AIDS, leadership and service delivery in South Africa: What the people think - Halogen · 2012. 4....

AIDS, leadership and service delivery

in South Africa:

What the people think

IDASA’S GOVERNANCE AND AIDS PROGRAMME (GAP)

Written by Godknows Giya1

Technical editing by Kondwani Chirambo2

1 Godknows Giya is a senior economist working for Idasa’s Governance and AIDS Programme (GAP) as a researcher in the AIDS Budget Unit.

2 Kondwani Chirambo is Director of Idasa’s Governance and AIDS Programme (GAP)

Idasa-GAP would like to thank the Swedish International Development Agency (SIDA) for supporting this research project.

Published by Idasa, 357 Visagie Street, Pretoria 0002

© Idasa 2010

ISBN 978-1-920409-48-7

First published 2010

Copy-edited by Melanie ChambersCover by Joan Baker, WaterBerry Designs ccLayout by Joan Baker, WaterBerry Designs ccProduction by Idasa Publishing

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without prior permission from the publishers.

Bound and printed by MegaDigital, Cape Town

TABLE OF CONTENTS

1. Introduction ....................................................................................................................................5

1.1 Motivation of the study .....................................................................................................5

1.2 The AIDS epidemic in South Africa: the problem in perspective ..................................... 6

1.3 Context of study: objectives, methods and means .......................................................... 8

1.4 Research objectives .............................................................................................................. 8

1.5 Research questions ............................................................................................................... 9

2. Methodology .................................................................................................................................. 9

2.1 Sample design ........................................................................................................................ 9

3. Findings of the study ...................................................................................................................11

3.1 Election potential of HIV-positive candidates .................................................................11

3.2 Accessibility to good HIV and AIDS-related services ..................................................... 18

3.3 Availability of HIV and AIDS goods and services in wards ............................................. 26

4. Conclusion and policy recommendations ................................................................................. 35

5. References .................................................................................................................................... 38

AIDS, leadership and service delivery in South Africa: What the people think • 5

1. Introduction

1.1 Motivation of the study

This paper builds on the findings of the Governance and AIDS Programme’s (GAP) local government study

by Chirambo and Steyn (2009). In that study it was discovered that there is a fear of ostracism among

councillors that influences their attitudes towards disclosure, voluntary counselling and testing and

antiretroviral therapy, with implications for their effectiveness in service delivery. Apart from one female

councillor in the Free State, none of the respondents disclosed their HIV-positive results. The dominant

opinion suggests that HIV-positivity is an anathema within their communities and may result in councillors

losing their support bases or careers. Councillors were only happy to disclose that they had been tested

where the results proved to be negative. The study generally points to the need for local authorities and

political parties to address the stigma of HIV and AIDS. The impression created is that if members of a

political party disclose, it can generate negative public perceptions of their organisation and possibly reduce

it to ridicule in the eyes of its opponents. This may inhibit the fielding of HIV-positive candidates and further

marginalise people living with HIV from political and economic life (Chirambo and Steyn, 2009).

Promoting an enabling environment through active campaigning and monitoring to promote human rights

and reduce stigma and discrimination in South Africa is an integral objective of the 2007-2011 national

strategic programme (NSP). The NSP explicitly provides for the promotion and protection of human rights

and attempts to create benchmarks for compliance with human rights standards and the reduction of

stigma (Department of Health, 2007). However, the country has been slow to implement the monitoring

and evaluation system for HIV and AIDS. It is imperative to find out what progress has been made by society

to fight stigma, discrimination and exclusion. Although the political leaders indicated that they wouldn’t

disclose their status for fear of being voted out of office, getting the opinion of the citizens who form the

electorate will provide a balanced assessment of the situation.

An enabling environment is just one element in an array of HIV and AIDS-related programmes provided

to citizens. Other equally important HIV and AIDS interventions and activities include prevention, care

and treatment, support to orphans and vulnerable children and social protections and social services. The

efficient and effective delivery of HIV and AIDS services to society is one of the critical elements of a

successful HIV and AIDS implementation strategy. It is therefore important to engage citizens who directly

and indirectly benefit from such goods and services and solicit their opinion on the accessibility, availability

and quality of the HIV and AIDS interventions. The GAP realised that such an inclusive approach to the

assessment of the provision of HIV and AIDS interventions is a fusion of the concerns of the beneficiaries of

the interventions and the policy strategy of the providers.

Improving the system of provision of HIV and AIDS services can be enriched by assessing what the recipients

of the goods and services say. A more responsive system takes into account the beneficiaries’ evaluations of

the current system of provision of HIV and AIDS interventions. This approach places citizens at the centre

of the policy process by giving them an opportunity to give feedback on the goods and services.

6 • AIDS, leadership and service delivery in South Africa: What the people think

This paper is also motivated by the desire for a balanced involvement of consumers and suppliers

in the provision and consumption of HIV and AIDS goods and services, just like the supply chain of

purely private goods. The satisfactory provision of goods and services (public or private) is a consultative

process. Economists say that there is no ‘free lunch’, implying that every good or service consumed,

whether paid for or not by the consumer, has an intrinsic value. Thus, HIV and AIDS goods and services

provided to citizens through municipalities, though public in nature, should provide a certain level of

satisfaction that citizens as consumers derive and appraise. The provision of HIV and AIDS interventions

should be an interactive process between the supply side and demand side. Consumers should get an

opportunity to rate the amount of satisfaction derived from the HIV and AIDS goods and services provided

to them in the same way that they give feedback in the supply chain of bread. The feedback is critical in

order to expose the gaps, if any, in the production and consumption process, and come up with corrective

measures. Therefore, an evaluation of the progress made by the various HIV and AIDS interventions in the

respective municipalities is imperative in citizen oversight of HIV and AIDS programmes. This will provide

the municipalities and councillors, among other policy-makers, with important information about their

performance.

Overall, the GAP chose to solicit citizens’ opinions on the following HIV and AIDS-related issues:

1. Voting for an HIV-positive candidate;

2. Accessibility to good HIV and AIDS-related services; and

3. Availability of antiretrovirals, voluntary counseling and testing, home-based care support, counselling

services and free condom distribution.

Citizens’ opinions on the above issues were gathered in 2010 in Idasa’s Local Governance Barometer (LGB), a

tool aimed at measuring and assessing the state of local governance (see pg 8).

1.2 The AIDS epidemic in South Africa: the problem in perspective

Despite having the most advanced economy in Africa, with well-developed mining, manufacturing,

agricultural and financial sectors, South Africa is one of the countries most severely affected by the AIDS

epidemic (Karim et al, 2007). The Joint United Nations Programme on HIV and AIDS (UNAIDS) estimated

that in 2009, the total number of people living with HIV in South Africa was 5.7 million.3 In epidemiological

terms, South Africa is classified as a hyper-endemic country4 due to the high rate of HIV prevalence and

the modes and drivers of HIV transmission. Heterosexual sex is recognised as the predominant mode

of HIV transmission in the country, followed by mother-to-child transmission. Other key drivers

include migration, low perceptions of risk, and multiple concurrent sexual partnerships (Department of

Health, 2008).

3 ASSA2003 AIDS and Demographic model - the most recent version of the ASSA model to be released by the Actuarial Society of South Africa.

4 Hyper-endemic scenarios refer to those areas where HIV prevalence exceeds 15% in the adult population, driven through extensive heterosexual

multiple concurrent partner relations with low and inconsistent condom use (UNAIDS, 2008).


A significant amount of investment into HIV and AIDS interventions has been made in South Africa by both

state and non-state bodies to achieve the country’s goal of universal access to treatment, prevention,

care and support. The 2010 national budget allocated funds to expand access to antiretroviral treatment

to specific groups of patients, namely pregnant women and people with dual HIV and TB infection with

CD4 counts of 350 or less. In addition, plans have been put in place for all HIV-infected infants to start

treatment, irrespective of their CD4 count.

The government of South Africa has invested in HIV and AIDS revenue-sharing across various government

departments providing three-year projections of both unconditional equitable share grants5 and conditional

grants to provinces and municipalities. Traditionally, allocations for HIV and AIDS were channelled through

the departments of Health, Education and Social Development. However, to embrace the cross-cutting

nature of the epidemic, all the government departments have HIV and AIDS-related expenditures. Bilateral

and multilateral donors have complemented government efforts by supporting the NSP, notably the US

President’s Emergency Plan for AIDS Relief (Pepfar), and United Kingdom, European Union and United

Nations agencies. South Africa was also awarded funds from the Global Fund grant. The private sector has

also played a significant role in its response to the epidemic.

Budgetary allocations for social HIV and AIDS activities have been increased to maintain or increase

expenditure to deal with the realities of the epidemic. A calculation of AIDS spending using data from

the National Treasury Department shows that combined domestic and foreign spending on HIV and AIDS

interventions had increased by 21% from R13.97 billion in 2008 to R17.58 billion in 2009. According to data

from the Treasury, domestic expenditure contributed more than 70% of the total combined expenditure on

HIV and AIDS interventions, both in 2008 and 2009. Domestic expenditure on HIV and AIDS interventions

increased from R10.8 billion in 2008 to R12.8 billion in 2009, while international expenditure on HIV and

AIDS increased from R3.2 billion in 2008 to about R5 billion in 2009. Domestically, conditional grants

for HIV and AIDS through the national health budget increased by 23.3% from R4.3 billion in 2008 to

an estimated R5.3 billion in 2009. Spending on social development and education, which helps improve

families’ circumstances, particularly orphans and vulnerable children, also increased between 2008 and

2009 (United Nations General Assembly Special Session final report, March 2010).

However, an evaluation of the HIV and AIDS programmes implemented in provinces and municipalities

is imperative in order to assess government’s performance over time. One of the key means by which

performance may be measured is through the involvement of the key beneficiaries. The complex nature of

the epidemic requires that its broad impacts on society were clearly defined and understood for beneficiaries

to benefit from national strategic interventions. For instance, it is important to know the extent to which

society is accommodating and inclusionary or exclusionary to people living with HIV and AIDS after

investment on outreach education programmes to create an enabling environment. It is equally vital to

know the extent of the availability, accessibility and quality of HIV and AIDS-related goods and services

5 Unconditional equitable share grants were allocations made according to equitable share formulae guided by set factors but can be used in any

way the provinces or local government determine is best.


in provinces and municipalities relative to the size of investment in HIV and AIDS interventions. In AIDS

service delivery, particularly matters relating to awareness, the place of leadership is paramount. Since the

2009 study by Chirambo and Steyn, it has become more apparent that when elected representatives were

themselves affected by stigma and discrimination, they were unlikely to enhance service delivery or indeed

see themselves as viable electoral candidates through whom the challenges of local communities may be

effectively presented to policy mechanisms.

Hence, establishing citizen opinion about the existence and quality of HIV and AIDS-related services

presumably offered in their areas is a useful feedback mechanism on the progress made by the respective

investments in HIV and AIDS interventions. It is also critical in understanding community perceptions of

their leaders and the potential impediments HIV might pose to their work.

This paper, therefore, seeks to evaluate the extent to which the HIV status of election candidates influences

the voting preferences of citizens. The paper also seeks to evaluate citizens’ opinions on the availability,

accessibility and quality of HIV and AIDS-related services offered in selected provinces and municipalities.

The paper makes use of primary data on citizens’ opinions from the LGB survey in KwaZulu-Natal (KZN),

Limpopo, Mpumalanga and North-West.

1.3 Context of study: objectives, methods and means

As stated earlier, the means by which citizen perceptions were gathered was through the LGB developed

by the Local Governance Unit (LGU) of Idasa’s Political Governance Programme (PGP). The instrument uses

a bottom-up approach in assessing service delivery. In other words, the LGB tool emphasises the active

engagement between local government and citizens in service provisions. The tool uses the citizen report

card (CRC) to solicit community feedback on a set of goods and services provided by councils. The CRC

measures the level of satisfaction of citizens regarding the performance of municipalities and the quality of

the services they provide.

The LGB tool involves the administration of a questionnaire to gather citizens’ opinion on the satisfaction

of municipal services. Citizens’ opinions were measured against commonly defined standards. The LGB tool

is very broad in scope, covering a wide range of goods and services provided by municipalities. GAP linked

with LGU to incorporate the set of HIV and AIDS issues cited above in the LGB tool as it carried out the

opinion survey in the selected provinces. This paper is based on HIV and AIDS data collected by LGU using

the LGB tool.

1.4 Research objectives

The study seeks to assess the level of progress made in creating an enabling environment for political

participation of HIV-positive people in selected municipalities in South Africa. The study also seeks to

evaluate citizens’ opinions on the availability, accessibility and quality of HIV and AIDS interventions in the

same selected municipalities in South Africa. Because these matters entail effectiveness at institutional


and leadership levels, citizens’ perceptions on the health status of councillors is factored in. The study seeks

to address the following specific objectives:

1. Examine if citizens would vote for an HIV-positive candidate;

2. Examine citizens’ opinions on the accessibility of HIV and AIDS-related goods and services in their

municipalities;

3. Examine citizens’ opinions on the quality of HIV and AIDS-related goods and services provided in their

municipalities; and

4. Examine citizens’ opinions on the availability of the following selected HIV and AIDS interventions in

municipalities:

i. Voluntary testing and counselling services;

ii. Antiretroviral drugs dispensary;

iii. Home-based care support;

iv. Counselling services; and

v. Free condom distribution.

1.5 Research questions

The study asked the following research questions through the use of the LGB tool:

1. If a candidate was HIV-positive, would that affect your voting?

2. Do people in your ward have easy access to good HIV and AIDS-related health services?

3. Are the following HIV and AIDS interventions available in your municipality?

i. Voluntary counselling and testing services;

ii. Antiretroviral drugs dispensary;

iii. Home-based care support;

iv. Counselling services; and

v. Free condom distribution.

2. Methodology

The paper is based on primary data collected using the LGB Citizen Report Card. Data analysis is largely

descriptive and the initial data processing was done using SPSS.

2.1 Sample design

The CRC sample process targeted a representative sample of adult South African citizens residing in

the 21 participating municipalities across the four provinces of Mpumalanga, North West, KwaZulu-

Natal and Limpopo. The design sample of 2 400 adults, with a margin of error of +-3 percentage points


at 95% confidence, was thus proportionately stratified across province, municipality and urban-rural

divides.

In addition, the CRC study attempted to generate large enough local level sub-samples as possible to enable

municipal-level analysis of results. A minimum of 100 municipal interviews, where possible, were targeted.

The over-sampling of smaller municipalities (and subsequent under-sampling of bigger municipalities) was

based on the population size, number of listed villages and the minimum sample. Appropriate weights were

also determined to ensure that the effects of the over-sampling were nullified in the entire sample. See

Table 1 for details, which summarises the selected provinces and corresponding municipalities.

Table 1

Province Municipality

KwaZulu-Natal Mkhambathini

Richmond

Umshwathi

Umvoti

Limpopo Greater Tzaneen

Makhado

Modimolle

Molemole

Mookgopong

Greater Marble Hall

Mpumalanga Thaba Chweu

Albert Luthuli

Bushbuckridge

Dipaleseng

Msukaligwa

North-West Moretele

Kgetlengriver

Ventersdorp

Maquassi Hills

Naledi

Tswaing

The sample was based on Statistics South Africa’s 2001 census frame with 2007 household survey updates

(supplied by the fieldwork contractor) that listed population breakdown by:

1. Place name (and code);

2. Total population, male and female;

3. Type of dwelling (urban, tribal, sparse, farm, informal, small holding, industrial, recreational and

institutional) populations;

4. Ethnicity (coloured, black, white and Indian/Asian); and

5. Annual average income and annual per capita income - among other breakdowns.


For the ease of stratification and reporting, the type of dwelling was further grouped into the following four

levels to create fewer, but distinct, units within which to stratify and sample:

1. Urban (including urban settlement, industrial, institutional and recreational);

2. Tribal (including tribal settlements);

3. Rural (farm, small holding and sparse); and

4. Informal (including informal settlements).

The primary sampling unit for the CRC was the village level, whereby 200 villages were randomly

selected (according to a proportionate stratification) from the 21 participating municipalities. The 2 400

design sample was first stratified at the province with an over-sample to ensure that each municipality

(where possible) had at least the total sample size of about 100 interviews. However, the total number of

Enumeration Areas (census level villages) available on the census list could not permit assigning a minimum

of nine Enumeration Areas, meaning that in some cases the number of Enumeration Areas covered was

much less than nine.

Within each municipality, the allocated sample was then proportionately allocated to the urban, rural,

informal and tribal portions of the municipality. Thus, where the over-sample allocation was larger than the

number of Enumeration Areas available on the list, a transfer was made within the same municipality (or

province) and within the same Enumeration Area type.

3. Findings of the studyThe findings of the LGB CRC survey reveal interesting citizen opinion on the availability and quality of

HIV and AIDS-related services in selected municipalities and voting preferences in relation to HIV-positive

candidates. The findings will be discussed under the following three vectors:

• ElectionpotentialofHIV-positivecandidatesinwards;

• AccessibilitytogoodHIVandAIDS-relatedservicesinwards;and

• AvailabilityofHIVandAIDSgoodsandservicesinwards.

3.1 Election potential of HIV-positive candidates

The survey solicited opinions on whether the HIV status of a candidate influences the electorate’s voting

preferences in provinces and municipalities. Establishing community attitudes regarding the likelihood of

HIV-positive candidates to be elected is critical in that the elected candidates form an integral part of the

service delivery mechanism. The question: “Does the HIV status of candidate affect voting?” was meant

to establish whether or not HIV status affected a candidate’s chances of holding public office. Finding

information on the electorate’s attitude is important because it is also likely to either establish some

form of social solidarity with their HIV-positive leaders, therefore strengthening their resolve in leading

the response, or conversely, confirm their fears of disclosure, potentially deflating their enthusiasm for


public engagement. It is important to state that community members may themselves, in responding to our

questions, not wish to be publicly perceived as discriminatory toward HIV-positive people and will therefore

present convenient answers. Responses on voting for a candidate who is HIV-positive were limited to the

following three options:

1. Will vote;

2. Will not vote; and

3. Don’t know.

Across all provinces, an average of 84.6% of the respondents said that they would vote for an HIV-positive

candidate, 11.5% said that they would not vote for an HIV-positive candidate while a mere 3.9% of the

respondents said that they didn’t know whether or not they would vote for an HIV-positive candidate (See

figure 1 below).

Figure 1: Average opinion on whether candidates would vote for an HIV-positive candidate


Figure 2: Proportion of citizens who would/would not vote for an HIV-positive candidate in

selected provinces

The highest proportion of respondents who would not vote for a candidate who is HIV-positive reside in

Limpopo (22.8%), followed by Mpumalanga (11.6%), North-West (10.6%) and a mere 1% in KZN. The highest

proportion of indecisive respondents who did not know whether or not they would vote for a candidate who

is HIV-positive reside in North-West (7.1%), followed by KZN (5.5%), Limpopo (2.7%) and Mpumalanga (0.3%)

(See figure 2).

It is highly probable that the reason Limpopo has the largest number of people indicating that they

would not vote for those who were HIV-positive, when compared with other provinces, is a lower level of

education among Limpopo citizens. This perpetuates the ostracism of those perceived to be HIV-positive.

The education statistics of Limpopo largely trail behind the average national statistics.6 For instance:

• 22.1%ofpeopleaged20andabove inLimpopohadsomeprimaryeducation,comparedwith31.9%

nationally;

• Ofthepeopleaged20andaboveinLimpopo(12.5%)hadStandard10/Grade12,whichislowcompared

with the national average of 18%.

• 6.4% of the people aged 20 and above in Limpopo had a tertiary education, compared with 8.8%

nationally; and

• 19.4%ofthepeopleaged20andaboveinLimpopohadnoschooling,whichishighcomparedwiththe

national average of 9.4%.

6 Limpopo Employment Growth and Development Plan (LEGDP 2009‐2014 Document 3, 2009 ‐ 2014.


Figure 3: Proportion of citizens who would vote for an HIV-positive candidate in their

municipalities

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Municipal opinion on whether or not citizens would vote for an HIV-positive candidate follows the average

provincial trend. All municipalities had no less than 70% of the respondents expressing that they would

vote for an HIV-positive candidate save for Maquassi Hills (68.8%). One third of the municipalities had at

least 90% of the respondents saying that they would vote for an HIV-positive candidate and all four KZN

municipalities fell into this category (See figure 3).


Figure 4: Proportion of citizens who would not vote for an HIV-positive candidate in their

municipalities

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Not more than 20% of the respondents in all municipalities said that they would not vote for an HIV-

positive candidate, with the exception of four out of 21 municipalities. The four municipalities - three of

which were from Limpopo and one from Mpumalanga - had more than 20% of the municipal respondents

saying that they would not vote for an HIV-positive candidate (See figure 4).


Figure 5: Proportion of citizens who don’t know whether or not they would vote for an

HIV-positive candidate in their municipalities

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There is a difference in opinion between rural respondents and the rest of the designations in terms of

voting choices for an HIV-positive candidate. The proportion of rural citizens who would vote for an HIV-

positive candidate is 78.4% compared with 86.1% in urban, 85.3% in informal and 82.1% in tribal areas. The

proportion of rural and tribal respondents who said that they would not vote for a candidate who is HIV-

positive was very close. A total of 16.8% and 15.7% of citizens in rural and tribal areas respectively said that

they would not vote for an HIV-positive candidate, compared with 9.8% and 8.7% in urban and informal

areas respectively. Less than 6% of the respondents in all the designations said that they didn’t know

whether or not they would vote for an HIV-positive candidate, with the informal area topping the proportion

with 5.9% of the respondents (See figure 6).

Less than 10% of the respondents in all municipalities were indecisive on whether or not they would vote

for an HIV-positive candidate, with the exception of Ventersdorp municipality in the North-West province

where 17.9% of the respondents were unsure. Therefore, the majority of the electorate in all the provinces is

sure about whether or not they would vote for an HIV-positive candidate (See figure 5).


Figure 6: Proportion of citizens who expressed whether or not they would vote for an

HIV-positive candidate

A significant proportion of citizens in rural and tribal areas indicated that they would not vote for an HIV-

positive candidate. For instance 22.8%, 11.6% and 10.6% of the respondents in Limpopo, Mpumalanga and

North-West provinces respectively, indicated that they would not vote for a candidate who is HIV-positive

while North-West province had 7.1% of citizens who were indecisive. There is also a difference in voting

preferences between rural and tribal citizens versus urban and informal citizens. 16.8% and 15.7% of citizens

in rural and tribal areas respectively said that they would not vote for an HIV-positive candidate compared

with 9.8% and 8.7% in urban and informal areas respectively. Other things being equal:

1. An HIV-positive candidate who is open about their HIV status is more likely to hold office in KZN,

followed by North-West, Mpumalanga and Limpopo; and

2. An HIV-positive candidate who is open about their HIV status is more likely to hold office in urban and

informal areas than in rural and tribal areas.

The chances of an HIV-positive candidate being elected into office are therefore determined by community

attitudes. In a receptive community, there are equal chances for both the HIV-positive and HIV-negative

candidate to be elected into office, holding other factors constant.


Figure 7: Average opinion on availability of HIV and AIDS-related services in provinces

3.2 Accessibility to good HIV and AIDS-related services

One of the most contentious issues in South Africa concerns service delivery, or lack of it, by municipalities.

This survey solicited opinions on the accessibility to good HIV and AIDS-related services in provinces and

municipalities. The question posed was: “Do people in your ward have easy access to good HIV and AIDS-

related health services?” Respondents were limited to the following three options in their opinions:

1. Services were not available;

2. Services were available but not good;

3. Services were available but not accessible to all;

4. Yes, the services were available and good;

5. Refused to comment; and

6. Don’t know.

The results of the survey show that citizens were not very enthusiastic about the accessibility and quality

of HIV and AIDS-related services in their municipalities. On average 56.8% of the respondents said that HIV

and AIDS-related services in their provinces were available and good, 12.6% said that HIV and AIDS-related

services were available but not good, 7.8% said that services were available but not accessible to all, 4.3%

said that HIV and AIDS-related services were not available, 18.1% said that they didn’t know whether or not

good HIV and AIDS-related services were available in their wards while a mere 0.4% refused to comment on

the subject (See figure 7).


Figure 8: Accessibility to good HIV and AIDS-related services in the ward

Figure 8 shows the detailed opinion of the citizens in the respective provinces. In Limpopo 70.8% of citizens

said that HIV and AIDS-related services were available and were generally good, followed by Mpumalanga

(62.2%), North-West (50.7%), and KZN (43.2%). The opinion of citizens in KZN is fairly balanced with 35.2%

of citizens indicating that HIV and AIDS-related services were available but not good compared with 10.1% in

Mpumalanga, 2.7% in Limpopo and 2.4% in North-West. North-West province has the highest proportion of

citizens who said that HIV and AIDS-related services were not available. 6.5% of the citizens in North-West

province said that HIV and AIDS-related services were not available in their area, compared with 4.8% in

Mpumalanga, 4.6% in KZN and 1.3% in Limpopo. Mpumalanga province has the highest proportion of citizens

who said that HIV and AIDS-related services were available but not accessible. 10.7% of the citizens in

Mpumalanga province said that HIV and AIDS-related services were available but not accessible in their area,

compared with 6.9% in North-West, 7% in Limpopo and 6.6% in KZN. A significant proportion of respondents

in North-West province said that they didn’t know whether or not good HIV and AIDS-related services were

accessible in their area. 32.8% of the citizens in North-West province said that they didn’t know whether or

not good HIV and AIDS-related services were accessible in their area compared with 17.2% in Limpopo, 12% in

Mpumalanga and 10.3% in KZN. An insignificant (less than 2% combined citizen total) in all provinces refused

to comment on the subject.


Figure 9: Proportion of citizens who expressed that HIV and AIDS-related services are

available and good in their municipalities

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On average, municipal opinion is just a mirror image of the provincial responses with slight variations in

individual municipal responses. Municipalities which had at least two-thirds of the respondents expressing

that services were available and good were Greater Tzaneen (85.2%), Modimolle (76.4%), Mookgopong

(73.4%), Bushbuckridge (73.6%), the first three of which were from Limpopo. All KZN municipalities had less

than 50% of the respondents expressing that services were available and good. These were Mkhambathini

(38.9%), Richmond (40.3%), Umshwathi (42.1%) and Umvoti (49.4%) (See figure 9).


Figure 10: Proportion of citizens who expressed that HIV and AIDS-related services are

available but not good in their municipalities

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Three out of four KZN municipalities had at least one-third of citizens expressing that HIV and AIDS-related

services were available but bad in their municipalities. These were Mkhambathini (42.7%), Richmond (36.6%)

and Umvoti (37.6%) (See figure 10).


Figure 11: Proportion of citizens who expressed that HIV and AIDS-related services are not

available in their municipalities

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Three out of twenty one municipalities had at least 10% of citizens expressing that HIV and AIDS-related

services were not available in their municipalities. These were Mookgopong (13.1%), Msukaligwa (13.6%) and

Tswaing (10.2%) (See figure 11).


Figure 12: Proportion of citizens who expressed that good HIV and AIDS-related services

are available but not accessible in their municipalities

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Four out of twenty one municipalities had at least 10% of citizens expressing that HIV and AIDS-related

services were available but not accessible to all citizens in their municipalities. These were Richmond

(10.1%), Greater Marble Hall (7.5), Bushbuckridge (13.8%) and Moretele (11.5%) (See figure 12).


Figure 13: Proportion of citizens who expressed that they don’t know whether or not

good HIV and AIDS-related services are accessible in their municipalities

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The three municipalities with at least one-third of the respondents expressing that they didn’t know whether

or not good HIV and AIDS-related services were accessible in their area were from North-West province.

These were Ventersdorp (38.9%), Maquassi Hills (47.1%) and Naledi (38.5%) (See figure 13).

In total 62.4% and 64.3% of citizens in tribal and urban areas respectively said that HIV and AIDS-related

services were available and good in their areas, compared with 49.8% and 53.9% in rural and informal areas

respectively. 13.4% and 17.8% of citizens in rural and informal areas respectively said that HIV and AIDS

related services were available but not good in their areas, compared with 7.5% and 6.7% in tribal and urban

areas respectively. 8.1% and 6.6% of citizens in rural and informal areas respectively said that HIV and AIDS-

related services were not available at all in their areas, compared with a mere 3.8% and 2.6% in urban and

tribal areas respectively.

The tribal area has the highest proportion of citizens who said that HIV and AIDS-related services were

available but not accessible at all in their areas. 9.7% of respondents in tribal areas said that HIV and AIDS-

related services were available but not accessible at all in their areas, compared with 5.1% in informal area

and less than 5% in urban and rural areas. The urban and rural areas have the highest proportion of citizens

who said that they didn’t know whether or not good HIV and AIDS-related services were accessible in their

areas. 24% and 22% of the citizens in rural and urban areas respectively said that they didn’t know whether

or not good HIV and AIDS-related services were accessible in their areas, compared with 15.2% and 16.7% in

tribal and informal areas respectively (See figure 14).


Figure 14: Accessibility to good HIV and AIDS-related services by designation

Generally, the proportion of citizens who said that HIV and AIDS-related services in their provinces were available

and generally good was relatively low. Specifically 43.2% of the citizens in KZN and 50.7% of the citizens in

North-West said that HIV and AIDS-related services in their provinces were available and generally good. 35.2%

of the citizens in KZN said that HIV and AIDS-related services in their provinces were available but not good

while 32.8% of the citizens in North-West said that they did not know about the quality and availability of HIV

and AIDS-related services in their provinces. This can be attributed to the high burden of disease in KwaZulu-

Natal and North West Provinc. With KwaZulu-Natal having the second highest population of more than 9.8

million people in 2005 (after Gauteng province), with 5.3 million people living in poverty, 1.2 million people living

on less than US$1 a day (R6.50 a day or R200 a month) and 1.5 million people living with HIV and AIDS (15% of

the population in 2005), the burden of HIV and AIDS is very high in the province.7

The North-West province is mostly rural in nature with a low population density and relatively inadequate

infrastructure, especially in the remote rural areas. The province has inherited an enormous backlog in basic

service delivery and maintenance that will take time to eradicate.8 The burden of HIV and AIDS is very high

in the province with an HIV prevalence rate of more than 30% in the province in 2007.9

7 Provincial Spatial Economic Development Strategy (PSEDS) Development of an Economic Cluster Programme of Action.8 North-West Provincial Growth and Development Strategy 2004 – 2014.

9 Annual Antenatal Sero-prevalence Survey (2008).


The high prevalence rate in KZN and North-West and the high burden of the disease against the background

of high poverty levels hamper easy accessibility to good HIV and AIDS-related services in the provinces.

This implies that efforts must be stepped up to improve accessibility of good HIV and AIDS-related health

services in the provinces. Although these two provinces lag behind Limpopo and Mpumalanga in terms of

accessibility of good HIV and AIDS-related health services, the situation is generally unsatisfactory in all

the provinces.

There is significant difference in opinion between rural and urban respondents on accessibility to good HIV

and AIDS-related services. The rural and informal respondents displayed similar behaviour while tribal and

urban opinions were close. Accessibility to good HIV and AIDS-related services is higher in urban and tribal

areas and lower in rural and informal areas. The high poverty levels and poor infrastructure in rural and

informal areas exacerbate the challenges of accessibility to good HIV and AIDS-related services in rural and

informal areas relative to the tribal and urban areas.

3.3 Availability of HIV and AIDS goods and services in wards

The survey also solicited opinions on the availability of voluntary counselling and testing, antiretrovirals,

home-based care support, counselling services and free condom distribution in the respective provinces.

These selected HIV and AIDS goods and services reflect the level of prevention, treatment and care and

mitigation of the adverse effects of HIV and AIDS in the respective provinces and municipalities. The

provision of the HIV and AIDS goods and services is vital for a holistic approach to fighting HIV and AIDS in

communities. Citizens were asked closed questions on whether or not the cited HIV and AIDS goods and

services exist in their wards with responses limited to the following three options:

1. Yes;

2. No; and

3. Don’t know.

Citizens’ responses generally pointed to the availability of the cited HIV and AIDS goods and services in

their localities with significant need for improvement. Across the selected provinces, at least 66% of the

respondents indicated that the cited HIV and AIDS goods and services were available and the remainder

either indicated that the goods and services were not available or the citizens were unaware of whether or

not the goods and services were available (See figure 15).


Figure 15: Average opinion on availability of cited HIV and AIDS goods and services across

selected wards

On average, antiretroviral availability lags behind all the cited HIV and AIDS goods and services while free

condom distribution tops the availability list of HIV and AIDS goods and services across provinces. Across

provinces, the average proportion of citizens who do not know whether or not the cited HIV and AIDS goods

and services were available is more than the proportion of citizens who said that the cited HIV and AIDS

goods and services were not available in all the provinces.

KZN has the highest proportion of citizens who indicated that voluntary counselling and testing were

available in the province but has the lowest proportion of citizens who indicated that antiretrovirals were

available. 90.9% of the respondents indicated that voluntary counselling and testing is available in KZN

compared with 88.3% in Limpopo, 70.5% in Mpumalanga and a low 53.5% in North-West (See figure 16).


Figure 16: Proportion of citizens who answered “yes” to availability of cited HIV and AIDS

goods and services in provinces

In total 92.8% of the respondents indicated that counselling services were available in KZN, compared

with 88.8% in Limpopo, 86.4% in Mpumalanga and a low 59.5% in North-West. An overwhelming 96.5%

of the respondents indicated that free condom distribution was available in KZN, compared with 88.6% in

Limpopo, 89.6% in Mpumalanga and a relatively low 62% in North-West.

Limpopo had the highest proportion of respondents who indicated that home-based care is available in their

area while Mpumalanga tops antiretroviral availability. 85.8% of the respondents indicated that home-based

care support was available in Limpopo, compared with 80% in Mpumalanga, 66.9% in KZN and a low 48.8% in

North-West. 82.4% of the respondents indicated that antiretrovirals were available in Mpumalanga, compared

with 78.5% in Limpopo, 57.2% in North-West and 46.5% in KZN. It is possible that the reason for the relatively

high provision of antiretrovirals and home-based care in Mpumalanga and Limpopo is that these were among

the first provinces in the country to implement antiretroviral treatment at primary health care level. The low

availability of ARVs in KwaZulu-Natal and North West is due to the high burden of the disease in these two

provinces as discussed before. This requires relatively high supplies of ARVs to meet the demand.

Generally, a small proportion of citizens indicated that the cited HIV and AIDS goods and services were

not available in their area. KZN has the highest proportion of citizens who indicated that antiretrovirals

and home-based care support were not available in their area. 31.4% of the respondents indicated that

antiretrovirals were not available in KZN, compared with 7.7% in Mpumalanga, 7.4% in North-West and

a mere 3.8% in Limpopo. 17.6% of the respondents indicated that home-based care support was not


Figure 17: Proportion of citizens who answered “no” to availability of cited HIV and AIDS

goods and services in provinces

Mpumalanga has the highest proportion of citizens who indicated that VCT was not available in their area.

18% of the respondents indicated that VCT was not available in Mpumalanga, compared with less than 10%

of the respondents in all the other provinces. North-West province has the highest proportion of citizens

who indicated that counselling services and free condom distribution were not available in their area. 6.7%

and 7.7% of the respondents indicated that counselling services and free condom distribution respectively

were not available in North-West, compared with less than 5% of the respondents who shared the same

sentiment in all the other provinces.

Generally, a modest proportion of citizens indicated that they didn’t know whether the cited HIV and AIDS

goods and services were available in their area. North-West tops all the other provinces in terms of the

proportion of citizens who were unsure whether or not the cited HIV and AIDS goods and services were

available in their area (See figure 18).

available in KZN, compared with 12.7% in North-West, 8.2% in Mpumalanga and only 3.4% in Limpopo (See

figure 17).


Figure 18: Proportion of citizens who answered “don’t know” to availability of cited HIV

and AIDS goods and services in provinces

In total 38.3% of the respondents indicated that they didn’t know whether or not VCT was available in

North-West province, compared with less than 12% in each of the remainder of the provinces. 35.3% of the

respondents indicated that they were unsure whether or not antiretrovirals were available in North-West

province, compared with 22% in KZN, 17.7% in Limpopo and 9.9% in Mpumalanga. 38.9% of the respondents

indicated that they were unsure whether or not home based care were available in North-West province

compared with less than 16% in each of the remainder of the provinces. 33.8% and 30.3% of the respondents

indicated that they were unsure whether or not counselling services and free condom distribution respectively

were available in North-West province, compared with less than 10% in each of the remainder of

the provinces.

Generally, citizen municipal responses on the availability of cited HIV and AIDS goods and services reflect

the provincial responses, with small variations in individual municipalities. For example, Bushbuckridge and

Greater Tzaneen municipalities, in Mpumalanga and KZN province respectively, have overwhelming citizen

responses on availability of all the cited HIV and AIDS goods and services in their areas, compared with

Maquassi Hills and Naledi municipalities. More than 90% of the respondents in Bushbuckridge and Greater

Tzaneen indicated that all the cited HIV and AIDS goods and services existed in their municipalities, with

the exception of voluntary counselling and testing (72.5%) in Bushbuckridge.

By contrast, in Maquassi Hills and Naledi provinces respondents who indicated that HIV and AIDS goods

and services were available in their municipalities ranged between 36% and 55%, with most responses

below 50%. Maquassi Hills and Naledi also had the highest proportion of citizens who didn’t know whether


Figure 19: Proportion of citizens who answered “don’t know” to availability of cited HIV

and AIDS goods and srvices in selected municipalities

or not the cited HIV and AIDS goods and services were available in their municipalities, ranging from 35%

to 51% (See figure 19).

Another anomalous opinion was echoed by citizens from KZN municipalities. Overall, more than one third of

respondents in each of the KZN municipalitities, except Umvoti municipality, indicated that antiretrovirals

were not available in their municipalities (See figure 20).


Figure 20: Proportion of citizens who answered “no” to availability of ARVs in KZN

municipalities

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Figure 21: Proportion of citizens who answered “yes” to availability of cited HIV and AIDS

goods and services by designation

Generally, the highest proportion of citizens who said they were aware of the existence of voluntary

counselling and testing reside in tribal areas (See figure 21).


Figure 22: Proportion of citizens who answered “no” to availability of cited HIV and AIDS

goods and services by designation

In total 82.2% of respondents who said they knew about the existence of VCT reside in informal areas,

followed by 80% residing in tribal areas, 73.5% residing in urban areas and 65.9% residing in rural areas. Tribal

areas had the highest proportion of citizens who said that antiretrovirals were available in their areas. 76% of

the respondents said that antiretrovirals were available in tribal areas, compared with 69.8% in urban areas,

62% in rural areas and 58.2% in informal areas.

Rural and urban areas, however, trail behind tribal and informal areas in terms of home-based care support

based on citizen responses. 83.6% of the respondents said that home-based care support was available in

tribal areas, compared with 62.6% in informal areas, 57.9% in urban areas and 56.5% in rural areas.

At least 70% of citizens in all designations said that counselling services and free condom distribution were

available in their areas. 87.9% of the respondents said that counselling services were available in tribal

areas, compared with 82% in informal areas, 75.4% in urban areas and 70.3% in rural areas. 88.9% of the

respondents said that free condom distribution was available in informal areas, compared with 88.5% in

tribal areas, 78.9% in urban areas and 75% in rural areas.

Overall, fewer than 21% of the respondents said that the cited HIV and AIDS goods and services were not

available in their areas, with home-based care support and antiretrovirals accounting for the bulk of the

respondents. Rural citizens dominated the proportion of citizens who said that the cited HIV and AIDS

goods and services were not available in their areas (See figure 22).


Figure 23: Proportion of citizens who answered “don’t know” to availability of cited HIV and

AIDS goods and services by designation

Rural citizens also dominated the proportion of citizens who didn’t know whether or not the cited HIV and

AIDS goods and services were available in their areas. Overall, less than one-third of the respondents said

that they didn’t know whether or not the cited HIV and AIDS goods and services were available in their

areas, with home-based care support and antiretrovirals accounting for the bulk of the responses again (See

figure 23).

Based on citizen opinions, the provinces that faced more challenges in terms of accessibility to good

HIV and AIDS-related services also have more challenges with respect to the availability of the selected

HIV and AIDS interventions. The North-West province lags behind all the other provinces in terms of awareness

of the availability of the selected interventions in provinces. The North-West also falls behind all the

other provinces in terms of the availability of all the selected HIV and AIDS-related interventions, apart

from antiretroviral provision, where KZN lags behind all the other provinces. KZN tops all the other provinces

in terms of availability of all the HIV and AIDS interventions, except antiretroviral provision and home-

based care support, topped by Mpumalanga and Limpopo respectively. KZN has the highest proportion

of citizens who indicated that antiretrovirals were not available in their provinces. This is possibly the

major reason why the life expectancy in KZN is lower in relation to all other provinces. The average life

expectancy for men and women ranges from 48.5 years in KZN to 62.9 years in the Western Cape. As

indicated earlier on, the high poverty levels, poor infrastructure and lack of information were possibly the


major causes of the differential availability of HIV and AIDS-related goods and services in the respective

provinces.

In many respects, rural citizens were disadvantaged in terms of availability of selected HIV and AIDS

goods and services. There exists a backlog in the delivery of services, especially in rural areas. The lowest

proportion of citizens who expressed knowledge of the existence of the selected HIV and AIDS goods and

services, apart from antiretroviral provision, reside in rural areas. The rural citizens also largely dominate the

proportion of citizens who said that the interventions were not available in their areas and the proportion

of citizens who didn’t know whether or not the selected HIV and AIDS goods and services were available

in their areas. Again, the possible challenges for rural citizens in terms of HIV and AIDS goods and services

include high poverty levels, poor infrastructure and lack of information.

4. Conclusion and policy recommendations

The findings of the survey generally reflect interesting citizen opinions on the provision of good HIV and

AIDS-related interventions in the respective municipalities in South Africa. The findings show that more can

be done to improve the availability, accessibility and quality of HIV and AIDS-related services. For instance,

across the selected provinces, about one-third of the respondents indicated that the cited HIV and AIDS

interventions were not available in their provinces while slightly less than half of the citizens indicated that

good HIV and AIDS-related services were not accessible in their areas. It has also been underlined that voting

preferences may be influenced by the HIV-positivity of the candidates in three out of four municipalities.

The rural-urban geographical divide also seems to be rampant in most HIV and AIDS-related interventions,

although it narrows for other HIV and AIDS interventions such as home-based care support. There is no

significant difference between the proportion of rural and urban respondents who said that home-based

care support is available in their areas, possibly because of the resilience of people in rural areas. Rural

dwellers play a significant role in caring for ailing HIV and AIDS patients through strong family ties and

communal life. This means that structures for home-based care support already exist in rural areas and

the activities of state and non-state organisations build on such foundations. There is a difference in voter

preferences between rural respondents and the rest of the designations regarding the likelihood of electing

an HIV-positive candidate.

Based on the findings of this study, generally there is a need for fundamental policy shifts and corrective

actions in the provision of HIV and AIDS-related interventions in municipalities. This also applies to

community attitudes regarding the potential for election of HIV-positive candidates in individual provinces,

municipalities and across designations.

There were significant proportions of citizens who indicated that they either don’t have access to good HIV

and AIDS-related services or they were unaware whether or not such services existed in their municipalities,

especially in KZN. Fewer than five in every ten citizens indicated that HIV and AIDS-related services were

available and good, while more than three in every ten citizens indicated that HIV and AIDS-related services

were available but not good in KZN.


It is also worrying that a significant proportion of citizens indicated that either the selected HIV and AIDS

interventions were available but bad or they were unsure of the existence of such goods and services in

their municipalities. For instance, more than four in every ten citizens in KZN indicated that HIV and AIDS

interventions were available but bad. More than one-third of citizens indicated that antiretrovirals were not

available in KZN while about one-fifth of the citizens indicated that home-based care support and voluntary

counselling and testing were not available in KZN and Mpumalanga respectively. Less than six in every ten

citizens in North-West province indicated that all the HIV and AIDS interventions were available in their

areas. North-West also tops all the other provinces in terms of the proportion of citizens who were unsure

whether or not the cited HIV and AIDS goods and services were available in their area. More than one-third

of the citizens in North-West province said that they didn’t know whether or not all the HIV and AIDS

interventions were available in their areas.

The fact that average antiretroviral availability lags behind all the cited HIV and AIDS goods and services,

while free condom distribution tops the availability list of HIV and AIDS goods and services across provinces,

reflects a lack of balance between prevention strategies and treatment strategies. Not discounting an

expansion of prevention programmes, including free condom distribution, greater availability of antiretrovirals

is equally important given that South Africa has the highest number of people living with HIV. It is well

established that antiretrovirals prolong the lives of millions of South African living with HIV and AIDS and

restore economic productivity, and stabilise societies. Generally, the long-term success against HIV and

AIDS in hyper-endemic countries like South Africa requires simultaneous expansion of both antiretrovirals

and prevention programmes.

It will be important to find out what deters accessibility to good HIV and AIDS-related services in

North-West and the low quality of HIV and AIDS-related services in KZN, in order to take necessary

corrective measures. It will also be important to find out the reasons for either the high unavailability of HIV

and AIDS interventions or uncertainty of the existence of such interventions in municipalities. The possible

drivers are:

1. Low supply of the interventions due to poor infrastructure;

2. Overwhelming demand of the HIV and AIDS-related interventions due to high burden of HIV and AIDS

in the respective provinces;

3. High poverty levels that incapacitate societies; and

4. Information asymmetry on the nature and types of HIV and AIDS-related interventions available in

respective provinces.

The availability, accessibility and quality of HIV and AIDS-related services in provinces determine the

outcomes of the HIV and AIDS interventions.

Based on citizens’ opinion, the rift between rural areas and the rest of the designations is visible in terms

of availability of HIV and AIDS-related interventions. Rural citizens were largely disadvantaged relative

to their urban, tribal and informal counterparts. The responses of rural citizens largely reflect a deficit


relative to all the other areas. The lowest proportion of citizens who said that HIV and AIDS goods and

services are available reside in rural areas while the highest proportion of citizens who said that HIV and

AIDS goods and services are not available except for antiretrovirals, also reside in rural areas. The highest

proportion of citizens who don’t know whether or not all the cited HIV and AIDS goods and services exist

in their areas also reside in rural areas. Generally, good HIV and AIDS-related services were relatively more

accessible to urban and tribal citizens than their rural and informal counterparts. Urban and tribal citizens

were also relatively more satisfied with the HIV and AIDS-related services in their areas than their informal

and rural counterparts. The factors that marginalise the rural citizens relative to their counterparts include

infrastructural challenges, knowledge gap, information asymmetry, high poverty levels and differences in

perceptions that aggravate the variance in accessibility, availability and quality of HIV and AIDS-related

services between rural areas and the rest of the designations. Bridging the gap between designations is

necessary for equitable distribution of high quality HIV and AIDS-related services in all municipalities.

A critical analysis of the community attitudes regarding the likelihood of election of HIV-positive candidates

reflects interesting traits. In most municipalities, voting is swayed by the HIV status of the candidate. There

were significant proportions of citizens who indicated that they either would not vote for an HIV-positive

candidate or they were indifferent about whether or not they would vote for such a candidate.

At face value the figures might be low, but where voter margins are small the HIV-status of a candidate

could determine the election result. Publicity, which can be engineered by a competitor, could lose the

election for an HIV-positive candidate. This is particularly true of some provinces, especially Limpopo.

There is lack of social solidarity with HIV-positive leaders in all the provinces, except in KZN. This largely

confirms the fears of disclosure by the leadership and hence potentially deflating the enthusiasm of HIV-

positive leadership for public engagement. The creation of a level playing field is necessary for active political

participation and openness about candidates’ HIV status. In this respect, more work needs to be done to

create an enabling environment in municipalities and reduce stigma, discrimination and political exclusion

to insignificant levels.

Geography also influences voting preferences in some way. Rural and tribal citizens were least likely to vote

for an HIV-positive candidate. Thus more work needs to be done in the rural and tribal areas to create an

enabling environment for equal political participation.


5. References

Abdool, K.S.S, Abdool, K.Q, Gouws E., Baxter C. (2007) Global epidemiology of HIV-AIDS. Infect Dis Clin

North Am.

Chirambo and Steyn (2009). Aids and Local Government in South: Examining the Impact of an Epidemic on

Ward Councillors, Idasa.

Department of Health (2008). South Africa National HIV and Syphilis Prevalence Survey, Pretoria: Department

of Health.

Department of Health (2007). HIV and AIDS and STI Strategic Plan for South Africa, 2007-2011, Pretoria:

Department of Health.

United Nations General Assembly Special Session on HIV and AIDS (UNGASS), (March 2010). Republic of

South Africa Country Progress Report on the Declaration of Commitment on HIV and AIDS 2010 Report.

Reporting Period: January 2008 - December 2009.

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