United Nations Public Service Awards Case Studies

As has been outlined in numerous articles and reports, South Africa has one of the most serious HIV epidemics in the world. A National HIV Prevalence Survey conducted by the Human Sciences Research Council (HSRC, 2009) reported that more than 5.5million people in the country are infected with HIV; with the adult prevalence estimated to be roughly 10.9%. Rural areas are disproportionately affected, with the more rural provinces generally having higher prevalence rates. Eg. KwaZulu-Natal has an estimated adult prevalence of 15.8%, while the Western Cape (a relatively urban and developed province) is estimated at 3.8%. Healthcare provision in rural areas is also much more difficult, as large areas will often have only one or two hospitals or clinics, and many people will not be able to reach these when they need care or treatment. Unemployment in rural areas is often also very high, meaning that those that many people cannot afford either the treatment or the trip to get there. Services at these medical centres are often inadequate, with too few staff, too many patients, minimal medical supplies, and out-of-date medical equipment.

The South African government initially responded very poorly to the HIV epidemic. It refused to roll-out anti-retrovirals (ARVs) to those infected (including HIV+ pregnant women); and blocked hospitals that tried to do so. A recent article in the Journal of AIDS (2008: 49 (4), pp. 410-415) estimated that the policies by the Mbeki-government directly led to around 330 000 deaths from AIDS between 2000 and 2005; and that 35 000 babies were born HIV+ during this time. This adversely affected all people infected and affected by HIV, except those who were rich enough to buy or import ARVs by themselves. However, this has since started to change, with government beginning to make ARVs freely available across the country, and better standards of treatment and care being introduced. The Department of Health also began identifying priority nodes, which were areas where the epidemic was having the greatest impact. Health clinics and hospitals in these areas were asked to focus on HIV/AIDS as much as possible. However, many of these health centres did not have the necessary resources in terms of staff, medication, buildings, and laboratory facilities to be able to do this, and were unable to respond to the epidemic effectively.

Those who were on ARVs would often default due to not understanding the importance of treatment adherence, fear of stigma, lack of ability to return to the hospital regularly to receive medication, and numerous other reasons. Thus, once again, despite government’s new commitment to the issue, many people in rural areas were still unable to access good and effective treatment for HIV and other communicable diseases.

What is the initiative about? (the solution)
The main benefit of this project was to help an under-resourced, relatively rural hospital to be able to begin providing good, effective ARV treatment (ART). A wing of the hospital was renovated and equipped, and opened as the new ART centre. New staff were hired and trained in HIV/AIDS treatment and care, including ART roll-out and voluntary counselling and testing (VCT). Staff also provide education around HIV, medication, treatment, and healthy living. Pre- and ante-natal facilities are available, as well as fertility services. Better equipment and resources were installed in the clinic; and better follow-up could be carried out, ensuring that fewer patients were lost to defaulting. Patients are encouraged to start support groups amongst themselves; and many have begun vegetable gardens. Rollout to other clinics in the area has also begun, and each clinic is assisted in establishing its own vegetable garden. Roughly 1600 patients are being seen per month (around 170 per day). 3120 patients were on ART by the end of 2009; with a defaulter rate of only 3%; and a 0.43% death rate. 116 children were on ART by the end of 2008. 95% of patients attending the clinic took HIV tests; and the uptake of Nevirapine (to prevent mother-to-child transmission of HIV) was 81%. Two tracing teams were established to do follow-up on patients on ART, and this has contributed to the low defaulter rate. Rollout has been completed to 13 other local clinics, and the project employs 20 staff. 42 resident nurses and counsellors received training in basic pediatric AIDS management in 2007. Nutritional support packs are also made available to clinic patients who need it. Project HEART is now able to provide adherence counselling, VCT, ART, CD4 counts, treatment of opportunistic infections, prophylaxis screening for TB, and cervical screening and fertility services.

Who proposed the solution, who implemented it and who were the stakeholders?
The initial focus on HIV+ patients at Vryheid hospital was initiated by the Department of Health in 2004, with an ART project starting in that year. In 2006, the Edith Glaser Pediatric AIDS Foundation South Africa (EGPAF SA) began discussions with the KwaZulu-Natal DoH regarding sponsorship of the ART programme at Vryheid Hospital. In 2007, the HEART project began. The funding was made available to help the ART programme expand, through capacity-building of existing staff, hiring new staff, technical assistance, health system- and monitoring and evaluation system-strengthening, and infrastructure rehabilitation. Staff salaries were paid, and three computers and a fax machine were bought to assist in monitoring and evaluation. Furniture and equipment were also provided; and tracing teams were employed to help do follow-up on patients on long-term treatment. The funding is intended to be phased out over time, with the Department of Health taking over management and funding of the project in the future. Thus, the main partners are the KwaZulu-Natal DoH, EGPAF SA, and the Vryheid Hospital.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objective is for the Vryheid Clinic to deliver an effective ART programme, covering all aspects of HIV treatment, prevention and care. A secondary objective is for the main funder to be able to pull out of the programme over time, leaving an effective ART centre, supported by government. In order to achieve this, the first step was to provide appropriate premises, with sufficient resources and equipment. A ward of the hospital was renovated and refurbished, which included office and medical equipment. The DoH provided the necessary medication. Staff at the hospital also needed to be properly trained to be able to provide effective healthcare in an ART programme. They were therefore trained in all aspects relating to HIV/AIDS, including in VCT, behaviour change which could assist in prevention, treatment, long-term care, nutrition, and follow-up. Also included were common opportunistic infections (including tuberculosis, and sexually transmitted infections), and how to prevent and treat these. Facilities for patient database management were provided, and staff were also trained how to use these. One of the most important aspects of this was keeping good records of patients and their treatment, including whether they were attending their follow-up appointments. Patients who default on treatment are traced and followed up, to ensure a low defaulter rate. Facilities for the prevention of mother-to-child transmission were also established, as well as family planning and fertility. Education is also provided to patients who attend the clinic, to try to prevent further future infections. Patients on ART are encouraged to start support groups, and to establish vegetable gardens to provide healthy food for themselves and for the clinic. This also helps to reduce stigma around HIV. In order to ensure that the initiative remains functional, and that the DoH is able to take over its management and funding in the future, considerable capacity-building interventions were carried out. Along with training on issues relating to HIV/AIDS, nurses at the hospital were trained in mentoring and training, meaning that they could help to train and mentor new staff at the hospital in the future. This helps to reduce the need for external training in the future. DoH district managers were also trained in all aspects of HIV/AIDS, and in project management, to ensure that they would be able to manage the project in the future without external assistance. Roll-out to other clinics in the area also helps to spread the impact of the initiative beyond just the patients of Vryheid. The other clinics also aim to establish vegetable gardens on their premises.

b. What were the key development and implementation steps and the chronology? No more than 500 words
In 2004, the KwaZulu-Natal Department of Health identified priority nodes where the HIV epidemic was having the largest impact. This included the Vryheid Hospital. The DoH asked the hospital to begin focusing on HIV+ patients, but there was minimal funding available for this. At first, the hospital battled to provide good quality ART, due to a lack of funding, resources, space and personnel. Thus, in 2005/06 only 634 patients were initiated onto ART. In 2006, the Elizabeth Glaser Pediatric AIDS Foundation began discussions with the DoH, as part of their International Family AIDS Initiative. One of the main focuses of this initiative is to increase access to treatment and care for those with HIV. The agreement was that EGPAF would provide funding for set-up costs to renovate the premises, install equipment, and provide training for staff. Salaries for staff would also be subsidised. Feeder clinics in the area would be identified and supported; and the initiative would begin to be rolled out to other medical centres in the area. The DoH would provide all the medication, including ARVs, and would begin to take over the salary costs in the future. A ward in the Vryheid Hospital was renovated, and opened as the new ART clinic in May 2007. DoH district managers were trained in a number of skills (outlined above) to ensure that they would be able to effectively manage the project in the future. Staff at the hospital were also provided with training in different aspects of HIV/AIDS treatment and prevention. This included training in patient monitoring, and database management. As more patients were initiated onto ART, they were encouraged to establish support groups, and to develop food gardens. By 2008, EGPAF was only providing funding for staff salaries, while the DoH was covering the rest of the costs.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
The main challenge facing the project is attracting staff to the hospital, especially in the entry level posts. Many of these jobs are not attractive for people, who would rather go to urban areas to find work for better pay. The only real way to combat this is to make the job more appealing, and the salary competitive with other similar posts in more urban areas. The project has managed to hire new staff because of the funding from EGPAF, but this has remained difficult. A further problem is the difficulty in accessing resources, including medication and laboratory services. Because the hospital is in a relatively rural area, it is not always possible for them to get all the required medication on time. However, because of the partnership with the DoH, this is not a common problem. The fact that all specimens have to be sent to hospitals with the necessary laboratories means that test results often have a very long turn-around time. This includes tests for CD4 counts, and on sputa for TB. There is not much that the hospital can do about this, unless a significant amount of funding becomes available to establish the necessary laboratory services in-house. A final problem is treatment adherence among patients. The default rate among all ART projects is high, with patients defaulting on treatment for a wide range of reasons. One of the most worrying is the fact that people prefer to keep low CD4 counts in order to continue accessing social grants. The grants are only made available to those with CD4 counts under a specific level, and if patients take ART for too long, they will no longer be eligible for these. Thus, some patients default purposefully, to ensure they can continue receiving these grants. However, the project has been able to maintain a low default rate (3%) by providing education to patients on HIV and its treatment; and by conducting follow-up on patients who miss appointments.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The funding for the project was almost entirely provided by EGPAF SA, and was originally received from US PEPFAR. EGPAF SA initially sponsored all aspects of the programme, but over time this is being scaled down, with the DoH taking over increasing responsibility. At the moment, EGPAF SA provides funding to cover staff salaries. The total cost of the project at Vryheid Hospital is estimated to be around R3 820 000. R2 070 175 was spent on refurbishing and renovating the ward which now houses the ART clinic; and additional project costs amounted to R176 535. Human resources costs totalled R1 385 477. In the future, the DoH will subsidise the staff salaries. EGPAF SA also provided training to a wide range of stakeholders. This included project management training to the DoH programme managers; and PMTCT, ART, HIV/AIDS prevention, TB/HIV integration, family planning, and the management of STIs. Nurses at the hospital received training in mentoring and coaching (to help them mentor and coach new staff); and Integrated Management of Adolescent and Adult Illnesses (IMAI – developed by the World Health Organisation). In partnership with Baylor International Pedicatric Aids Initiative (BIPAI), EGPAF SA carried out training in basic and advanced pediatric AIDS management for the doctors and professional nurses working in the hospital. The staff also received training in monitoring and evaluation, as well as how to use the patient registers supplied by the DoH. New staff attend a one-day training from EGPAF SA on the Basics of monitoring and evaluation; introduction to data collection procedures, and DoH and PEPFAR indicators.

Is the initiative sustainable and transferable?
The project seems to be relatively sustainable. Although funding from EGPAF is due to be scaled down and eventually stopped over a number of years, the DoH has undertaken to support the project through staff salaries into the future. The project also has full support from the DoH, and is in line with government’s HIV/AIDS policies. Thus, the project will hopefully be financially and institutionally secure for the coming years. In terms of personnel sustainability, the nurses were trained in how to mentor and coach new staff themselves, reducing the need for external interventions in the future. DoH district managers were also trained to be able to manage the project in this hospital and others throughout the region in the future, again reducing the need for further external interventions. Patients are provided with education and information on HIV/AIDS, its treatment and prevention, and this helps to ensure that the project’s impacts remain sustainable into the future as well. It also helps to reduce the stigma attached to HIV infection, meaning that more people will be willing to seek treatment in the future. Encouraging patients to start support groups again helps to improve the long-term impact of the project, as will the development of vegetable gardens by these support groups. Thus, its impact is also likely to be sustainable. The aim is for the project to be replicated across the country, and it has already been rolled out to a number of other clinics in the region. The implementation is relatively straightforward, and mainly revolves around making existing structures and services more efficient. Thus, it does not require huge amounts of training for current hospital staff to implement at other hospitals and clinics. Start-up funding will be required, and establishing a partnership with the DoH at the outset will also be a huge factor. If funding can be accessed to start the project, and the DoH commits to take on management and staff salaries into the future, the likelihood of project replication is strong. There is a fairly large amount of funding available for HIV/AIDS projects, from both local and international groups (such as PEPFAR, UNAIDS, Gates Foundation) and this improves the chances of groups being able to attract donors, and therefore replicate the project.

What are the impact of your initiative and the lessons learned?
The main impact of the initiative is that it has enabled the ART project at a relatively rural hospital to operate much more effectively. It has therefore improved the reach and impact of the ART programme, and allowed many more people to access treatment, education and support. It has also done this in a relatively simple way, meaning that it can be rolled out to other clinics or hospitals in the region, and across the country. Because of the project’s success, the stigma attached to HIV/AIDS infection in the area has decreased, meaning more people are willing to access treatment, and this once again improves the reach of the programme. The main lesson learned is that similar projects do not always need to be privately initiated and implemented – this project came about through a partnership between government and a private donor. Funding from the private donor helped the project to establish itself, but the support and funding from government also means that the project has a better chance of sustainability, as it has official backing from the Department of Health. It has also shown that similar projects can be initiated relatively easily, even in rural areas, and that there are not any real obstacles to ARV roll-out in the country.


Institution Name:		Vukuphile Clinic, Vryheid Hospital
Institution Type:		Government Agency
Contact Person:		Thandeka Zulu
Title:		Hospital CEO
Telephone/ Fax:		+27 34 981 4381
Institution's / Project's Website:		+27 34 980 9757
E-mail:		thandeka.zulu@kznhealth.gov.za
Address:		Private Bag X9371
Postal Code:		3100
City:		Vryheid
State/Province:		KwaZulu-Natal
Country:		South Africa

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information