South Africa’s HIV response.
Likewise, the plan includes decade-old language that commits the country to “taking steps” to decriminalise sex work, but it is of little use without a clear plan for making this a reality.
A 2014 study conducted by the health department found that between 40% and 70% of almost 2200 sex workers surveyed were living with HIV. Research published in 2014 in The Lancet medical journal found that decriminalising sex work could help avert almost half of all new HIV infections globally in the next 10 years.
What's behind the #AIDS2016 protest that almost left S. Africa's health minister speechless https://t.co/mg6muuLYyS pic.twitter.com/ZlDYMpQNC2— Bhekisisa M&G Health (@Bhekisisa_MG) 20 July 2016
What's behind the #AIDS2016 protest that almost left S. Africa's health minister speechless https://t.co/mg6muuLYyS pic.twitter.com/ZlDYMpQNC2
— Bhekisisa M&G Health (@Bhekisisa_MG) 20 July 2016
For these reasons, we cannot uncritically endorse the national HIV and TB plan in its current form — but there’s hope for the plan yet.
The South African National Aids Council could save the plan by drafting addendums to the document that not only provide guidance and measurable targets for provinces on implementation but also set out the human resource needs and costs required to put the plan into action.
This must include a budgeted and quantified plan and policy on community healthcare workers.
Second, all key interventions must be costed and funding sources identified within the revised plan. All provincial Aids councils must be chaired by premiers and must be required in the new national strategy to produce realistic implementation plans.
And who should track all of this? We propose the creation of an entity independent of the health department and South African National Aids Council to collate, verify and make public data used to monitor progress made towards the national strategic plan.
South Africa knows what needs to be done to bring the crisis of HIV and TB — the major question remains whether it will step up and measure up to the task before it.
Anele Yawa is the secretary general of the Treatment Action Campaign. You can follow him on Twitter @AneleYawa
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Bhekisisa means "to scrutinise" in Zulu
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