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HIV and tuberculosis (TB) remains at crisis levels in South Africa. Every year around 270 000 people are still newly infected with HIV. A recent Statistics South Africa report listed TB as the number one reported cause of death in South Africa. Drug-resistant TB is a serious and growing problem that our healthcare system is struggling to cope with. Meanwhile, reports from the Office of Health Standards Compliance (OHSC) and from Treatment Action Campaign (TAC) members on the ground paints a picture of a public healthcare system that is often severely dysfunctional and which impact negatively on implementation of HIV and TB programmes. The lack of infection control in many clinics and hospitals is an obvious example. In many cases the public healthcare system has fallen prey to the same corruption and cadre-deployment that has crippled much of the public service in South Africa.

It is with this context in mind that South Africa’s new National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 should have been developed. Unfortunately, there is no indication in the NSP that the realities on the ground has been taken into account. There is no awareness of the impact that widespread corruption and cadre deployment is having on the public sector. 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.

We recognise that the NSP does at a superficial level, on paper, say many of the right things. There is recognition of the need for a new HIV Counselling and Testing campaign, there is a commitment to providing HIV treatment for all who need it, there is acknowledgement that we need to utilise new TB treatments and diagnostics quickly and efficiently, there is an in-principle indication that we should do more contact tracing for TB. While this wish-list of ideas is welcome – it is of little real value without concrete and realistic plans as to its implementation. We do not want a list of new year’s resolutions – we want a real plan. The crisis in our healthcare system demands it, the people who depend on the public healthcare system have a right to it.

In our view the NSP fails in four broad areas:

Lack of accountability: One of the most fundamental problems in our public healthcare system is the lack of accountability. Policies made at national level are often simply not implemented in provinces. When the healthcare system is poorly managed or mismanaged at provincial or district level, there is often no consequences for those responsible. A critical flaw in the NSP is that it shifts all the responsibility for implementation of the NSP to provinces. This is to be supported in principle but the NSP provides very little guidance to provinces on how to develop implementation plans. It also does not set up any mechanisms by which provinces or districts can be held accountable for implementation. Without a radical and high-level political intervention, it seems very likely that we will see a continuation of the situation whereby the NSP simply gathers dust once it reaches provinces. The lack of accountability is also reflected in the poor choice of health indicators – as explained by our MSF colleagues in this Spotlight article.

No meaningful engagement with human resource shortage: Many of the interventions proposed in the NSP will require substantial increases in human resources. For example, introducing a positive intervention like widespread contact tracing for TB, would require large numbers of healthcare workers to do the contact tracing – as would providing HIV treatment to an additional two to three million people. It is a disgrace that over the last ten years we have made almost no progress on the employment of community healthcare workers in South Africa – an area in which this NSP also fails. A more serious NSP document would have connected the dots and spelt out the substantial human resource requirements of its various interventions. Had these details been spelt out we would be in a better position to plan how we will go about recruiting the right people and to make the case to treasury to fund such an HR expansion. Simply acknowledging that we will need increased HR capacity is not good enough. We have known that for years. An NSP requires actual planning. We don’t see any meaningful planning in this NSP relating to the most critical factor in our HIV and TB response, people.

No meaningful engagement with cost and funding: Similarly to the HR crisis, the NSP hardly at all engages with what the various interventions may cost and if we have the money secured. Some mention is made of the need to find sustainable sources of funding and to explore innovative new funding mechanisms – but again, this is also something we have known for years. In a serious planning document like the NSP we would have expected to see at least rough estimates of what certain interventions may cost and how they might be funded. As it stands, many of the positive interventions mentioned in the NSP might end up unfunded and thus unimplemented. It is deeply disappointing and a major flaw that the NSP did not engage more deeply with this reality.

The NSP is weak on a number of serious issues: While the NSP does contain some language on the decriminalisation of sex work and on the provision of condoms as part of a programme in schools, the language is relatively weak and fails to plot a concrete way forward. We cannot really take talk of reducing HIV infections in women and girls seriously while we fail to provide easy access to condoms to women and young girls. Ensuring the provision of both condoms and comprehensive sex education in schools should have been front and centre in this NSP. Similarly, having the decriminalisation of sex work on the table once again is welcome – but it is of little use without a clear plan for making decriminalisation a reality.

What is the way forward?

For the reasons stated above we cannot uncritically endorse the NSP in its current form. We will however reconsider this position if the following conditions are met:

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 outline by MSF (see link above).

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. f 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. Since the NSP is shifting responsibility to provinces, we cannot endorse without adequate provincial implementation plans – they are sides of the same coin.

In addition to the above, we are concerned about the quality of data being shared by the Department of Health. While the NSP does contain promising language on making better use of data, it is critical that the public has access to this data and can trust its accuracy. We therefore propose that an entity independent of the Department of Health and SANAC should be tasked to collate, verify, critically assess, and share data with the public.

Finally, we are deeply concerned by the ongoing governance crisis at SANAC. Serious questions about governance at SANAC remains unanswered despite various letters from TAC and meetings with key individuals. We are particularly concerned by the lax way in which SANAC has handled conflicts of interest and the process of appointing a new CEO. In addition, a lack of clear terms of reference has meant that there is hardly any linkage between national, provincial and district structures.

A lack of NGO audits has left unanswered whether all NGOs represented at SANAC are legitimate and whether they represent constituencies in the real world. Both the SANAC board and the Head of SANAC, the Deputy President of South Africa, have failed to treat these governance concerns with sufficient urgency and transparency. While the governance crisis remains unresolved, we fear the concerns raised in this statement will not be addressed and the implementation of this NSP will suffer.

Issued by SECTION27 and TAC