aids, leadership and service delivery in south africa: what the people think - halogen · 2012. 4....
TRANSCRIPT
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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)
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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
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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
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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.
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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).
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AIDS, leadership and service delivery in South Africa: What the people think • 7
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.
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8 • AIDS, leadership and service delivery in South Africa: What the people think
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
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AIDS, leadership and service delivery in South Africa: What the people think • 9
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
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10 • AIDS, leadership and service delivery in South Africa: What the people think
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.
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AIDS, leadership and service delivery in South Africa: What the people think • 11
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
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12 • AIDS, leadership and service delivery in South Africa: What the people think
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
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AIDS, leadership and service delivery in South Africa: What the people think • 13
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.
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14 • AIDS, leadership and service delivery in South Africa: What the people think
Figure 3: Proportion of citizens who would vote for an HIV-positive candidate in their
municipalities
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Dip
ales
eng
Msu
kalig
wa
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 15
Figure 4: Proportion of citizens who would not vote for an HIV-positive candidate in their
municipalities
100
90
80
70
60
50
40
30
20
10
0
%
Mkh
amba
thin
i
Um
shw
athi
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Dip
ales
eng
Msu
kalig
wa
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
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).
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16 • AIDS, leadership and service delivery in South Africa: What the people think
Figure 5: Proportion of citizens who don’t know whether or not they would vote for an
HIV-positive candidate in their municipalities
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 17
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.
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18 • AIDS, leadership and service delivery in South Africa: What the people think
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 19
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.
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20 • AIDS, leadership and service delivery in South Africa: What the people think
Figure 9: Proportion of citizens who expressed that HIV and AIDS-related services are
available and good in their municipalities
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Dip
ales
eng
Msu
kalig
wa
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 21
Figure 10: Proportion of citizens who expressed that HIV and AIDS-related services are
available but not good in their municipalities
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Dip
ales
eng
Msu
kalig
wa
Mor
etel
e
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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22 • AIDS, leadership and service delivery in South Africa: What the people think
Figure 11: Proportion of citizens who expressed that HIV and AIDS-related services are not
available in their municipalities
Mkh
amba
thin
i
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Msu
kalig
wa
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 23
Figure 12: Proportion of citizens who expressed that good HIV and AIDS-related services
are available but not accessible in their municipalities
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Dip
ales
eng
Msu
kalig
wa
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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24 • AIDS, leadership and service delivery in South Africa: What the people think
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
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Gre
ater
Tza
neen
Mak
hado
Mod
imol
le
Mol
emol
e
Moo
kgop
ong
Gre
ater
Mar
ble
Hal
l
Thab
a C
hweu
Alb
ert
Luth
uli
Bus
hbuc
krid
ge
Dip
ales
eng
Msu
kalig
wa
Mor
etel
e
Kge
tlen
griv
er
Ven
ters
dorp
Maq
uass
i Hill
s
Nal
edi
Tsw
aing
100
90
80
70
60
50
40
30
20
10
0
%
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 25
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).
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26 • AIDS, leadership and service delivery in South Africa: What the people think
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 27
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).
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28 • AIDS, leadership and service delivery in South Africa: What the people think
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
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AIDS, leadership and service delivery in South Africa: What the people think • 29
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).
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30 • AIDS, leadership and service delivery in South Africa: What the people think
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
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AIDS, leadership and service delivery in South Africa: What the people think • 31
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).
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32 • AIDS, leadership and service delivery in South Africa: What the people think
Figure 20: Proportion of citizens who answered “no” to availability of ARVs in KZN
municipalities
Mkh
amba
thin
i
Ric
hmon
d
Um
shw
athi
Um
voti
Con
dom
100
90
80
70
60
50
40
30
20
10
0
%
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).
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AIDS, leadership and service delivery in South Africa: What the people think • 33
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).
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34 • AIDS, leadership and service delivery in South Africa: What the people think
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
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AIDS, leadership and service delivery in South Africa: What the people think • 35
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.
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36 • AIDS, leadership and service delivery in South Africa: What the people think
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
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AIDS, leadership and service delivery in South Africa: What the people think • 37
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.
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38 • AIDS, leadership and service delivery in South Africa: What the people think
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.