NSP 2012 - 2016

SUBMISSION ON OVERALL STRUCTURE OF DRAFT ZERO:

WHAT IS A STRATEGIC PLAN?

The draft National Strategic Plan (NSP) for HIV & AIDS, STIs and TB, 2012-2016 (Draft Zero for Consultation ("Draft Zero")) - published for public comment on 15 August 2011 - represents a significant advance in South Africa's response to the epidemics.  It marks closure on our history of conflict, recognising the importance of evidence-based underpinnings, the value of meaningful consultation and the centrality of constitutional values and human rights.  Importantly, it starts to give expression to recent government commitments regarding HIV/TB integration.[1]

In addition, Draft Zero takes as its starting point that the new NSP should learn from its predecessor (the NSP 2007-2011): where it succeeded; where it fell short. In chapter 3, which considers monitoring, research and surveillance, Draft Zero notes as follows:

The 2007-2011 NSP had an unwieldy number of indicators that were undifferentiated between those that relate to outcome from those related to process.  The NSP targets were not clearly defined and monitoring and evaluation systems were not well coordinated.  Throughout the system, monitoring [and] evaluation (M&E) and analysis capacity is lacking, reducing the reliability of date used for budget and planning processes.

Linked to this, the introduction to Draft Zero speaks about agreement "on a range of principles that should guide the development and finalisation of the NSP as well as the provincial strategic implementation plans and the implementation plans of all [South African National AIDS Council (SANAC)] sectors."  Amongst others, it states that the NSP will be based on the principles of simplicity, high impact and scalability:

Simplicity: "the content must be kept simple and easy for people to engage".

High impact and scalability: "in line with international trends, preference should be given in planning to a small number of high value, high impact and scalable initiatives rather than a ‘shopping list' of smaller diffused initiatives."

Purpose of this submission and key recommendations

Unfortunately, Draft Zero does not deliver on what it promises.  It is lengthy and, at times, difficult to read.  In large part, it appears as little more than an updated version of the current NSP, albeit with new pillars and a handful of innovations.  Instead of the "small number of high value, high impact and scalable initiatives" that it promises, it provides a "shopping list"; the plan includes more than 40 objectives and almost a hundred interventions.  This is not what SANAC contemplated.

This submission is one of three that SECTION27 is making on Draft Zero.  In contrast to the other two, which focus on specific substantive issues,[2] this submission considers the overall structure of Draft Zero instead.  This is because, in the main, we do not dispute the broad thrust of the objectives and interventions proposed.  Instead, we are committed to ensuring that the consultation process gives rise to a well-structured and focused strategic plan that is indeed capable of implementation.   

In summary, this submission states as follows:

On what is an NSP

The NSP must resist the temptation to be everything to everyone; it cannot - and should not - become the focal point for dealing with all social ills that undermine the response to HIV & AIDS, TB and STIs.

With a clear focus on overarching principles, objectives and interventions, the NSP should be structured in two ways: first, it should provide a strategic framework in terms of which detailed operational plans are developed; and second, it should set out the basis upon which it will be assessed and stakeholders held to account.

On dealing with science

The NSP must capture the science accurately if it is to provide the framework for an evidence-based response.

The rapid pace of scientific developments in the field of HIV makes it plain that the framework, as well as the various implementation plans that are developed, need to be sufficiently flexible to enable amendments as and when necessary.

On prioritising objectives and interventions

Many of the interventions identified in Draft Zero fall outside of an NSP's appropriate mandate.  In our view, it is not for SANAC to co-ordinate these interventions that are central to the mandates of various government departments.

The evidence should be scrutinised to identify well-defined objectives and "high value, high impact and scalable" interventions; public and expert consultations should focus on identifying the priority objectives and interventions that will be the basis of SANAC's focus for the next five years.

On dealing with the law and human rights considerations

In respect of its chosen interventions, the NSP should identify law reform processes that will need to be completed if the interventions are to be successful, as well as any human rights concerns relating to their implementation. 

In addition, pillar 3 should provide a separate focus on what's needed to protect, promote and fulfil human rights.

On reporting, responsibility and accountability

Government departments, other organs of state and other non-state implementers need to be identified in respect of each proposed intervention; they also need to be tasked expressly with developing and implementing plans - within defined timelines and in terms of broadly consultative processes - to give effect to their NSP mandates.

The new NSP needs to consider how and to whom SANAC and its secretariat should both report and account. 

The proposed principles for a new governance structure need to be clarified, tightened and developed into a coherent set.  As currently proposed, they do not reflect any consistency of vision or approach.

What is an NSP?

The Merriam-Webster Dictionary defines a plan as "a method worked out in advance for achieving some objective". The Oxford Compact English Dictionary defines the adjective strategic as "relating to the identification of long-term or overall aims and interests and the means of achieving them".  Put together, a strategic plan is -

• A method worked out in advance;
• For achieving certain overall aims;
•  That identifies the means of achieving these aims.

Understood in the context of a national response to HIV & AIDS, STIs and TB, as informed by the analysis of the strengths and weaknesses of the NSP 2007-2011, this means that an NSP should -

• First, develop a vision: works out the broad aims;
• Second, prioritise: identify the key - but not all - means of achieving these aims;
• Third, deal with processes: develop a framework in terms of which these aims will be implemented, monitored and evaluated; and
• Fourth, address accountability: set out - in broad terms - how stakeholders will be held to account.

By definition, an NSP must be focused; it cannot be the sum of all parts of the country's response.  In addition to providing the basic framework in terms of which all stakeholders - government at all three spheres, business, labour and civil society - are to develop their detailed operational plans, an NSP must also provide the basis upon which it will be assessed and stakeholders held to account.  Importantly, it must provide some degree of co-ordination in relation to identified priorities; it should not seek to replace stakeholders' plans and programmes.

With this in mind, an NSP on HIV & AIDS, STIs and TB must resist the temptation to be everything to everyone; it cannot - and should not - become the focal point for dealing with all social ills that undermine the response to HIV and its related epidemics.[3]  In particular, it needs to be drafted in a manner that recognises the roles and responsibilities of organs of state such as the National Planning Commission (NPC),[4] as well as a wide range of line-function departments with primary responsibility over a number of HIV-relevant - but not necessarily HIV-specific - interventions.[5]

The fact that an NSP does not expressly address all HIV-relevant issues does not mean that these issues are unimportant; it is simply to state that it is neither feasible nor appropriate to include every possible intervention under the rubric of an overarching national framework for HIV.  That said, there are numerous important policies, programmes and structures - including many that are already in existence - that should be developed and implemented by relevant government departments.  Amongst others, this include the following:

Health: primary health care revitalisation; national health insurance; enforcement of quality control though an Office of Health Standards Compliance; and a human resources for health strategy;

Social Development: prevention and treatment of substance abuse; regulation of alcohol use and advertising; and social assistance; and

Police, Justice & Constitutional Development and Correctional Services: prevention of sexual violence and the successful prosecution and incarceration of offenders; and an efficient and effective criminal justice system that protects the vulnerable.

So how then should the NSP deal with such issues, if at all?

Consider the example of gender-based violence (GBV), in particular rape.  In our view, the NSP could focus attention on providing a range of key stakeholders - police officers, correctional services members, prosecutors, health care workers, their respective departments - with a strategic framework that provides the basis for ensuring access to post-exposure prophylaxis (PEP) services.  For this to happen the identified stakeholders would also have to work on a broader range of interventions necessary to ensure access; but for the purposes of the NSP, the focus would be much narrower with clearly defined indicators.

With this in mind, we submit that the NSP should be comprised of two key parts: a first part dealing with a strategic framework for developing detailed operational plans; and a second part dealing with the basis upon which the NSP will be assessed and stakeholders be held to account.  In support of both parts, background material - in the form of annexures - could simply be added to the main document.  Unlike 2007, the political context within which the NSP is being developed no longer requires that a public case be made in support of an evidence-based response.

The main aim of doing this would be to keep the policy document as short as is reasonably possible, with a clear focus on the overarching principles, objectives and interventions.  We therefore propose that Draft Zero be restructured along the following lines:  

Strategic framework for developing detailed operational plans

• Identify the four key pillars;
• In respect of each of these pillars, identify no more than three to four objectives;
• In respect of each of the ± 15 objectives, identify no more than three (and in exceptional circumstances four) interventions; and
• In respect of each of the ± 50 interventions, identify the following:
  • Lead organ(s) of state and non-state implementer(s);
  • Broad parameters guiding substantive intervention;
  • Processes (such as law reform and budgeting) that will need to be completed if the intervention is to be successful, as well as timelines for their completion; and
  • Human rights concerns, if any, relating to the implementation of the intervention.[6]

Basis upon which the NSP will be assessed and stakeholders held to account

SANAC must be tasked with overall responsibility for developing and implementing a monitoring and evaluation (M&E) framework within a specified time

The NSP should specify that the M&E framework should, at a bare minimum, deal with the following procedural and substantive issues:

§  Processes and timelines in terms of which the following bodies will be required to submit requested information to SANAC:

• National organs of state;
• Other AIDS councils; and
• Departments of health at provincial and local spheres of government;
  • Identification of only one key indicator (for M&E purposes) in respect of each of the following:
    • The four key pillars;
    • The ± 15 objectives; and
    • The ± 50 interventions; and
  • The NSP should specify the process and timelines in terms of which the structure and legal status of SANAC will be finalised, including resolution of the following issues:
    • To whom and in what manner and form SANAC reports; and
    • To whom and in what manner and form SANAC accounts.[7]

Supporting documentation to be annexed to the NSP

Chapters 3, 4, 5 and 6 - all of which essentially provide background information - should be edited substantially and annexed to the NSP as background material; and

A bibliography of publications cited and on the basis of which decisions were taken should also be annexed.

Dealing with science

The NSP correctly recognises that interventions must be evidence-based; if this is to happen, the NSP - where it describes the science - must do so accurately.  In reality, however, Draft Zero does not accurately capture the current state of HIV science.  For example, it relies on a relatively old slide - at page 40 - dealing with "combination HIV prevention".  This slide was put together before the most recent developments in 2011: HPTN 052 on treatment as prevention;[8] Partners PrEP and CDC TDF2 on pre-exposure prophylaxis (PrEP) for heterosexuals (especially women);[9] and the late-breaker presented at the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention entitled "Effect of the Orange Farm (South Africa) male circumcision roll-out (ANRS-12126) on the spread of HIV".[10]

In addition, the evidence seemingly relied upon for the treatment of STIs as an HIV prevention intervention - Grosskurth et al, "Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials"[11] - is over a decade old.  The relationship between STIs and HIV infection appears to be particularly complex.[12]  This is what the summary of a Cochrane review of population-based interventions for reducing HIV infection says:[13]

Community- or population-based sexually transmitted infection control does not appear to be an effective HIV prevention strategy in most settings.  In the early 1990s, improved STI treatment services were shown to reduce HIV incidence in northern Tanzania, in an environment characterised by an emerging HIV epidemic, where STI treatment services were poor and where STIs were highly prevalent.  Subsequent trials, however, failed to confirm these findings and also failed to show a substantial benefit for community-wide presumptive treatment for STIs.  This is likely due to the endemic nature of HIV and relatively low incidence of STIs in these populations.[14]

It is not our role to advise on science.  Instead, we make the point that the next draft must capture the science accurately if it to provide the framework for an evidence-based response.  In addition, the rapid pace of scientific developments in the field of HIV makes it plain that the framework, as well as the various implementation plans that are developed, need to be sufficiently flexible to enable amendments as and when necessary.  Science is a moving target; the country's response must ensure that it may indeed be aligned - and readjusted - with this in mind.   

Prioritising objectives and interventions: what's in and what's out?

With so many objectives and interventions, it is clear that Draft Zero has not managed to prioritise interventions.  But not only are too many interventions included, many of them are also overly broad.  For example -

Pillar 2 speaks about an intervention to "[i]mplement integrated wellness education as part of life skills education in schools";

Pillar 3 speaks about "[i]mplement[ing] measures to reduce access to alcohol, especially children, such as strict penalties for selling to children, amending hours of purchase, and higher taxes on alcohol"; and

Pillar 4 speaks about "[i]nstitut[ing] community-based programmes targeting parents and other adults focusing on reducing hazardous drinking and sexual violence".

In addition, many of the proposed interventions are also vague ("Implement programmes targeting male masculinity to change sexual behaviour of boys and men"), which by definition means they are unfocused.

Of greatest concern, however, it that many of these interventions also fall outside of an NSP's appropriate mandate.  For example, dealing appropriately with alcohol abuse is not primarily an HIV intervention; it is central to the mandate of the Department of Social Development and should be pursued regardless of its nexus with HIV.  As already stated, we are of the view that it is not for SANAC to co-ordinate a wide range of interventions that are central to the mandates of various government departments.

We do not believe that it is appropriate - in this submission - to make recommendations on what should be in and what should be out.  Instead, we have provided a basis for a smaller number of objectives (± 15) and interventions (± 50).  With these numerical limits in place, we recommend that the evidence be scrutinised to identify well-defined objectives and "high value, high impact and scalable" interventions.  Public and expert consultations should focus on identifying the priority objectives and interventions that will be the basis of SANAC's focus for the next five years.[15]

Dealing with the law and human rights considerations

In dealing with a strategic framework for developing detailed operational plans, this submission - in respect of the interventions identified in the NSP - has recommended the following measures for addressing the law and human rights in the NSP:

First, the NSP should identify law reform processes that will need to be completed if the interventions are to be successful, as well as timelines for their completion; and

Second, the NSP should identify human rights concerns, if any, relating to the implementation of the interventions.  As already mentioned, this will not be necessary in respect of pillar 3, which - by definition - already deals with human rights.

The first measure - a legislative audit - is aimed at identifying legal barriers (both problematic laws and gaps in the law) that could undermine the interventions in question.  In our view, the NSP should not identify these barriers itself, but rather set out a process for conducting the legislative audit; this would include the identification of responsible government departments, timelines for the audit to be conducted and timelines for the law reform process - if necessary - to be conducted.  The aim should be to ensure that the programme of law reform is tabled in Parliament within a reasonable time period.

The second measure - the identification of human rights concerns - is aimed at ensuring that substantive interventions are implemented in a manner that respects human rights.  Put differently, the aim is to ensure that human rights are not violated when interventions are implemented.  This is alleged to have happened, for example, with the HIV counselling and testing campaign; coercive means were alleged to have been used effectively to compel people to test.  In our view, the NSP should indeed identify these concerns; interventions should thereafter be designed and implemented mindful of the identified concerns.

In addition, we support a separate focus - in pillar 3 - on what's needed to protect, promote and fulfil human rights.  In particular, this means considering how the human, financial and institutional resources of existing constitutional and statutory structures - such as the South African Human Rights Commission, the Public Protector and Legal Aid South Africa - should be harnessed to advance the NSP's human rights agenda.  It also means ensuring that the NSP expressly deals with the monitoring of HIV-related human rights abuses and ensuring the accessibility of appropriate mechanisms for redress in the event that rights are indeed violated.     

Reporting, responsibility and accountability

While Draft Zero does include some tentative proposals on governance, management and organisational effectiveness, it does not deal appropriately with the assignment of responsibilities, reporting requirements and accountability measures.  Many lessons have been learnt on these issues over the past five years; these need to be considered and addressed.  Not only do government departments, other organs of state and other non-state implementers need to be identified in respect of each proposed intervention, but they need to be tasked expressly with developing and implementing plans - within defined timelines and in terms of broadly consultative processes - to give effect to their NSP mandates.

As already indicated, the new NSP needs to consider how and to whom SANAC and its secretariat should both report and account.  Draft Zero seems to suggest an ongoing role for the SANAC Trust, rather than the more interim role that it is currently playing.  Further, Draft Zero does not deal with the new joint committee on HIV and AIDS that is being established in Parliament.  Finally, the proposed principles for a new governance structure - as set out on page 85 - need to be clarified, tightened and developed into a coherent set.  As currently proposed, they do not reflect any consistency of vision or approach.

Issued by SECTION27, September 7 2011

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[1] This is crucial given very high co-infection rates and data confirming TB as the leading cause of death amongst people with HIV.

[2] The first of these two additional submissions will provide more detail on how the NSP should deal with the law and human rights; the second will address costing and budgeting and the legal and policy framework within which these are to be done.

[3] See, for example, Bernhard Schwartländer et al, "Towards an improved investment approach for an effective response to HIV/AIDS", (2011) 377: 9782 The Lancet 2031

[4] The NPC is responsible for developing a long-term vision and strategic plan for South Africa.

[5] Amongst many others, these interventions include the regulation of alcohol use, the determinants of health (such as access to housing and basic education) and the proper functioning of the criminal justice system and the way in which it responds to the needs of survivors of gender-based violence.

[6] This will not be necessary in respect of pillar 3; by definition, it already deals with human rights.

[7] Reporting and accounting are dealt with in greater detail below.

[8] Myron S. Cohen et al, "Prevention of HIV-1 Infection with Early Antiretroviral Therapy", (2011) 365 N Engl J Med 493

[9] See Tim Horn, "PrEP Cuts Sexual HIV Transmissions 62% to 78% in Men and Women", available at http://www.aidsmeds.com/articles/hiv_prep_truvada_2636_20846.shtml

[10] See http://pag.ias2011.org/Abstracts.aspx?SID=43&AID=4792

[11] (2000) 355: 9219 The Lancet 1981, available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02336-9/abstract

[12] See http://www.cdc.gov/std/hiv/STDFact-STD-HIV.htm

[13] Ng BE et al, "Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection", Cochrane Database of Systematic Reviews 2011, Issue 3, available at http://www2.cochrane.org/reviews/en/ab001220.html

[14] That said, the summary also provides as follows:

There are, however, other good reasons as to why STI treatment services should be strengthened and the available evidence suggests that when an intervention is applied and accepted in a community, it can improve the quality of services provided.

[15] Line-function government departments at all three spheres of government should be entitled to supplement these interventions, provided that this will support the achievement of NSP objectives.