Activists need to pick their battles because a strategy that pleases everyone is doomed to fail.
Scepticism over South Africa’s forthcoming HIV and tuberculosis (TB) plan is understandable.
The previous plan was often ignored by government. In some provinces, the public healthcare system is so dysfunctional that implementing any plan or policy is extremely difficult.
Those in charge of developing the plan at the South African National Aids Council (Sanac) do not have an easy job. They must consult widely to keep everyone happy. But a plan that pleases everyone, including government, will almost by definition lack the teeth required to make a difference in South Africa’s response to HIV and TB. Partly because of the difficulty of this balancing act, the finalisation of the plan has been delayed until March 2017.
The very substantial challenge they face in coming months is to formulate a progressive, highly targeted plan and then to convince people that this plan is the way forward.
When formulating such a strategy, it is worth keeping in mind that government will make some decisions with or without the document.
Health minister Aaron Motsoaledi has made good policy decisions in recent years. But there is little indication that he was guided in these decisions by the previous National Strategic Plan (NSP) on HIV, TB and STIs or by Sanac.
With the limited capital it has, the new NSP must be focused and avoid placing too much emphasis on things that will happen with or without it. It should instead identify a few points where change is needed, but not guaranteed. These include proposals that government may be actively resisting, or where the department of health’s hand needs to be strengthened when approaching treasury or donors for funding.
A strong NSP could help to shift the dial in our HIV and TB response if it focused on four areas: data transparency, partnerships, comprehensive sex education and human resources.
Firstly, the new NSP must bring about a radical change in the health department’s mind-set about how it shares its data publicly. At present, the health department doesn’t share much of its information for fear of bad publicity. The trouble with this is that it makes it harder for the public to take ownership of the healthcare system and create accountability at a local level. We may know through reports from media and organisations such as the Treatment Action Campaign (TAC) that certain healthcare facilities are severely dysfunctional. But we rarely get up-to-date statistics to back up such complaints. When figures are published by the health department, they are rarely in a form accessible to the general public.
Yet the department has access to incredibly useful statistics on the performance of healthcare facilities.
One important example is data on HIV viral load testing, which measures the amount of HIV in a person’s blood and is the best way for health workers to identify whether patients are responding well to treatment. According to HIV treatment guidelines, people living with HIV should get at least one viral load test a year.
Government should regularly publish data on whether everyone at a clinic has been given their viral load tests. It should also report what percentage of those people who have received the tests have so-called “undetectable” or very low viral loads — a marker that people are able to adhere to and access their antiretroviral medication daily.
These two pieces of information tell us an enormous amount about the quality of care at a healthcare facility. Such up-to-date viral load statistics must be made easily accessible to patients, clinic committees, hospital boards, local and district Aids councils and, in short, to anyone with a stake in ensuring a public health facility functions as it should.
Secondly, rather than trying to manage HIV and TB efforts on their own, national and provincial health departments must do much more to bring other government departments, labour and business on board. The new NSP must provide practical guidance on how to do this. For example, if we are to launch a new mass HIV counselling and testing campaign, as we should, then employers and unions must play a part in providing testing services to their members and employees.
Thirdly, the new NSP must break the ongoing impasse between the departments of health and basic education, as well as school governing bodies to make comprehensive sex education and condoms available to learners in schools. We have a moral duty to provide our young people with the tools they need to prevent unwanted pregnancies and HIV infection. We can’t keep tip-toeing around people’s moral qualms while young people continue to be infected with HIV at alarming rates. The initial draft of the next NSP was disappointingly weak on the critical question of providing condoms in schools.
Lastly, the plan must set out a realistic road map of how to reach its HIV and TB targets. If reaching those goals means employing many more people — and it does — then we should put together a strong case in the NSP for treasury to provide the funding for this.
We need to know whether we have enough health workers to support a rapidly growing antiretroviral treatment programme. If we don’t, then we need a plan to train them. Similarly, to step up our TB response we need community healthcare workers to go out into our communities to find people with TB rather than waiting for them to come to the clinic. We need to know that provinces are budgeting for all this and not simply burying their heads in the sand.
Although the initial draft of the NSP did contain encouraging language about active TB case-finding, it should go further and make the case for why it is a worthwhile investment that must be made urgently. In this, as in other key areas, we need not only a set of targets, but a clear road map for how to reach those targets.
With the United Nations reporting over 250 000 new HIV infections in South Africa every year, around seven million people living with HIV, and tens of thousands of people dying of TB every year, South Africa continues to face a medical emergency. We have no choice. We simply have to get this plan right.
Marcus Low is the editor of Spotlight magazine, which focuses on monitoring HIV and TB in South Africa. He is also the former head of policy at the Treatment Action Campaign.