Only!6!activities!were!focused!on!paying!for!the!staff!and!programming.!
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- Carol Ramsey
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1 3rdFloorWestminsterHouse,122 LongmarketStreet,CapeTown, 8001,SouthAfrica POBox2069,CapeTown,8000, SouthAfrica Tel:+27(0) Fax:+27(0) NPONumber:043T770 VATNumber: Registration:2000/029181/08 EasternCapeOffice 18EmbassyBuilding JacarandaStreet Lusikisiki4820 Tel: ECSatelliteOffice 62UnionStreet OldCNABuilding 3rdFloor,No31 EastLondon 5200 Tel: FreeStateOffice OfficeNo.7,StIvesBuilding,101St AndrewStreetBloemfontein9301 Tel: GautengOffice JorissenStreet,OrionHouse 3 rd floor,braamfontein Johannesburg2001 Tel: KwaZulu8NatalOffice IdubeBuilding,1 st Floor 249BurgerStreet Pietermaritzburg3201 Tel: LimpopoOffice 21APeaceStreet Tzaneen0850 Tel: MpumalangaOffice Office4,5Firstfloor,TrigonBuilding, 100JoubertStreetErmelo2351 Tel:017811T5085 WesternCapeOffice Town1Properties,SulaniDriveSite B,Khayelitsha CapeTown7784 Tel: DIRECTORS AneleYawa (GeneralSecretaryofTAC) NkhensaniMavasa (ChairpersonofTAC) QondisaNgwenya (ChairpersonoftheBoard) LordNtambw (Treasurer) VuyisekaDubulaTMajola JaneBarrett MbuyiseloBotha EricGoemaere ThembekaGwagwa MorayHathorn MarkHeywood Revision4xT25/2/2011RM CharlesPill SouthAfricaPEPFARCoordinator Per pillc@state.gov Submittedby: TreatmentActionCampaign SECTION27 13May2016 DearCharles, RE:SouthAfricaCOPFeedback ThankyouforsharingthedraftCountryOperationalPlanforSouthAfrica.Weappreciatethe significantworkthathasgoneinandthemovetomakethisavailablebeforeitisfinalizedfor ourreview.wenotebelowaseriesofpoints,buthavefocusedmostonthecorequestionof whatpepfariscurrentlyplanningtofundandouroverarchingconcernaboutovertfocuson TAmodels.WehavethustriedtoidentifyanalternativehighTimpactsetofprogrammingto whichaportionofcop2016fundingcouldbefocusedtoaugmentcurrentgoalsandhavea greaterimpactontheepidemic.. OverRelianceonTraining,Mentoring,TechnicalAssistance(includingwithintheHDTX) With6billionRand/US$410milliontospend,PEPFARisnearlyaquarteroftheAIDSfunding spentinsouthafrica.thisportionhasonlygrowngivenexchangeratefluctuations.weare thereforequiteconcernedtoseethatsuchalargeportionoffundingisgoingtraining, mentoring,andtechnicalassistanceactivities.therearemajorhealthsystemsweaknesses andwehavebeenontheforefrontofidentifyingthemanddemandingtheybeaddressed andwetrustthatsomeoftheactivitiesproposedforfundingarecriticalforthehiv programme. HoweveronthefrontlinestheHIVresponseisfacingacrumblinghealthsystemthatneeds directinputsfarmorethanitneedstechnicalassistance.wearethereforeconcernedthata largeportionofpepfarfundingisgoingtoremarkablyexpensivemodelsoftechnical assistancebylargeimplementers.directingasignificantpartofthisfundingintoahandfulof expanded,hightimpactprioritiescouldbetterfillcriticalgapsinthehealthsystemand supportthemohtledaidsresponse. Inparticular,wereviewedSection6.0, ProgramSupport, inthecop whichcorrectly identifiesalackofhumanresourcesatboththefacilityandcommunitysideasdrivinglow viralloadsuppression,significantlossttotfollowtup.yetwesee: 55activitiesareproposedtobefundedaspartofAdultTreatment(HTXSbudget) Nearallofthemaretraining,mentoring,technicalassistanceandsupport,tool development. Only6activitieswerefocusedonpayingforthestaffandprogramming. Inthe sitelevel activitiesplanned,wesimilarlyseealargefocusedonmentoring,training, qualityimprovement,andtechnicalsupport.becausefundinglevelsforalltheactivitiesare notincludedinthecopwecannottellwhatportionoffundingisdoingintocore programmaticcosts,butweareconcernedthatatthenational,subtnational,anddistrict levelpepfarhascorrectlydiagnosedtheproblemsofinsufficientsupplyoffacilitystaff, insufficientcommunitytbasedprogramming,inadequatesupplyofcommunitytbasedhealth workers butisinsufficientlyfocusedondirectlyresourcingthosegaps. Theproblem,toputitbluntly,isthatthereareinsufficientstafftobetrained,mentored,and technicallyassistedandweworrythedraftcopdoesnotsufficientlyaddressthis.meanwhile SouthAfricabadlyneedsdirectresourcesneededtomakecommunityTbasedeffortswork,to
2 3rdFloorWestminsterHouse,122 LongmarketStreet,CapeTown, 8001,SouthAfrica POBox2069,CapeTown,8000, SouthAfrica Tel:+27(0) Fax:+27(0) NPONumber:043T770 VATNumber: Registration:2000/029181/08 EasternCapeOffice 18EmbassyBuilding JacarandaStreet Lusikisiki4820 Tel: ECSatelliteOffice 62UnionStreet OldCNABuilding 3rdFloor,No31 EastLondon 5200 Tel: FreeStateOffice OfficeNo.7,StIvesBuilding,101St AndrewStreetBloemfontein9301 Tel: GautengOffice JorissenStreet,OrionHouse 3 rd floor,braamfontein Johannesburg2001 Tel: KwaZulu8NatalOffice IdubeBuilding,1 st Floor 249BurgerStreet Pietermaritzburg3201 Tel: LimpopoOffice 21APeaceStreet Tzaneen0850 Tel: MpumalangaOffice Office4,5Firstfloor,TrigonBuilding, 100JoubertStreetErmelo2351 Tel:017811T5085 WesternCapeOffice Town1Properties,SulaniDriveSite B,Khayelitsha CapeTown7784 Tel: DIRECTORS AneleYawa (GeneralSecretaryofTAC) NkhensaniMavasa (ChairpersonofTAC) QondisaNgwenya (ChairpersonoftheBoard) LordNtambw (Treasurer) VuyisekaDubulaTMajola JaneBarrett MbuyiseloBotha EricGoemaere ThembekaGwagwa MorayHathorn MarkHeywood Revision4xT25/2/2011RM increasedemandandadherenceforviralsuppression,andincreasetheaccountabilityofthe publicsectorhealthsystem. Wethereforsuggestthefollowingfourmainalternativeareasforrepurposingaportionof COP2015funding: 1. Directfundingoflaycouncillorsandcommunityhealthcareworkers: AtpresentthesituationwithlaycouncillorsandCHWsinSouthAfricaischaotic.Thereisno nationalpolicy.differentprovincesaretakingdifferentapproaches.inthefreestateandkzn seriouscriseshavedevelopedasaresultofabotchedtransitionbetweenmodelsofcare.the lackoflaycouncillorsandchwshaveremovedanessentialpillarofthehealthcaresystemin manyareasandisunderminingtheefficacyofvariousotherinterventions.forexampleata timewhenweareexpandingthearvprogramme,ourcapacitytodosoislimitedbythefact thatthereductionoflaycouncillorsandchwsisleadingtoeffectiverecentralisationinsome areas insteadofreducingthepressureonfacilitiesthroughtasktshifting,weareincreasing thepressurethroughreversedtasktshifting.weproposethatpepfarshouldundertakethe directfundingofamuchlargercadreoflaycouncillorsandchwsthatcurrentlycoveredin areasofconcern. WenotethattheCOPcallsforsignificanttrainingofCHWs butweareconcernedthereisa lackoffundingfortheircoresalariesandassociatedcosts.withouttheresourcesallocatedto payfortheseservices,thetrainingprovidedandsupportwillbeinsufficientandlikelylostas itwillgotowardsanunstablecadreofworkerswhowillmoveontoalternateeconomic opportunitiesoronlyworkverylimitedhourswhilstpursuingsuchopportunities.pepfar shouldconsiderfundingthisdirectlythroughthepublicsectorwhereverpossible.itmightbe thatitneedstoberesourcedthroughpartnersinitially,butnegotiatingamediumtermplan totransferthisworkbacktothedohoncethedohdevelopsclearandrationalpolicieson theemploymentoflaycouncillorsandchwsisessential.pepfarfunding,however,for multipleyearsforthiscriticaladditionalcadrecouldbegametchanging. 2.Treatment&PreventionLiteracyCampaigntakentoscale: HSRCsurveyssuggestthatknowledgeandengagementhasgonedowninrecentyears.We proposeanambitioustreatmentliteracycampaigncoveringhiv,tb,ncds,andrightsinthe healthcaresystem. WenotethatthedraftCOPdoescallforsocialmobilisationforViralLoad(p100)andfor supportforcommunitymoblisationeffortstowardvmmc,condom,andtestinguptake (p132,133).inthepastpepfarfundedeffortshavelargelyreliedonlargeinternationaland domesticngosthathavefocusedonbroadcastingmessagesinmassmedia whichhave shownlimitedevidenceofsuccess.thereisadifferencebetweentreatment/prevention literacyandsimpleawareness. WeproposeanalternativeeffortbeexplicitlyspelledoutinCOP2016: ThiscampaignshouldbemodelledonTAC streatmentliteracycampaign.thisfirstlymeans accessible,nontpatronisingmaterialsmustbeproducedandtranslatedintoallrelevant languages(thismustincludesimpleappsandprintedbookletsandposters).secondly,people fromaffectedcommunitiesshouldthenbetrainedandpaidtoconducttreatmentliteracy sessionsatpublicsectorclinicsthroughoutthecountry.thesetrainersmustbefromthe communitiesinquestion. ThesepeoplecouldbeemployedthroughorganisationslikePositiveWomen snetwork,tac, andnapwa.weproposethateachtrainershouldbeprovidedatabletormobilephonethat canbeusedtoreportonsessionsconducted(usinggpsetc)andthatcancontainessential referencematerials.inaddition,anationaltreatmentliteracytelephonehotlineandonline Q&Aforumshouldbesetup thiscanruninparallelwiththecurrentgovernmenthelpline,
3 3rdFloorWestminsterHouse,122 LongmarketStreet,CapeTown, 8001,SouthAfrica POBox2069,CapeTown,8000, SouthAfrica Tel:+27(0) Fax:+27(0) NPONumber:043T770 VATNumber: Registration:2000/029181/08 EasternCapeOffice 18EmbassyBuilding JacarandaStreet Lusikisiki4820 Tel: ECSatelliteOffice 62UnionStreet OldCNABuilding 3rdFloor,No31 EastLondon 5200 Tel: FreeStateOffice OfficeNo.7,StIvesBuilding,101St AndrewStreetBloemfontein9301 Tel: GautengOffice JorissenStreet,OrionHouse 3 rd floor,braamfontein Johannesburg2001 Tel: KwaZulu8NatalOffice IdubeBuilding,1 st Floor 249BurgerStreet Pietermaritzburg3201 Tel: LimpopoOffice 21APeaceStreet Tzaneen0850 Tel: MpumalangaOffice Office4,5Firstfloor,TrigonBuilding, 100JoubertStreetErmelo2351 Tel:017811T5085 WesternCapeOffice Town1Properties,SulaniDriveSite B,Khayelitsha CapeTown7784 Tel: DIRECTORS AneleYawa (GeneralSecretaryofTAC) NkhensaniMavasa (ChairpersonofTAC) QondisaNgwenya (ChairpersonoftheBoard) LordNtambw (Treasurer) VuyisekaDubulaTMajola JaneBarrett MbuyiseloBotha EricGoemaere ThembekaGwagwa MorayHathorn MarkHeywood Revision4xT25/2/2011RM whichprovidesserviceofvariablequality.itmightbenecessarytoestablishasmalltlunit (alongthelinesofhivitbaseintheuk)thatcanworkonthedevelopmentandupdatingof materialsandrespondingtoquestions.abasicm&estructurethattakespainsnottoposea overlargeburdenwouldbeessentialtoensurethesystemisnotbeinggamed.akeyindirect functionofthisworkwillbetocontributetothedestigmatisationofhiv. 3.Strengthenthesystemanddemocratichealthgovernancethroughfunding independentmonitoringandaccountabilitywork: WhenPEPFARtransitionedprogrammestogovernment,itcorrectlyrefocusedtheprogram s majorinvestmentofu.s.aidfundingonsupportingthepublictsectorledresponseandmade alargebetongovernmentsuccess.thecophasidentifiedaseriesofsystemicchallengesto realizinghivepidemiccontrol fromsupplychainfailurestopoorsupervisionofstaffto corruption.further,pepfarhasnotedthesignificantstigmaexperiencedbyplwhaandkey populationsinthepublicsector.thesolutionproposed,however,isfartoofocusedon technicalassistanceandmentoringthatmaybeuseful,butdoesnotaddressthesystemic issueofaccountability. WethereforecallonPEPFARtosupportacoordinated,independentcivilsocietyTledeffortof monitoringandaccountabilityforthehivresponseinthepublicsector.thereisnobetter pressureforpublicsectorreformandimprovedperformancethansouthafricanusersofthat systemwhoareinformedandcoordinatedinholdingthesystemaccountableatthepointof delivery.thetechnicalworkpepfarsupports,infact,willonlyhavemajorimpactwhenitis pairedwithaccountabilitywork.wehaveseenthisinthe StopStockTOuts campaign coordinatedbytac,msf,section27,hivclinicianssociety,andrudasa.supplychain managementsupporthasgoneonforoveradecade,yetproblemsremaininclinics throughoutthecountry.whenpeopleaccessingservicesjoinwithcliniciansonthefrontlines toidentifystocktoutsandthisisbackedupbypublicaccountabilityandtransparencythrough themediaplusstrategicadvocacytoaddresstheproblems,changehappens.this,inturn, generatestheinformationandthepoliticalwillfortechnicalsupporttomakeadifference. Afunded,coordinatedeffortcouldbringindozensoforganizationsthroughoutSouthAfrica toidentifyandaddress Medicinestockouts Poorqualityservices Brokenandunavailableinfrastructure Stigmaanddiscrimination StaffshortagesandnoTshows Etc. PEPFARshouldalsoconsiderpublicizingwhichimplementingpartnersaresupportingspecific facilitiesindistricts.thiswouldprovideindependentorganizationswithanalternativeroute toreportissuesatthesitelevel. ThiseffortgoestotheheartofPEPFAR sinvestmentinthesouthafricanhivresponseand directlyaddressespefpar sgoals(coppage3)of: Achieving90/90/90andtheeffectiveroleoutofTestandStart,whichwillnotbe possiblewithoutqualityimprovement Supportinghealthsystemsstrengthening accountabilityisa(maybethe)key missingcomponent Sustainability buildingcapacityincommunitiesandcivilsocietygroupsacrossthe countrywillgeneratelongtermchange 4.Viralsuppression:Supportmakingdatapubliclyavailableandfocusonsuppressionas thegoalinpepfarprograms.
4 3rdFloorWestminsterHouse,122 LongmarketStreet,CapeTown, 8001,SouthAfrica POBox2069,CapeTown,8000, SouthAfrica Tel:+27(0) Fax:+27(0) NPONumber:043T770 VATNumber: Registration:2000/029181/08 EasternCapeOffice 18EmbassyBuilding JacarandaStreet Lusikisiki4820 Tel: ECSatelliteOffice 62UnionStreet OldCNABuilding 3rdFloor,No31 EastLondon 5200 Tel: FreeStateOffice OfficeNo.7,StIvesBuilding,101St AndrewStreetBloemfontein9301 Tel: GautengOffice JorissenStreet,OrionHouse 3 rd floor,braamfontein Johannesburg2001 Tel: KwaZulu8NatalOffice IdubeBuilding,1 st Floor 249BurgerStreet Pietermaritzburg3201 Tel: LimpopoOffice 21APeaceStreet Tzaneen0850 Tel: MpumalangaOffice Office4,5Firstfloor,TrigonBuilding, 100JoubertStreetErmelo2351 Tel:017811T5085 WesternCapeOffice Town1Properties,SulaniDriveSite B,Khayelitsha CapeTown7784 Tel: DIRECTORS AneleYawa (GeneralSecretaryofTAC) NkhensaniMavasa (ChairpersonofTAC) QondisaNgwenya (ChairpersonoftheBoard) LordNtambw (Treasurer) VuyisekaDubulaTMajola JaneBarrett MbuyiseloBotha EricGoemaere ThembekaGwagwa MorayHathorn MarkHeywood Revision4xT25/2/2011RM a)asagoalcop16setsoutasitsmajorgoal90/90/90butsetsasatargetonly81%art coverage.giventhemajorproblemsinprogrammequality,thisisnotagoodproxyforthe ultimategoalofviralsuppression.itisthethird90thatmattersforpreventionandhealth. WethereforeproposethatPEPFARreTfocusforCOP16onensuringviralsuppressionasthe ultimategoal. b)supportapublicreportingeffort:incombinationwithsupportingindependentmonitoring andaccountability,pepfarshouldsupportmakingviralsuppressiondatapubliclyavailableat theprovincial,district,andfacilitylevel.viralloadcoverageandsuppressiondataare particularlyimportantastheyareanexcellentproxyformeasuringservicequality.facilities thatexperiencedropsinviralsuppressionorhavechronicallylowsuppressionratesmustbe investigatedforpoorservicequality. ThisdataisavailablesinceNHLSisgatheringit,whichisalsoreflectedinthePEPFARdata packs(whichwebelievearebasedonthesamesource?) butitisinsufficientlydetailedas theviralloadandsuppressiondataonlygotothedistrictlevel.weappreciatethattheseare newindicatorsforpepfar,butmakingthemavailableatthefacilitylevelisessentialfor independentmonitoringandaccountabilityofthesystem. PEPFARcoulduseaportionofitshealthsystemsstrengtheningfundingtoensurethesedata aremadepubliclyavailableatleastevery6months.secundmentandtamaybeneededto format,analyze,ensureanonymityandprivacyconcernsareappropriatelydealtwith,and makethedatapubliclyavailable.pepfarsupporttomakethisdataavailabledowntothe facilitylevelwouldenabletacandotherstobemoreeffectiveinouradvocacy. ADDITIONALCOMMENTS&SUGGESTIONSontheSDS: 1. ReTalignorClarifyActivitiesSupportingTestandStart MinisterMotsoalediannouncedon10MaythatSouthAfricawilladoptWHOTestandTreat guidelinesasofseptemberofthisyear.manyoftheactivitiesthatareproposedforfunding inthesdsareonthepresumptionthattestandtreatwillnotbeadopteduntilsometime aftercop16isalreadyineffect(seepages75t77). GiventhatTestandTreatisnowslatedforimplementationasofSeptember,someofthese activitiesseemasthoughtheywillbecomingtoolateasguidelineswillalreadyneedtobe readyforimplementation. IsitPEPFAR sviewthatactivitiessuchas SupportingtheNDoHtodeveloppolicyand guidelinesontest&offer (page76,activity4.1.3)willremainnecessarywhenthefundsfor COP16aredeliveredtocountry? 2. HCT:WestrongsupportPEPFAR scommitmentonhct andurgethatasmuchas possibleofthisfundinggointodirecthctactivitiesincludinghrhneededatcommunity level.wehavemajorconcernsabouthivtestingratesnotbeingsufficient.inthecophctis clearlyamongthe core activities,andwethinkdirectfundingofaggressivescreening campaigns(especiallyaimedatkeypopulations)isagooduseofpepfarfundsandshould,if anything,beexpanded. 3. PilotstotestTBactivecaseTfinding:Thereseemssomeagreementthatweneeda muchmoreaggressiveactivecasefindingprogrammeifwearegoingtogetontopoftb.the problemisthatthegovernmentseemsunwillingtoinvestinthehrrequiredtoimplement suchaggressiveactivecasefinding.thereisthusaneedtopilotaggressivecasefindingina hightbprevalencecommunityinsouthafrica.ifsuchapilotisasuccess,thenitcouldhelp makethecaseformuchwiderimplementationofactivecasefinding. 4. SinglePatientIdentifier:WeseesignificantmentionofTier.netandsupportfor CMMD.HelpingtheSADoHimplementasinglepatientidentifierandaproperelectronic
5 3rdFloorWestminsterHouse,122 LongmarketStreet,CapeTown, 8001,SouthAfrica POBox2069,CapeTown,8000, SouthAfrica Tel:+27(0) Fax:+27(0) NPONumber:043T770 VATNumber: Registration:2000/029181/08 EasternCapeOffice 18EmbassyBuilding JacarandaStreet Lusikisiki4820 Tel: ECSatelliteOffice 62UnionStreet OldCNABuilding 3rdFloor,No31 EastLondon 5200 Tel: FreeStateOffice OfficeNo.7,StIvesBuilding,101St AndrewStreetBloemfontein9301 Tel: GautengOffice JorissenStreet,OrionHouse 3 rd floor,braamfontein Johannesburg2001 Tel: KwaZulu8NatalOffice IdubeBuilding,1 st Floor 249BurgerStreet Pietermaritzburg3201 Tel: LimpopoOffice 21APeaceStreet Tzaneen0850 Tel: MpumalangaOffice Office4,5Firstfloor,TrigonBuilding, 100JoubertStreetErmelo2351 Tel:017811T5085 WesternCapeOffice Town1Properties,SulaniDriveSite B,Khayelitsha CapeTown7784 Tel: DIRECTORS AneleYawa (GeneralSecretaryofTAC) NkhensaniMavasa (ChairpersonofTAC) QondisaNgwenya (ChairpersonoftheBoard) LordNtambw (Treasurer) VuyisekaDubulaTMajola JaneBarrett MbuyiseloBotha EricGoemaere ThembekaGwagwa MorayHathorn MarkHeywood Revision4xT25/2/2011RM recordtkeepingsystemisimportant.thisisalreadyaworkinprogress,butithasbeenfor manyyears andpepfarhasconsistentlyincludedsupportinthecop.wewonderwhatthe barriersarebecauseitistakingfartoolong. 5. LabTechs:WenotethesignificantinvestmentinlabservicesandsupporttoNHLS, largelyintechnicalcapacity.weurgepepfartofocusalsoonensuringmorelabtechsare actuallytrainedandplaced.weseeafocusoncurriculumdevelopment,butnoton supportingthecorecostsoftrainingandstaffingwhicharemissing.wesuggestpepfarset anexplicittargetfor#oflabtechsworkinginkeydistricts. AdditionalCommentsonDataandDataAvailability: 1. WenotethattheDataPackprovidedwiththeSDSdoesnotcontainanySIMSdata, thoughthesedataarereferredtointhesds.inahighlytechnicalassistancefocusedplan, thesedataseemrelevanttohoweffectivethetechnicalassistancehasbeenatresolving issuesatthefacilitylevel.weaskthattheybesharedinfullalongwiththeexistingdataset. Ifyouhaveanyfurtherquestionspleasedonothesitatetocontactus. AneleYawa GeneralSecretary TreatmentActionCampaign anele.yawa@tac.org.za MarkHeywood ExecutiveDirector SECTION27 heywood@section27.org.za
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