It's been a steep learning curve for provinces that sometimes don't have the know how - or the data - to write and track local plans.
Almost a year after South Africa tasked provinces with developing HIV and TB plans, only the Free State has a finalised strategy.
Every five years, South Africa develops a new national HIV and TB plan. The latest national strategic plan (NSP) lays out goals for reducing new infections and ensuring that those most at risk of contracting HIV and developing TB are able to get care.
This NSP, which was released in 2017 and will end in 2022, marks the first time that provincial governments and Aids councils have to formulate their own individual strategies, called provincial implementation plans (PIPs). The PIPs have to map out how South Africa's national plan will be implemented in the health districts of provinces.
The move is aimed at letting provinces tailor strategies for HIV and TB that are specific to each province's needs. But at the time of national plan's 2017 release, not everyone was behind it.
"A critical flaw in the national HIV and TB plan is that it shifts all the responsibility for its implementation to provinces," Treatment Action Campaign (TAC) national chairperson Anele Yawa told Bhekisisa in April 2017.
"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."
About eight months after provinces had to submit their plans to the South African National Aids Council (Sanac) in December, only the Free State has a completed PIP. Proposals for Gauteng, the North West and Western Cape are still in draft form and the Eastern Cape calls its PIP a "working" document.
Aids councils in the North West, Mpumalanga, Limpopo and Northern Cape did not respond to requests for comment.
South Africa's move to a more localised approach to fighting its twin epidemics has been a steep learning curve for districts, provinces and the national Aids council alike, Sanac's NSP Executive Manager Connie Kganakga says. Delays in finalising plans allowed provinces to learn crucial lessons ahead of the launch of the country's next NSP in 2023, but some activists fear a lack of finalised plans will make it difficult to track how well provinces - and the nation - are doing with regards to meeting national goals.
Kganakga says many initial PIPs were just copy and pasted versions of the national plan. In fact, some provincial documents contained what Kganakga calls "thumb-sucked" numbers that don't reflect what is happening at the district level.
South Africa has 52 health districts.
Kganakga explains: "We assumed that because the provinces were involved in the [drafting of the] NSP, that they understood that...alignment [to the NSP] does not mean that provinces must go and duplicate the national plan."
Sanac asked that each province consults with its districts before submitting second drafts of PIPs in May.
But the national Aids council has since learned that many districts simply don't have the kind of data provinces need to develop the best plans they can. This means provinces were forced to rely on international estimates when drafting their plans. It also translated into a scant baseline data against which progress can be measured.
"How do I achieve anything if we don't have baselines?" Kganakga asks.
Activists fear that the delays in finalising provincial HIV and TB plans could hinder those seeking to track whether provinces are effectively implementing strategies, especially in cases like the Eastern Cape where the PIP is open to revisions.
The Eastern Cape submitted its PIP before the December 2017 deadline. But after it was submitted, it made extensive revisions to the document, including changing targets for condom distribution, teenage pregnancy and alcohol abuse.
The head of the Eastern Cape Provincial Aids Secretariat Vuyisa Dayile argues the province's plan is being amended as needed during implementation.
The province's "working plan", however, has already run into trouble, Dayile admits. He says a local NGO, for instance, tested primary school students for HIV without their parents' consent. Reports by EWN in March alleged that the NGO revealed two students' statuses in front of classmates.
Persons younger than 18 years are considered minors in South Africa, but 2008 amendments to the Children's Act make special provisions for HIV testing, lowering the age of consent to 12 years. This is provided children demonstrate an understanding of the test's benefits, risks and social implications.
The health department will now meet with the school governing body, staff and parents to work out how to deal with the problem. The department will also talk to the school about access to contraception, including condoms.
More than a year into the national HIV/TB plan, the TAC's national organiser Amukelani Maluleke says Aids councils should be focused on tracking - not writing - their plans.
Maluleke maintains there was a lack of "widespread consultation", which is reflected in provincial plans.
"[I]f there was a flop at the national level, which need[s] to guide provinces, the PIPs themselves would have flops before implementation," he says.
The HIV lobby group has also criticised the national plan for ignoring the need to strengthen the health sector as a whole to allow it to better deliver HIV and TB services.
"People are not getting adequate services at a local level because of the infrastructural challenges that exist: The shortage of nurses, the lack of specialists... " he says.
"[Care and treatment] at a local level requires specialists to respond to issues of HIV and TB."
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