The coming local government elections may mean changes in office bearers, which could undermine advances made in improving the lives of homeless people who use drugs, and may even halt future progress.
A large number of people who use drugs are also living on the street and what society should be doing is finding ways of managing this social problem in a way that reduces harm. Local governments should be thinking about how to implement harm-reduction strategies in all aspects of governance, but particularly in relation to drug use.
A harm-reduction approach that takes account of all people’s human rights is the only way to bring marginal population groupings into a governance agenda, and in so doing making all lives safer and healthier. In carving out strategies that do this for homeless people, and particularly for those who are both homeless and have a drug-use disorder, all of society would feel more secure in their localised settings.
Developing this type of rights-based and participatory form of governance at the local level requires involvement by those most affected. The reality is, however, that most homeless people do not have the required identification documents to take part in the elections, which disenfranchises them, further silencing their voices and leading to the implementation of programmes that have little or no impact.
As it stands, local governments do not have dedicated budgets for remedying homelessness, pushing homeless people further to the margins. This has consequences not just for the homeless, but also for the rest of the community who feel that homelessness underpins public health and public safety threats.
Homelessness is a growing issue, given the combination of rapid urbanisation and sharp increases in inequality. As the phenomenon increases, local governments will not have the capacities, skills or resources to deal with it on their own.
We are calling for collaborative relationships with NGOs, universities and civil society groupings to co-create sustainable solutions. Such solutions require moral and financial support from local government. They can provide law enforcement with an operating paradigm that steps away from criminalisation and rather finds solutions that take people off the street and give hope to those with a drug-use disorder. Tshwane and eThekwini have come to the fore in this approach.
In 2016, the City of Tshwane Metropolitan Municipality became the first (and presently the only) municipality to fund opioid substitution therapy and needle syringe services through the community-oriented substance use programme (Cosup) implemented by the University of Pretoria’s Department of Family Medicine.
By 2019, Cosup had established 20 service sites across Tshwane (consolidated to 16 sites in 2021), started 2,178 adults on substitution therapy, managed more than 240,000 clinical and psychosocial consultations with 11,350 beneficiaries, and distributed more than 50,000 needles per month. Service delivery includes screening for substances at household level and follow-up of clients; outreach/education and awareness campaigns and capacitance of local NPOs and other service providers to meet demand (including harm reduction).
City budgets have been stretched by Covid-19, meaning that the total budget available for managing substance abuse is significantly lower, which threatens the sustainability of services currently delivered.
The Sediba Hope Medical Centre (NPC), based in central Pretoria since 2012, provides vulnerable, hard-to-reach populations such as homeless people who use drugs, with primary healthcare services. Working with public-private partners such as the University of Pretoria and Doctors Without Borders, they offer psychosocial services and mental health interventions to help people normalise their lives.
These partnerships also provide resources and mechanisms to reduce the harm that comes to those who use drugs. This non-state clinic provides compassionate and non-judgmental healthcare services to people who use drugs as well as other key population groups such as sex workers, people living with HIV, homeless people, the uninsured and refugees. In addition, the centre has assisted city and non-profit organisations with capacity building, oversight, monitoring and evaluation of services.
The partnership between the Urban Futures Centre at the Durban University of Technology and the City of eThekwini is significant because the metro now boasts the country’s first public-private comprehensive and low-threshold harm-reduction centre. The Bellhaven Harm Reduction Centre serves roughly 200 homeless and low-income people daily, providing medical interventions and a psychosocial service, a drop-in centre for socialising, and a nutrition programme. The municipality would not have been able to do this alone and wisely partnered with the university and non-government organisations engaged in public health.
The centre, located in the heart of Durban, has become a national model for the delivery of evidence-based interventions. With several NGOs and the eThekwini Municipality, it provides social workers to conduct individual psychosocial sessions as well as needle and syringe exchanges, and HIV testing and counselling.
The service mostly prioritises those who inject drugs. Beneficiaries include people who are on medication for ARVs, TB, opioid replacement and other chronic diseases. The centre has been in operation for just over a year and has already won multiple awards. As a lead partner, the municipality has benefited significantly from the positive attention that Bellhaven has received, both locally and globally.
Local governments need to tap into the successes achieved in both Tshwane and eThekwini during Covid-19.
Through a combination of funding and collaboration, progress was made in a strategy aimed at housing and harm reduction for homeless people in Tshwane. Unfortunately, many of the gains made have since been lost, but there is evidence that cities can make such programmes work. A proactive step that can be taken by local governments is to review and repeal all by-laws that discriminate against homeless people and deny them dignity.
Worryingly, the Cape Town City Council recently approved a new unlawful occupation by-law, alongside updates to the streets, public places and prevention of noise nuisances by-law. However humanely these are to be enforced, the fact that the bylaws will be applied to already traumatised people should not be taken lightly.
Non-state organisations such as the South African Network of People Who Use Drugs have taken much of the responsibility for assisting and supporting people who are homeless and/or who use drugs, emphasising a humane approach. This organisation depends on international funding, which threatens the sustainability of its interventions.
Local governments can play an active role in the implementation of the national framework on harm reduction, as set out in the National Drug Master Plan. This would go a long way to ensuring that homeless people who use drugs are not left behind through the provision of evidence-based interventions in partnership with non-state actors. This is dually beneficial for the community of homeless people who use drugs and the community around them.
City governments should take ownership of their role in shaping a better future for all, including people who use drugs. Most voters would love to see cities where marginalised and vulnerable groups are cared for. This would improve public safety and health. It would also pave the way for a more investment-friendly environment with the greater confidence it would engender. DM