Closeup picture of a young African girl in a classroom

by Matthew M. Kavanagh, PhD, Director, Global Health Policy & Governance Initiative, O'Neill Institute and Vuyiseka Dubula-Majola, Director, Africa Centre For HIV/AIDS Management, Stellenbosch University

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The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) policy in South Africa has recently shifted—centralizing funding in 27 districts, with increased focus on facility-level interventions to speed scale-up and address program efficacy. To understand how these shifts are being implemented and gain insights from health leaders at the front lines of the AIDS response, we conducted semi-structured interviews with managers and clinicians at randomly selected sites in the highest priority districts. The data suggest that U.S.-funded implementing partners are playing an important role in these high-burden districts.

The PEPFAR intervention at facility level, however, remains a "light touch" in a context of facilities with large numbers of patients on treatment. About half of clinics report visits by PEPFAR-funded NGO staff multiple times per week. In addition, PEPFAR supports a small set of human resources for health (HRH) based at or near full time at each clinic—in about half of facilities, this includes clinical staff, most often one nurse, alongside a light complement of lay workers.

We find little evidence that adding these staff results in government staff shifting away from doing HIV, but our data do suggest that the number of staff in many clinics may be too small to drive significant changes in service delivery. We also find that the distribution of staff does not correlate to the size of the anti-retroviral treatment program. There is a particular gap in outreach, default tracing, and community service delivery staff in both PEPFAR and government HRH complements. Training and data-sharing is common at site-level but, after many years, may be providing diminishing returns. Together, our findings suggest an opportunity for PEPFAR South Africa to revisit its model and consider increasing service delivery intensity at site level. At least as importantly, challenges identified by facility leaders suggest funding for community-based services linked to the facility may have the greatest impact to address linkage and adherence.

Importantly we also show a significant governance challenge—a disconnect between significant PEPFAR funding through NGOs tasked with improving HIV outcomes in the public health system governed by the provincial and municipal governments.