13 April 2023


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In 2022, HRI partnered with Shaun Shelly who used an HRI tool to assess the landscape for increasing domestic financing for harm reduction in South Africa. This report outlines the process used and the findings that emerged, covering the operational landscape for community-led, community-based and civil society organisations and the financial landscape for harm reduction. It maps advocacy opportunities and partnerships and makes key recommendations for increasing the domestic harm reduction financing.

Key Findings

  • South Africa has a very supportive and relatively simple process for registering non-profit organisations and not-for-profit companies. Registration with the Department of Social Development is free and can be done online. Annual reporting requirements are not particularly challenging and can also be submitted online.
  • Social contracting between the government and CSOs (civil society organisations) is well established, and mechanisms are in place to transfer funds from the treasury to CSOs. The National Department of Health and the National Department of Social Development have contributed significant amounts to large NGOs and lesser amounts to community-based organisations; and no funding has been made available for harm reduction except in the City of Tshwane.
  • The City of Tshwane funds South Africa’s largest opioid agonist therapy (OAT) and needle and syringe (NSP) programme: the Community Oriented Substance Use Programme (COSUP). Built on the principles and lessons of community-oriented primary care, COSUP is unique in its approach to drugs and is the only low-threshold city-wide OAT and needle and syringe programme in the country. COSUP currently accounts for almost half of all South Africa’s harm reduction services and provides these at about half the cost of the Global Fund programme.
  • Surprisingly, COSUP’s success has gone largely unrecognised and unnoticed by government and policymakers.
  • While the National Strategic Plan and the National Drug Master Plan highlight harm reduction as an essential part of both plans, there is no current commitment to fund harm reduction from any National Government Department.
  • The National Government does not fund any harm reduction services or commodities in South Africa. The only domestic funding is from the City of Tshwane Municipality.
  • The largest international donors for harm reduction in South Africa are the Global Fund and US CDC/PEPFAR. The Global Fund is now in the third round of three-year funding cycles. In the 2022- 2025 country allocation (NFM3), the Global Fund doubled its investment in harm reduction services for people who use drugs to USD$ 14,801,042. Even with increases in funding, needle and syringe programme coverage is still only 30% of the WHO target of 200 per person per year.
  • According to the South African country submission to the Global Fund in September of 2021, there is a 96% funding gap for HIV interventions for people who use drugs.

Recommendations for actions to improve the domestic funding landscape in South Africa

  • Decriminalise drug use and possession
  • Establish a formal people who use drugs sector within the South African HIV coordination structures (AIDS Councils)
  • Share the successes, utility, and potential of COSUP to encourage increased municipal and local government funding for harm reduction services
  • Prioritise network funding, inclusion, consultation, and equitable peer compensation for people who use drugs
  • Ensure funding to continue the work of harm reduction advocates, researchers, and activists.

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