Government-funded interventions for drugs are limited to abstinence-based programmes and inpatient rehabilitation, and medications for opioid dependence are not listed on the essential drugs list for long-term treatment. Significantly more money is spent on catching, convicting, and incarcerating people who use drugs than on harm reduction and treatment. One notable exception is the City of Tshwane, which funds the world’s first Community-Oriented Substance Use Programme (COSUP).

HRI convened the study to document COSUP as a model of harm reduction funding; with aims to offer guidance and inspiration to harm reduction and budget advocacy activists in understanding the way of domestic financing process, related payment mechanisms, in designing community-oriented programs and in gaining and maintaining political support and funding for the program.

There is a full report that include context, struggle and COSUP time-line; including intervention design process, funding model, reporting, impacts, recommendations and future plan. While briefing is a succinct version of the full report to provide a quick glance to COSUP’s introduction, funding model, governance etc.

The Community Oriented Substance Use Programme (COSUP) in Tshwane, South Africa represents an innovative model of domestic harm reduction funding. Established through collaboration between the City of Tshwane and the University of Pretoria’s Department of Family Medicine, COSUP adopts a community-oriented primary care approach. COSUP combines harm reduction, human rights and community integration into a continuum of care, providing comprehensive services such as opioid agonist therapy (OAT), needle and syringe programmes (NSP), psychosocial support and vocational training.

COSUP provides around 50% of all harm reduction services in South Africa and relies mainly on funding from the City of Tshwane. COSUP has survived opposition from prohibitionists, several changes in political leadership, a city placed under financial administration, and significant budget cuts.

The funding model used for COSUP combines procurement contracting and grant funding. The City of Tshwane makes scheduled payments based on the Service Level Agreement (SLA) and contract timeline. However, COSUP also has access to the flexibility and up-front payments that are typical of grants. The level of trust and historical dealings with the Department of Family Medicine meant that the funding was flexible, and line items were adjusted as priorities shifted. Unlike other municipalities, interventions for drug use in Tshwane are funded by the Department of Health.

A COSUP governance committee comprises Directors from Tshwane City’s Department of Health and Social Development, the Director of Support Services, the Dean of the Faculty of Health Sciences and the Head of Family Medicine from the University of Pretoria, or their appointed representatives. Committee meetings are scheduled quarterly, and the role of the Governance Committee is to ensure legal and financial accountability, strategic direction and oversight.

The Chair of the South African Network of People who Use Drugs (SANPUD) sits on COSUP’s central management team. Peer educators from the community of people who use drugs are central to the programme and services. Peer-led outreach services include screening, brief interventions, referrals, distributing and collecting needles and syringes, behavioural interventions and engaging with the community of people who use drugs.

Community advisory groups provide regular feedback on services. The groups decide their structure, which various stakeholders may lead. COSUP also engages with sex workers and people with experience of homelessness. Collaboration with stakeholders is broad and includes health, mental health, social services, law enforcement, education and other service providers from the government, NGOs and the private sector.

• High retention rate (around 60%) in OAT
• The NSP in Tshwane engaged people in broader health services and was considered to be of benefit to the whole community.
• The multidisciplinary approach has provided access to vital social and health services for people who use drugs, enhancing overall wellbeing.
• COSUP was named a best practice case for governance in the 2020/21 State of South African Cities report.
• The City of Tshwane was described as the most positive example of harm reduction scale-up in South Africa during the COVID-19 national lockdown.
• COSUP currently accounts for almost half of South Africa’s harm reduction services and provides these at about half the cost of the Global Fund programme.