South African Cities and the

Challenges of HIV/AIDS:

Lessons & Opportunities

Workshop Report

26-28 October 2003

Imperial Hotel

Pietermaritzburg

South Africa

Directors: Andrew Boraine (Chairperson); Mzimasi Mangcotywa; Mojalefa Matlole; David Morema (Vice Chairperson); Monty Narsoo (Executive Director); Bheki Nene; Thomas Phakathi; Michael Sutcliffe; Mxolisi Tsika

SOUTH AFRICAN CITIES NETWORK COMPANY Reg. No. 2002/031754/08


Table of Contents

Acknowledgements...... 3

Acronyms...... 4

Executive Summary...... 5

Introduction...... 6

Purpose of the Workshop...... 7

Key Research Findings...... 8

Main Discussion...... 11

Way Forward...... 12

Appendix I – Workshop Programme...... 14

Appendix II – Participant List...... 16

Appendix III – Distributed Papers...... 21

Acknowledgements

The South African Cities Network (SACN) wishes to acknowledge the contributions and commitment of its member municipalities in assisting the completion of this unique and groundbreaking research into the city responses to the HIV/AIDS scourge. The SACN appreciates the ongoing support of the Minister for Provincial and Local Government, and the South African Local Government Association (SALGA).

This workshop was conducted with the generous support of Cities Alliance, the United States Agency for International Development (USAID), World Bank and our current member cities:

  1. Buffalo City (East London)
  2. City of Cape Town
  3. Ekurhuleni Metropolitan Municipality (East Rand)
  4. City of eThekwini (Durban)
  5. City of Johannesburg
  6. Mangaung Municipality (Bloemfontein)
  7. Msunduzi Municipality (Pietermaritzburg)
  8. Nelson Mandela Metropolitan Municipality (Port Elizabeth)
  9. City of Tshwane (Pretoria)

SACN would also like to thank the Department of Public Service and Administration, the South African Business Council on HIV/AIDS, and the Msunduzi Municipality for their support and participation in this event.

Acronyms

AIDSAcquired Immune Deficiency Syndrome

ATICCAIDS Training Information and Counselling Centre

CBOsCommunity Based Organisations

CINDIChildren In Distress Network

DPLGDepartment of Provincial and Local Government

HIVHuman Immunodeficiency Virus

IDPIntegrated Development Programme

MLMMangaung Local Municipality

PEPPost Exposure Prophylaxis

SACNSouth African Cities Network

SABCOHA South African Business Council On HIV/AIDS

SALGASouth African Local Government Association

VCTVoluntary Counselling and Testing

Executive Summary

From 26-28 October 2003 the South African Cities Network in collaboration with Msunduzi Municipality hosted a workshop aimed at information sharing based upon researched commissioned by SACN on HIV/AIDS mitigation strategies in South African cities.

The workshop was the culmination of a six-week process during which primary filed research was performed to ascertain the current HIV/AIDS plans and implementation strategies of South Africa’s largest urban centres. Out of this intensive research a unique pattern emerged highlighting the remarkable measures being taken by new municipal structures with varying levels of resources, capacity and productive working relationships with other spheres of government.

The member municipalities of the South African Cities Network are in many ways at the forefront of dynamic programming that is ravaging the region at an alarming rate and threatens to retard the regions future economic and social development.

The workshop was a forum to present the research findings as well as obtain feedback from participants in each municipality on the research process. The workshop also served as an opportunity to have representatives from different sectors of each municipality highlight and prioritise their needs. Each municipality was invited to send a delegation consisting of four primary stakeholders. They are as follows:

  • Municipal HIV/AIDS Practitioners
  • Councillors who serve as political champions for HIV/AIDS issues with the municipality
  • Civil Society Organisations (CSOs)
  • Business sector

Additional information, including the presentationsfrom the plenary sessions can be found at

South African Cities and the Challenges of HIV/AIDS: Lessons & Opportunities

I. Introduction

South Africa has one of the fastest growing HIV/AIDS epidemics in the world. According to the 2002 National HIV and Syphilis Antenatal Sero-Prevalence Survey by the South African National Department of Health, at the end of 2000, between 4.7 and 6 million adults and children in South Africa were living with HIV/AIDS. It is estimated that new infections (currently about 1700 every day) are likely to increase the HIV/AIDS prevalence to 7.5 million (about 25% of the adult population) by 2010. AIDS-related deaths – which are currently estimated at 400 000 annually - could increase to between five and seven million by 2010. What will the impact be on South Africa’s urban centres?

Recent data from Statistics South Africa (Stats SA), demonstrates the role of cities in sustaining the national economy. Stats SA has calculated that 80% of the nation’s Gross Domestic Product is created in South Africa’s cities and towns. Increasing rates of urbanisation in South Africa’s economic hubs are creating further demand for municipal services, formal housing, and social services. In this context South African cities must also address high rates of unemployment, the expansion of informal communities and the deterioration of social networks all of which contribute to an increase in the vulnerability to HIV/AIDS. In a nation grappling with a history of social and legal inequalities, the HIV/AIDS epidemic further challenges the efforts to transform local government and service delivery for all citizens. How are South African cities coping with this growing epidemic? How can South African cities actively mitigate the impact of HIV/AIDS? These questions are central to research presented by the South African Cities Network (SACN) in Pietermaritzburg 26th-28th October 2003.

The SACN is an initiative of the Minister for Provincial and Local Government and nine city municipalities, in partnership with the South African Local Government Association (SALGA). The current members of the SACN are:

  1. Buffalo City (East London)
  2. City of Cape Town
  3. Ekurhuleni Metropolitan Municipality (East Rand)
  4. City of eThekwini (Durban)
  5. City of Johannesburg
  6. Mangaung Municipality (Bloemfontein)
  7. Msunduzi Municipality (Pietermaritzburg)
  8. Nelson Mandela Metropolitan Municipality (Port Elizabeth)
  9. City of Tshwane (Pretoria)

The mission of this recently established network of South African cities and partners is to encourage the exchange of information, experience and best practices on urban development and city management. Through an analysis of the strategic challenges facing South African cities, particularly in the context of global economic integration and national development the SACN aims to promote good governance and management of South African cities.

As HIV/AIDS is arguably the most important challenge currently facing the South African cities, the SACN, on behalf of its members commissioned research to survey current interventions aimed at preventing HIV/AIDS and mitigating its impact. The purpose of research was also to frame the selection of best practices within the realities of the South African legislative and policy environment pertaining to local government and HIV/AIDS. Site visits were conducted to each of the nine SACN member cities and an inventory of current municipal practice was done with a focus on existing capacity and current implementation practices that can inform development of best practices. The visits were focused on interviews with key informants from each municipality including municipal HIV/AIDS practitioners and partners from different sectors of civil society. The research aimed to explain the fundamental principles and components of best practices and critically assess the feasibility, effectiveness and efficiency of these models in the light of internal and external environmental realities confronting South African municipalities. Finally the research also identified tools and instruments that are available to facilitate and support municipalities in taking action against HIV/AIDS. This includes a set of core indicators against which municipal-led actions aimed at the prevention of HIV/AIDS and mitigation of its impact on municipalities and their constituencies can be monitored and evaluated. This research was done with a mind to move beyond the quest for data and take stock of existing resources and leadership that can be mobilized to help prevent HIV/AIDS and mitigate its impact on municipalities as such, as well as on their constituencies.

II.Purpose of the Workshop

Using the research findings as a platform, the SACN sought to bring together representatives from four sectors from each municipality. Each city was invited to send a delegation consisting of the following:

  1. Municipal HIV/AIDS coordinator
  2. HIV/AIDS political champion from the municipal council
  3. Business Sector Representative with a working relationship with the municipality
  4. Member of the NGO community working on HIV/AIDS service delivery

The objectives of the workshop were to:

  • To define the roles of cities in addressing HIV/AIDS
  • To share information on current practice in South African cities in response to HIV/AIDS epidemic.
  • To identify lessons learned and best practices in South African cities that can form a basis for knowledge sharing and building the capacity of cities to meet the challenge.

Furthermore, the workshop also provided an opportunity to for the research to be validated by those interviewed and to create a dialogue between different sectors of the city around HIV/AIDS particularly in the cases where none formally existed.

The commissioned work was aimed to serve as a policy guide and as the foundation for an information exchange event that would:

  • Encourage SACN members to mainstream HIV/AIDS mitigation strategies by including them in their City Development Strategies;
  • Promote their understanding of effective and efficient ways of managing the impact of HIV/AIDS on municipalities and their constituencies;
  • Facilitate shared learning among network members to encourage the adoption of practical, proven and locally appropriate mitigation strategies.

In addition to the research findings, a case study of the HIV/AIDS programme in

Msunduzi was also presented to workshop participants. Presentations from SACN

partners, the South African Business Council on HIV/AIDS (SABCOHA) and SALGA

were also given.

III. Key Findings

The consequences of HIV/AIDS are already being felt in South African cities. The challenge for cities posed by the epidemic is to provide consistent service delivery as well as responding to the dynamic needs of all sectors of communities infected and affected by HIV/AIDS. The research revealed that across the nine member municipalities, South African metros have all taken decisive action to address the growing scourge. However the level and type of response differs across cities depending on the nature of the relationships between key stakeholders, namely the municipality, provincial government, the business sector and civil society organisations.

Nature of the problem

According to the 2002 Nelson Mandela Foundation/ Human Sciences Resource Council study of HIV/AIDS in South Africa, urban formal and informal localities represent up to 50% higher prevalence rates than non-urban areas. Despite the urgency of the problem, local government faces a number of barriers that have severely hindered its ability to address the epidemic. Barriers include an unclear mandate from national government on the role of local government in the implementation of the national HIV/AIDS strategy. Another significant obstacle is the restructuring process resulting from the re-demarcation of municipal boundaries begun in 2000. As municipalities are re-organised, posts critical to the administration of HIV/AIDS programmes remain unfilled. The responsibility of tackling HIV/AIDS is further complicated by a lack of funding for municipalities to pay for additional burdens created by loss of ratepayers and, increases in the number of vulnerable households. Within this context local government has struggled to operationalize a developmental agenda that includes formulating and implementing programmes that mitigate the effects of HIV/AIDS. Municipalities have the dual responsibility of addressing the impact of the HIV/AIDS epidemic both internally with its workforce and operations as well as externally in its service delivery. The research demonstrates that this task is under way in all nine metros but at vastly different levels.

Internal Responses

Within each municipality there is a need to engage in a critical strategic planning process that answers the question how will HIV/AIDS change the way municipal services are delivered? How will the municipality maintain a productive workforce? The research revealed that not all of the SACN member cities have full-scale internal HIV/AIDS programmes. While post-exposure prophylaxis (PEP) for occupational exposure was universally available through the occupational health unit, there was inconsistent delivery of HIV/AIDS education, voluntary counselling and testing (VCT), support groups, peer counsellors and care and treatment options available in the majority of municipalities surveyed. The focus has been primarily on condom distribution and health calendar events rather than a systematic approach that incorporates the full continuum of services, from prevention-- to care. In some cases, the internal or employee wellness programmes are situated in the human resources department an in other cases they are housed in the health department under occupational health. As not all municipal workers have access to medical aid there is a need to address lack of confidentiality, stigma and ongoing care for workers remain at issue in many instances.

External Responses

Beyond the needs of the municipal workforce, what are municipalities doing to meet the changing needs of its residents? What is the impact on service delivery? The research shows that South African cities are employing several different approaches to the HIV/ADS epidemic.

The first approach is building from existing resources from the previous government. Many of the cities have established AIDS Testing, Information, Counselling Centres (ATICC), which were formally under the direction of provincial government. In most cases where ATICCs are still functional they are managed and staffed at the municipal level but receive funding from the province and the municipality. This has resulted in confusion on two levels. Firstly because these units exist, there is the belief that the municipality is responded adequately although this may be the only dedicated programme. Yet a secondary point but equally important point is that although these ATICCs remain based in cities, they are bound by conditions of provincial funding to serve communities beyond the municipal boundaries. Furthermore the ATICCs offer their services to the public at no charge. This includes training to the private sector without cost, there by missing an opportunity for cost recovery from a client that has the capacity to pay.

The second approach has been to use the ward committees as a point of entry to work with HIV/AIDS service organisations and address community needs. Some municipalities such as Ekurhuleni and Msunduzi have used ward committees as a way to gather information about existing services, assess gaps in service delivery and work with CBOs to fill those gaps, thereby increasing access to services. In both of these cases elected Councillors also play a role in supporting the development and expansion of community services for infected and affected residents. This approach also serves to empower communities as they play an active role in ensuring that their needs are known and get some

A third approach has been to use research to inform the development of realistic and effective policies to mitigate the impact of HIV/AIDS. In Mangaung Local Municipality (MLM) for example, the local university produced a study that corrected the perception within MLM that only the poor would need consideration under the municipality’s indigent policy. Eligibility for free services such as water and electricity were initially based upon property values. However the research highlighted the fact that many families living in areas with higher property values were in fact without income because the breadwinner had died of HIV/AIDS. So although on paper, the family may have a valuable asset, e.g. the home, they no longer had a regular source of income and were without means to pay for services. This information helped the MLM to adjust its indigent policy to ensure access to services by all citizens. Not all attempts at gathering data have been so successful and at times this has actually delayed or effectively stopped municipalities from taking a proactive stance on HIV/AIDS.

Lastly some municipalities have developed community forums that bring together existing HIV/AIDS service organisations and work closely with them to build capacity at the grassroots level. Capacity building activities range from awarding grants to CBOs or supporting forums where CBOs can share information, thereby minimising duplication of services and leveraging valuable resources. In the City of Cape Town, the municipality has created forums multi-sectoral AIDS teams (MSATs) to build a network of service providers that are supported by the municipal clinics in service delivery, funding and even the identification and leasing of under-utilised municipal property. This approach is also in practice in Msunduzi Municipality, and the City of Johannesburg.