According to statistics by South Africa’s Department of Health, an estimated 5.4 million South Africans were living with HIV in 2006. Since its discovery more than twenty years ago, it has become increasingly clear that HIV/AIDS is one of the most serious and important challenges that the world, and particularly those in the developing world, have ever had to face.
The epidemic has disproportionately affected those in poor and underdeveloped regions which has led recent research to repeatedly emphasise the role of underdevelopment and poverty in not only increasing vulnerability to infection but also decreasing the ability of people to develop effective coping strategies to deal with HIV infection.
In South Africa an important factor contributing to the spread of the epidemic has been the inability of policy makers to adequately take into account these factors of underdevelopment and inequality in increasing vulnerability. Like most governments across the world, the message from the South African government has largely been focussed around the ABC (Abstain, Be faithful, Condomise) approach, a narrow view that focuses mainly on preventing infection by emphasising the importance of individual responsibility in remaining safe from infection while also concentrating on the provision of treatment to HIV positive people.
What the state has to realise, however, is that through its day to day work it is often directly responsible for either increasing or decreasing vulnerability to HIV infection. For example, if the state is not able to adequately deliver services like water and sanitation, electricity and housing, it is failing in its role to provide the necessary resources that will enable people to make “safe sexual choices.” Thus, government’s ABC message will have little impact until it recognises the external factors that affect people’s ability to negotiate safer sexual practices. In addition, the lack of access to the above resources also negatively affects the ability of HIV infected and affected individuals and households to deal with the effects of the disease.
In terms of a national response from the South African government, there has been increasing recognition of the fact that HIV/AIDS is driven by an underdeveloped and unequal society that has failed to deliver on development goals which include access to health, basic services, education, poverty eradication and gender inequality. This move is somewhat illustrated by the Department of Health’s HIV/AIDS and STI Strategic Plan for South Africa, 2007-2011. The plan emphasises that “the fundamental drivers of this epidemic in South Africa are the more deep rooted institutional problems of poverty, underdevelopment and the low status of women, including gender based violence, in society.”
While this plan from the National Department of Health is an extremely crucial step in recognising the importance of the factors that drive the epidemic, the document does not go much further in explaining how it will attempt to address these issues. For example, the document notes that one of its goals is to “reduce vulnerability to HIV infection and the impacts of AIDS” but there is no interrogation of and discussion regarding the factors like unemployment, gender inequality and underdevelopment. It also does not state how the Department of Health will work together with other national departments to develop a multi-sectoral, integrated approach to development that will address these issues.
A further significant step towards a broader conceptualisation of HIV/AIDS interventions has been the response from the Department of Provincial and Local Government (DPLG) in recognising the important role of local governments in responding to the factors that drive the epidemic. As the site of service delivery in South Africa, local governments in particular have an important role to play in addressing the developmental backlogs that increase vulnerability amongst the poor and those living on the margins of society. This is because local government is directly responsible for the provision of services like water, sanitation and electricity as well as ensuring access to health care and adequate and sustainable human settlements.
The official response from the DPLG has been the development of its Framework for an Integrated Local Government response to HIV and AIDS. This document was launched in Bloemfontein on 11 April 2007 by the Deputy Minister for Local Government and Housing, Nomatyala Hangana, and is an attempt by the DPLG to promote HIV/AIDS as a broader issue of development and governance with a role to be played by all spheres of government at a national, provincial and local level. According to Deputy Minister Hangana “the Framework is not about prioritising HIV and AIDS in the context of other competing development demands, but it is more about HIV and AIDS being dealt with as a developmental planning issue through the IDP which is the main platform for delivering services … at local level.”
The Framework, which is to be rolled out nationally over a period of four years, recognises the importance of providing the necessary support to municipalities to mainstream HIV/AIDS by making it part of their day to day work. The introduction of this framework is a very commendable move on the part of the DPLG and will go a long way towards shifting the mindset the state in regard to developing a holistic response to HIV/AIDS. Most importantly it signals the acknowledgment from certain spheres of government that HIV/AIDS is not only a health issue and that an effective response should involve all spheres of government. However, like the Department of Health’s National Plan, the Framework has a number of shortcomings.
Firstly, in recognising the role to be played by all spheres of government, national, provincial and local, the document attempts to do too many things at once. For example, it appears to address too many audiences at once and as a result it is often not clear who its intended target audience is. This can lead to confusion as municipalities might battle to grasp their intended role. This is illustrated by the fact that the document at times appears to be providing guidance to DPLG and possibly provincial departments on how to assist municipalities and their mainstreaming efforts while at other times it appears to be guiding municipalities in their actual mainstreaming efforts.
Another shortcoming is that it does not adequately take into consideration the important role that gender plays in South African society. Given the patriarchal nature of South African society, relationships between men and women often tend to be influenced by particular prescribed roles that are exacerbated and more pronounced in impoverished and underdeveloped situations. For example, in impoverished situations many females are not always able to make “safe” choices about sexual behaviour. In addition, when families have to deal with the effects of HIV infection on the household some of the copy strategies for dealing with a possible loss of income in many instances involves young girls being removed from school in order to save money and also for them to take on more responsibility in terms of caring for the sick. Situations like these contribute to the already unequal relationship between men and women and serve to entrench these gender disparities. Thus, it is crucial that the Framework addresses this issue as women are not only biologically more vulnerable to HIV infection but also have to deal with the impacts of poverty, unemployment and gender inequality which makes them the most vulnerable to the epidemic and its far reaching effects.
A crucial concern relates to the fact that it is not clear how the DPLG intends to provide the resources and capacity for the roll out of the plan. While the Framework refers to possible partnerships with civil society organisations that do work on local government, if this Framework is to be successfully implemented and if it is to be of use to its target audience, it is essential that the roll out is adequately budgeted for. In addition, a successful roll out is dependent on the DPLG developing a plan, listing key targets, activities to reach those targets and details of a monitoring and evaluation strategy in order to measure the impact of the Framework on the plans of national, provincial and local governments to address HIV/AIDS.
Despite the limitations in both the DPLG Framework and the Department of Health’s National Strategic Plan these documents represent an important step by government to move beyond the narrow traditional conceptualisation of HIV/AIDS. It is absolutely crucial that initiatives such as these receive the necessary backing and support from senior policy makers. The DPLG Framework in particular is very important as it recognises the need to move beyond only implementing a health approach to what is clearly an epidemic that is disproportionately affecting the those who are poor and live on the margins of society. However, the DPLG should recognise that this should be regarded as only a first step and that it will take a large amount of resources, skills and time to make sure that all 283 municipalities in South Africa clearly understand what is meant by mainstreaming of HIV/AIDS and what implications mainstreaming has for them.
In addition, not only is the epidemic in South Africa not homogenous but all these municipalities are unique and therefore there is not one clear strategy that can be implemented in all situations. It is therefore important that the DPLG itself carry out its day to day work by taking HIV/AIDS into consideration, that it makes sure that provincial departments of housing and local government are adequately equipped to provide the necessary guidance and that municipalities, (metros, districts and local) clearly understand what is needed of them in order to develop an effective response to HIV/AIDS.
- Stacey Leigh Joseph is a policy researcher at the Isandla Insitute.