The Community-Oriented Substance Use Programme (COSUP), established in 2016 through a partnership between the City of Tshwane and the University of Pretoria, demonstrates how a publicly funded health intervention can be advocated for, financed, and sustained within a municipal system. COSUP was advanced through a pragmatic case built on local data, professional accountability, and fiscal logic.

It now stands as the country’s clearest example of divesting from punitive responses and investing in health-based solutions. COSUP supports over 6,000 clients across 17 service delivery sites (fixed and mobile). The average cost per client is approximately 22 times lower than the cost of incarceration, and the Tshwane health budget contribution increased from ZAR 17.4 million (USD 945,000) in 2016 to ZAR 29 million (USD 1.6 million) in 2023/24. COSUP’s value is not only financial: it reduces preventable harms and strengthens pathways into health care and social support.

6,000 – Over 6,000 people are supported annually by COSUP.

17 – COSUP has 17 fixed and mobile service delivery sites.

$1.6M – The dedicated municipal health budget allocation is approximately USD $1.6 million.

148% – The prison population is at 148% capacity: 156,600 people in space for just 105,474.

22x – Supporting one person through COSUP costs ~22× less per year than imprisonment.

$10,430 – The cost of imprisoning one person for a year is ~ZAR 169,700 (USD 10,340).

Prior to COSUP, opioid use and related harms (including heroin and the street drug nyaope) were primarily addressed through policing, detention, and abstinence-oriented treatment. People who use drugs were repeatedly arrested for non-violent offences and cycled through detention without access to sustained, evidence-based harm reduction.

Public sector treatment options, including NICRO’s diversion programmes, were largely limited to short-term detoxification or abstinence-based residential care, both associated with high relapse rates. Services were often inaccessible due to stigma, homelessness, criminal records, and administrative barriers, including the lack of identity documents (ID) required to access healthcare. Needle and syringe programmes were limited and donor-funded, and methadone was not available through routine public sector procurement.

The shift in Tshwane was driven by clinicians and public health leaders who reframed substance use as a health issue that require ongoing, evidence-based care. They argued that health professionals and public administrators have an ethical and professional duty to act on evidence, not ideology. This framing was crucial: it translated a harm reduction approach into the language of service delivery,
accountability, and cost-effectiveness that resonated with municipal decision-makers.

The punitive approach and limited access to harm reduction placed immense strain on the public health system. A multi-province cohort analysis of people who inject drugs engaged with harm reduction services in South Africa recorded 283 new HIV infections over 2,306 person-years of follow-up; HIV incidence in the broader Gauteng province was 16.7 per 100 person-years, underscoring ongoing transmission risk without consistent HIV care, harm reduction and OAT coverage.

Parallel policy advocacy and technical engagement with municipal leadership strengthened the case by demonstrating that the city was already paying heavily for punitive approaches through prisons, policing, and unmanaged health consequences, and that a health-based alternative could deliver better outcomes at lower cost.

In 2016, following sustained engagement between the City of Tshwane and the University of Pretoria, COSUP was formalised through a service-level agreement (SLA). Crucially, the programme was established as a municipal health intervention, not a pilot. The City committed domestic funding, while the University provided clinical, operational, and research capacity, enabling rapid scale-up with public accountability.

Municipal funding began at approximately ZAR 17.4 million (USD 945,000) in 2016 and rose to around ZAR 41.5 million (USD 2.53 million) by 2019, reflecting rapid expansion. Funding later stabilised, with approximately ZAR 29 million (USD 1.6 million) allocated in 2023/24 as a dedicated budget line.1 In early 2024, the City of Tshwane entered into a new SLA valued at ZAR 111.6 million (USD 6.8 million) to continue COSUP through to 2026, with a focus on geographic equity and integrated prevention and service delivery.

Municipal funding was invested in tangible service capacity, including a diversity of fixed and mobile clinics, clinical staff, peer outreach workers, data systems, and logistics. COSUP delivers opioid agonist therapy (OAT), sterile injecting equipment, HIV and tuberculosis screening, wound care, psychosocial support, and assistance with identity documentation, supported by a strong peer workforce to maximise outreach. This investment demonstrated that harm reduction can be financed and delivered through public systems in South
Africa.

Tshwane evidence also shows why low-threshold harm reduction is essential for women. Qualitative research with women who inject nyaope describes stigma and exclusion from care, elevated safety risks (including violence), and HIV vulnerability linked to social marginalisation, reinforcing the need for accessible services that combine OAT, NSP, and social support rather than relying on arrest or abstinence-only pathways.

A defining feature of COSUP is its peer workforce and community inclusion. Peer educators strengthen continuity of care through outreach, screening, referral navigation, NSP distribution/returns, and ongoing engagement, while governance mechanisms reflect lived experience through SANPUD representation and community advisory feedback.

Retention and affordability are decisive, and they strengthen the Divest/Invest case. COSUP reports solid OAT retention overall (around 60%), and retention beyond six months was substantially higher when OAT was city-funded (87%) compared with self-funded (62%) during 2016–2020, showing that public financing is a key driver of treatment continuity and outcomes.

When OAT is unaffordable or interrupted, people cycle back into instability, emergency care, and repeated criminal justice contact, the most expensive pathway. By contrast, stable, publicly funded, low-threshold delivery improves engagement and functioning, and reduces avoidable downstream costs. COSUP has proven resilient in the face of a funding crisis for harm reduction in the country and region, providing reliability and security while services reliant on donor-funding collapsed.

Shifting resources from punitive enforcement and short- term abstinence-only responses toward publicly funded harm reduction and OAT delivers better outcomes at lower long-term cost and treats opioid dependence as a health issue rather than a revolving door through courts and detention