MSH South Africa and the HIV & AIDS Movement: A Conversation with Jean-Pierre Sallet, Jackie Sallet, and Donald Harbick

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More than ten years after gaining independence and holding its first democratic elections, South Africa has made substantial development gains and boasts a growing economy. Despite these achievements, South Africa still faces the largest HIV-positive population in the world. Apartheid is no longer law, yet the health system still retains many inequities from that era. A major challenge for the government of South Africa is improving the accessibility and quality of basic health services.

MSH has been working in South Africa for 15 years, and currently operates four projects (of which two are regional) that are helping to strengthen the health care delivery system by supporting integrated primary health care services at the district, provincial, and national levels. We spoke with three MSH representatives working to improve HIV & AIDS prevention, treatment, or care in the country: Jean-Pierre Sallet, MSH Country Representative for South Africa and current director of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program; Jackie Sallet, Technical Lead for Leadership Development for the South Africa Sustainable Response to HIV & TB Services (SA SURE) project; and Donald Harbick, Country Director for the Building Local Capacity (BLC) for Delivery of HIV Services in Southern Africa project.

What is the state of the HIV & AIDS movement in South Africa today?

JACKIE SALLET: The South African government has invested heavily in HIV & AIDS programming for the past 10 to 15 years. Coupled with that investment is the launch of The US President’s Emergency Plan for AIDS Relief (PEPFAR) program in 2003. For the first five years of PEPFAR the response to the HIV epidemic in South Africa was largely an emergency response to get as many people living with HIV onto treatment as quickly as possible. But with the re-authorization of PEPFAR and the launch of the US government’s Global Health Initiative in 2010, there has been a shift from an emergency response to a sustainable response. The South African government’s new National Strategic Plan for HIV/STI and TB 2012–2016 takes a more developmental approach.

JEAN-PIERRE SALLET: The South African government started providing antiretroviral therapy (ART) in 2003 through public hospitals. Today, the government’s national plan for HIV & AIDS (mentioned by Jackie) is designed to not only reduce the impact of the disease and improve life expectancy, but also to improve overall mother and child health and overall health system effectiveness. The plan aims to address social and structural factors that influence the disease, prevent new infections, sustain health and wellness for people living with HIV, and protect human rights.

To date more than 1.5 million people living with HIV are on treatment, making the South African treatment program the largest of its kind in the world. More than 400,000 new patients are expected to receive ART each year. To support this massive scale-up, the government has started Nurse Initiated and Managed Antiretroviral Therapy (NIMART) with antiretroviral medicines expected to be made available through all 4,000 public sector health facilities, including hospitals, primary health care clinics, and community health centers.

Jackie, How does SA SURE’s work fit into the HIV & AIDS movement in South Africa?

JACKIE SALLET: As part of the government’s new strategic plan for HIV & AIDS, the national department of health is currently re-engineering the primary health care system with an emphasis on leadership and management capacity of the district and sub-district health teams. The SA SURE (South Africa Sustainable Response to HIV) project is focused on strengthening the district health system. It aims to build capacity of managers and technical staff to do population-based planning, target setting, and monitoring and evaluation; deliver integrated HIV and TB services; develop, implement, and maintain referral networks; and use high-quality health information as a key driver to decision-making. In its first year, the project has established good working relationships and buy-in in all 16 project districts. We intend to build local ownership to ensure sustainability when the project concludes.

Going forward, what are the biggest challenges for SA SURE?

JACKIE SALLET: One of the challenges for us is measuring and evaluating project outcomes in the midst of various government initiatives being implemented simultaneously at the district level by numerous implementing partners.

Don, why is capacity-building important in the HIV & AIDS movement in South Africa and the region? What is the role of the BLC project?

DON HARBICK: Many local, indigenous organizations in the region are doing wonderful work in the prevention and treatment of HIV & AIDS, but they are constrained by funding, limited skills, and poor structure and infrastructure. MSH’s Building Local Capacity (BLC) project works with these organizations—both government and civil society—to strengthen them, make them more sustainable, and help them qualify for and manage US government funds. BLC is active in five countries (Lesotho, Swaziland, Botswana, Namibia, and Angola), but the focus in each country is unique to the needs of each area. For example, in Lesotho our focus is on orphans and vulnerable children and in Namibia we are helping government ministries to lead and coordinate their programs.

How has the BLC project contributed to strengthening health systems overall?

DON HARBICK: As part of BLC’s work to build the capacity of individual agencies, we have developed innovative HIV prevention programs, increased the number and types of services to orphans and vulnerable children, worked to strengthen community approaches to prevention and treatment, improved the quality of services in hospitals where HIV & AIDS care is given, developed tools for assessing services and measuring progress, supported Global Fund and PEPFAR efforts to build regional HIV & AIDS services for mobile populations, and developed leaders and managers to move and inspire the creative approaches and do the hard work that is required.

Going forward, what are the biggest capacity-building challenges for HIV & AIDS in South Africa?

DON HARBICK: The challenges are many and varied, but one of the biggest challenges is simply a huge demand for assistance and finding ways to meet that demand. Everywhere we have described the BLC program we have had organizations eager to receive assistance.

Jean-Pierre, how does the SIAPS program strengthen the overall health system in South Africa?

JEAN-PIERRE SALLET: The overall goal of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program in South Africa is to strengthen the capacity of pharmaceutical systems to improve health outcomes. It builds on the work of the holistic approach of the Strengthening Pharmaceutical Systems (SPS) program, which not only supported the procurement and distribution of pharmaceutical supplies but also strengthened leadership development, infection control, and emerging government priorities. SIAPS will expand SPS to new areas such as pharmaceutical financing. All of these efforts strengthen the overall health system in South Africa, contributing to improved delivery of primary health services.

What are the biggest challenges for pharmaceutical management for HIV & AIDS in South Africa?

JEAN-PIERRE SALLET: The sheer size of the HIV & AIDS program is a major challenge, as is the increasing burden of co-infections and non-communicable diseases. There is a scarcity of qualified staff and a large number of health care facilities (about 4,300). In addition, it is a highly regulated environment with a complex governing system (including nine provincial governments).

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