Task Order 2 of USAID | Health Policy Initiative (HPI) in South Africa continues to strengthen existing partnerships and create new partnerships as an essential element of program implementation. Building on previous work and experiences, HPI works to foster an enabling environment for policy formulation and implementation. Solid partnerships in South Africa make it possible for beneficiaries to obtain and use the information and services that they require to improve health outcomes, especially in the area of HIV and AIDS.

Through HPI, PEPFAR supports a multi-sectoral approach. Programs are implemented in coordination with government departments, the business sector, and civil society through capacity building and technical assistance. HPI assists in formulating, implementing, monitoring, and evaluating HIV-related policies and programs.

In South Africa, HPI contributes to PEPFAR's Sexual Prevention Abstinence/Be Faithful, Strategic

Information, and Health Systems Strengthening program areas. HPI significantly contributes to Human Resources for Health and mainstreams gender into many of its activities.

HPI's HIV and AIDS strategy is consistent with South Africa's National Strategic Plan (NSP) for HIV and AIDS & STIs (2007-2011). It is designed to address the major challenges facing South Africa by adopting a comprehensive and multi-sectoral approach to the implementation of activities in important program areas. Priority areas of assistance include (1) building the capacity of leaders in all sectors to become advocates for and ensure high-level commitment to HIV and AIDS programs; (2) formulating and improving key HIV and AIDS policies and strategies with a focus on implementation; (3) informing and guiding policy development and implementation; and (4) supporting strategic planning, costing, budgeting, resource allocation, and the generation and analysis of data for evidence-based decision making. HPI devotes special attention to mainstreaming information and activities to mitigate stigma and discrimination and to address male norms that have the potential to undermine HIV and AIDS programs.

National Department of Health (NDOH), Department of Public Service and Administration (DPSA), National Department of Transport (NDOT) and other departments request technical assistance from Futures Group, through HPI, in addressing the above four components to respond to national goals. Futures Group, through the HPI project, implements a participatory process to increase capacity within the national and provincial departments, transfer knowledge and skills and create sustainable structures and processes that will continue to be implemented beyond HPI.

HPI specifically responds to the PEPFAR indicators under Human Resources for Health. All HPI activities support national policy development and reform. Futures Group, through HPI, is involved in ensuring a sustainable policy development process as outlined in Appendix 4 of Next Generation Indicators Reference Guide. Specifically, HPI COP 10 activities will address national policy development and reform in: human resources for health, gender, stigma and discrimination, strengthening a multi-sectoral response and linkages with other health and development programs and other policy areas. Supporting policy development and reform assists in creating sustainable structures for the host country to implement post-donor funding.

In order to address the fundamentals needed for policy development and to ensure that HPI is enabling a policy environment in South Africa, HPI intends to adapt its strategy for COP 10. Futures Group, through HPI will strengthen relationships with national and provincial departments, including NDOH, to ensure technical assistance provided is responding to identified gaps, needs and requests. This will ensure sustainability because NDOH and other departments will take ownership of knowledge transferred through participatory mechanisms, such as training of trainer workshops and resource allocation exercises. In response, HPI will diverge from its work with faith-based organizations and redirect its work

with traditional leaders to ensure that policy reform is strengthened through the engagement of other sectors. Each activity narrative includes proposed activities for each of the PEPFAR program areas. Each activity will enable the policy environment for South Africa and link to the goals of the National Strategic Plan for HIV and AIDS & STIs (2007-2011).

Strategic information supports sustainable programs. HPI will support the South African Government (SAG) through strategic planning, costing, budgeting resource allocation and ensuring that employees of the SAG can understand and use the information. Numbers are essential for evidenced-based decision making.

Supporting SAG through the numbers game The South African Government employs more than one million people, located at 39 national departments and 91 provincial departments. The Department of Public Service and Administration

(DPSA) has human resource oversight of all government departments and manages the implementation of HIV and AIDS policies in all government departments in accordance with the HIV & AIDS and STI National Strategic Plan for South Africa and the Employee Health and Wellness Strategic Framework for the Public Service (EHW&S).

Since 2007, HPI has forged a strong relationship with the SA Government, and at the request of the DPSA, provided technical assistance for the design and implementation of HIV and AIDS and TB Workplace policies and programs. This included technical support for the development of departmental policies and a costing model to ensure appropriate costing of operational plans. In response to a UNAIDS call on all government departments to mainstream HIV and AIDS into departments' core mandates, targets, policies and strategies, HPI assisted DPSA in facilitating the development of mainstreamed HIV and AIDS plans for three identified departments. These workshops brought together national and provincial program staff and employee health and wellness practitioners to develop an integrated departmental response to HIV and AIDS.

Building on these initiatives, the DPSA requested HPI to extend these workshops to all government departments and to support the development of integrated mainstreamed costed operational plans. In COP 10, HPI will collaborate with DPSA in the development and costing of its sector-level mainstreamed HIV business Plans for DPSA. HPI will also work closely with the DPSA to review and enhance current M&E systems to improve the quality of monitoring and reporting of departmental programs in accordance with the NSP.

Strategic information activities, through costing exercises, are varied and can support the understanding and implementation of every kind of program. They can range from simple to very complex.

NDOH requested HPI technical assistance on the development of a national laboratory strategic plan and a national blood services strategic plan. Currently, it is speculated that National Health Laboratory Service (NHLS) and South African National Blood Service (SANBS) charge more than some private and provincial level service providers. NDOH requested HPI to conduct a comparative costing of pricing strategies.

2009-2010 activities include HPI providing technical assistance in drafting a national laboratory strategy and a national blood strategy. In addition, HPI will review the pricing strategies of the NHLS and SANBS after benchmarking them against private for profit and private not for profit services nationally and internationally. This project will enhance laboratory and blood services in South Africa through an assessment of needs/gaps and the development of a national strategy to strengthen laboratory and blood services. Also, the costing exercise will determine whether the laboratory and blood services currently

offered by NHLS and SASNBS are competitive in comparison to the provincial level public services and for profit and not for profit services. COP 10 will include the development of the implementation strategy, pending a need identified by NDOH and a request for HPI technical assistance.

In addition, NDOH has requested HPI to develop costed business plans of the provincial and district level for comprehensive care, management and treatment of HIV and AIDS (CCMT). Activities in 2009-2010 will include HPI assisting with the costing and implementation of business plans in three provinces. The costing will be conducted from the provincial to the district level. NDOH will prioritize the three provinces for which HPI will assist. Other partners, who have yet to be named, will assist with other provinces. HPI will provide direct technical assistance in the development of the costing methodology. This project will provide vital assistance to the provinces and prevent poor financial and logistical management at the district and provincial levels and assist with effective and efficient resource mobilization and allocation. COP 10 activities will include further support to additional provinces per the need and request of NDOH.

The activities proposed for the Health Systems Strengthening program area for COP 10 are an organic extension of current activities and are in response to needs identified by government and private sector leaders currently involved in the response to HIV.

Through the HSS portfolio, Futures Group, through HPI, will strengthen emerging and existing leaders in the response to HIV to enable them to advocate and respond to the challenges of HIV effectively, efficiently, and collectively and with appropriate and timely knowledge in their places of work or home. HPI will provide leaders of all levels with the knowledge needed to make informed evidence-based policy decisions. HPI will collaborate with partners in South Africa to ensure that these programs are sustainable beyond donor funding. In COP 10, gender will remain an integrated component of activities; however, gender-based violence as a sub-topic within activities will be strengthened. In addition, HPI will provide technical assistance to South African Government partners, including NDOH, DPSA and SANAC to strengthen local capacity and ensure that entities can identify and respond to gaps in policy.

Strengthening leaders to address HIV using the university as a platform and partner In COP 08, HPI collaborated with two business schools at University of Kwa Zulu Natal and North West University in the integration of HIV into existing Masters in Business Administration courses. The course targets executive and senior managers within the public and private sector. It aims to provide capacity and guide the emerging leaders to make informed evidence-based policy implementation decisions for

HIV and AIDS in the workplace.

Following COP 08, COP 09 includes the implementation of the program with the existing two public universities and a private university, the Da Vinci Institute. The success of the emerging leaders program within the MBA programs has been documented and shared internationally with organizations such as the Brazil, India, Russia, China (BRIC) Business Association and Futures Group. Thus, we want to ensure that the successes are continued to be adopted and implemented within South Africa. The standing memorandums of understanding state that after approximately three years of implementation, the university will take on full support of integrating the modules and begin to implement the program on their own, sans donor support. In addition, they provide substantial support in the initial implementation of the modules. The initial hurdle is in convincing the universities to participate; however once they see the benefits of the capacity development in their students they are highly responsive. Therefore, in COP 10, HPI will add two more universities to implement the integrating modules.

In 2008 HPI began collaborating with Durban University of Technology (DUT) on the emerging leaders program targeting MBA students. That same year, DUT implemented internal organizational changes and was unable to continue to implement the emerging leaders program within their MBA courses; however, as a result of their changes, DUT recognized a gap in their own faculty knowledge. DUT identified the need to provide their faculty with the skills needed to mainstream HIV into their coursework. In COP 09, HPI will further define the scope of the collaboration and the development of materials. In COP 10, HPI will facilitate the training of the academic staff, identifying leaders and champions within the program to ensure that the activity can strengthen the capacity of the DUT faculty in the prevention and mitigation of the impact of HIV and AIDS.

Since 2003, HPI has collaborated with the Africa Center for HIV and AIDS Management in the Workplace at the University of Stellenbosch (SUN), in offering an accredited Post Graduate Diploma in the Management of HIV/AIDS in the World of Work (PDM) aimed at providing managers with knowledge and skills to manage HIV in the workplace. Each year an average of 250 students from South Africa and abroad participate in the PDM program. The course is several modules, facilitated by US and other organizations. HPI is responsible for facilitating the HIV and AIDS Policy Development module. In COP 08, the course modules on HIV and AIDS Policy Development in the Workplace were reviewed and updated in accordance with new data and trends. Three new modules were added to the existing course. These included: gender, costing, and monitoring and evaluation.

COP 09 activities include collaborating with SUN and the revising and implementing existing modules. In COP 10, HPI plans to continue facilitating the course and will collaborate with US to identify the optimal number of participating students on the course to ensure quality. This activity strengthens the capacity

individuals in the prevention and mitigation of the impact of HIV and AIDS in the workplace.

Modifying curriculums for multi-sectoral leaders In the programs developed for universities, HPI/South Africa has developed a repertoire of skills in addressing leaders at various levels in how to address and mainstream HIV into the workplace. There are leaders that need to be strengthened who cannot be reached through the university platform; however, the tools developed for the university platform can be adapted for a broader reach. It is important that leaders of all levels make informed evidence-based policy decisions related HIV and AIDS in the workplace.

In COP 10, HPI will implement a new curriculum developed in collaboration with the Da Vinci Institute, based on previous curriculums developed for leaders presented on the university platform. The new curriculum will include foresighting exercises to predict the future impact of HIV AND AIDS in the workplace and on trade and industry outputs in South Africa. HPI will collaborate with the South Africa Business Coalition on HIV and AIDS (SABCOHA) to identify executive leaders in top South African companies who will benefit from the new curriculum. In collaboration with HPI, SABCOHA will coordinate an intense short-course for these executive leaders. It is expected that the companies from whom the executive leaders hail will invest into the professional development of these leaders and thus, this activity will be a Public-Private Partnership between HPI, the private sector companies and SABCOHA, who will also invest resources into the coordination, identification and leveraging participation to ensure the program is successful.

In parallel, HPI will implement a similar program for government leaders and in subsequent years, will try to merge the two activities to ensure collaboration, communication and sharing of lessons learned among and between the private and public sector. In previous years, HPI developed a public sector costing model for workplace programmes. In addition, HPI conducted a series of workplace programmes costing and implementation trainings for Department of Public Service and Administration (DPSA) managers. There has been a failure among DPSA staff to implement the workplace programs.

In COP 10, HPI will use the curriculum developed by Da Vinci, and adapted for government, and facilitate a short course for Director Generals (DGs) and Deputy Director Generals (DDGs) of identified government departments to develop executive leaders within DPSA. The activity will empower influential government officials to understand the importance of HIV AND AIDS workplace policy and program implementation and provide them with the skills and resources they need to implement the workplace programs previously prescribed.

Leaders are not just in the traditional private and government sectors, but can also be found in the form

of health care workers who address HIV AND AIDS on a day to day basis in the management of care and in their own workplace. Since 2009, HPI has worked extensively with the South African Government, especially the National Department of Health, and professional bodies for health care workers, such as the Colleges of Medicine of South Africa (CMSA) and the Democratic Nursing Organisation of South Africa (DENOSA), to ensure that curricula for health care workers are responsive to the challenges posed by HIV AND AIDS.

The College of Medicine of SA (CMSA), established in 1955, is the professional and accreditation body for medical and dental specialists in SA recognised by the Health Professions Council of South Africa (HPCSA). The CMSA test the professional competence of candidates in 27 clinical specialities to practise in South African conditions and ensure consistent, nationally and internationally accepted standards of Medicine and Dentistry. The CMSA therefore has the potential to enhance the capacity of both new and practicing clincians and clinical managers to respond to HIV and AIDS.

Previous activities include support to the Education, Examination and Credentials Committees of the CMSA to revise existing curricula and criteria for examinations offered by the CMSA, to ensure that curricula are responsive to the bio-medical and psycho-social challenges posed by HIV AND AIDS. HPI further supported the CMSA to develop and present a series of professional development workshops for practicing clinicians and clinical managers in three provinces regarding emerging/innovative clinical and other developments re HIV and AIDS.

In COP 10, HPI will continue to support the CMSA to extend the number of professional development workshops for practicing specialists and clinical managers and refine curricula for new specialists to ensure its relevance given that HIV and AIDS is a dynamic field, which requires ongoing updates as new research and treatment strategies/regimes become available. These interventions will enhance the quality of clinical care to HIV infected clients in South Africa.

At the request of Democratic Nursing Organisation of South Africa (DENOSA), HPI reviewed the integration of HIV and TB, sexual assault care for survivors of gender-based violence, and stigma mitigation strategies into the guidelines for the establishment of support into the pre- and in-service training curricula for nurses. The project included a specific focus on care-for-the-care givers to counteract the impact of burnout and secondary traumatisation associated with ongoing care of traumatized clients such as victims of rape and terminally ill patients.

In COP 10, HPI will ensure that the integrated curriculum is disseminated through a series of training of trainer workshops.

Building local capacity by increasing skills for NDOH The original Support Group Guidelines for people living with and affected by HIV and AIDS were not popularized and widely adopted. The guidelines were not user-friendly and did not guide the reader in the implementation of what to do with a support group for people living with and affected by HIV and AIDS. As a result of the inability to disseminate widely, NDOH requested HPI to revise the guidelines based on the feedback received and to prepare for a lay audience. HPI conducted a series of participatory provincial-level consultative workshops to revise the original version of the Support Group Guidelines. HPI provided the requested revisions and technical assistance to NDOH to ensure ownership and future implementation.

In COP 10, HPI will develop an implementation strategy and facilitate workshops on the strategy for provincial Support Group Managers in the roll out and dissemination of the guidelines. HPI will also integrate the Support Group Guidelines into the package of tools introduced during capacity building workshops for nurses and other health professionals. This process will be participatory, create champions within the provinces to disseminate the guidelines and will be sustainable because the workshop will be a training of trainers whereby the managers are provided with the information and knowledge to disseminate at the district level.

In addition to the request for assistance with the support group guidelines, NDOH requested HPI to assist in the finalization of the National Male Circumcision (MC) policy. Currently, the policy has officially been endorsed by the South African National AIDS Council (SANAC) and is due to be approved by the Ministry of Health (MoH). Following the final approval by the MoH and per a request from the NDOH, HPI will provide technical assistance to cost the MC implementation plan/strategy.

Following the approval of the policy and costing of the MC implementation strategy NDoH requested HPI to provide technical assistance in the implementation of a national male circumcision facility audit to assess the general preparedness of the facilities towards the national roll-out of MC in South Africa to be implemented in 2009-2010. HPI will implement in collaboration with other implementing partners. This project will assist the NDoH in the assessment and addressing of needs and potential gaps at the facilities towards the implementation of the national MC plan/strategy. COP 10 activities will include a training of trainers workshop on the implementation of the national MC strategy.

Documenting and responding to a broader perspective of policy Despite substantial investment in HIV prevention strategies in recent years, HIV incidence rates have not declined substantially. The South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (2009), conducted by the Human Science Research Council (HSRC) confirmed that, although there had been an increase in the levels of awareness of HIV and AIDS and in the

acceptance of people living with HIV AND AIDS, behavior has not changed proportionally to the levels of awareness and availability of prevention methods, such as condoms.

In 2009, the South Africa Government through SANAC's Prevention Technical Task team established a "Know Your Epidemic, Know Your response" project to inform the development of an Integrated HIV Prevention Strategy for South Africa. SANAC requested HPI to identify and document the prevention policy gaps and priority needs and collaborate with the larger UNAIDS, World Bank, DFID, DPSA-led "Know Your Epidemic, Know Your Response" project.

In COP 10, HPI at the request of the SANAC Prevention Technical Task team will continue to provide technical assistance to the project, which will include the revision of prevention polices and strategies in support of the NSP.

The activities proposed for the Sexual Prevention Abstinence/Be Faithful program area will be redirected from previous year implementation to ensure leaders of all sectors are actively involved in the national response to HIV and that frameworks exist that link to the NSP for 2003-2011.

Through the prevention portfolio, HPI will strengthen the national platform for gender integration into HIV frameworks and activities.

Linking RH and HIV through the National Strategic Framework for Reproductive Health In 2009, HPI provided technical support to the NDoH in a desktop assessment of literature, programs and resources on reproductive health issues in South Africa, including specific focus on male reproductive health. The desktop review on male reproductive health is currently with the NDoH pending final approval. As a response to a direct request by the NDOH to HPI, HPI will provide NDoH with support in 2009 to develop a National Strategic Framework for Reproductive Health. HPI will develop a strategy that maximizes impact through linkages and integration with other programs to address broader reproductive health challenges that face South Africa. The core tenets of the strategy are Female Reproductive Health, Male Reproductive Health including MC and Reproductive Health for HIV positive individuals.

The strategic framework will ensure overall gender mainstreaming and integration into all prevention, care and treatment programs. The strategic framework will contribute towards increased gender equity in

HIV AND AIDS activities, services, reduction of gender-based violence and addressing male norms and behaviors and link to the NSP for HIV. As mentioned before, Futures Group is strengthening the partnership with NDOH through HPI. In COP 10, HPI will work with NDOH to develop guidelines for implementation of the framework. The HPI approach is participatory and will include workshops to ensure implementation of the framework is sustainable at all levels of government and with all sectors of impact.

Integrating gender into the operational plans of Traditional Leaders Beginning in 2003, Futures Group, first through the POLICY Project and later through HPI, implemented national HIV and AIDS prevention programs for TLs. The focus of the program was to mobilize and sensitize TLs to achieve increased awareness and participation in the national response to HIV prevention. The activities developed by HPI for FY09 specifically address high-risk behaviors, including sexual networks and multiple concurrent sexual partners. The collaboration with the National House of Traditional Leaders (NHTL) can impact social and normative change, specifically as it relates to gender based violence and gender equity.

In COP 10, HPI will conduct an evaluation of the national HIV prevention program for TLs implemented in the period 2003-2009. The activity will document activity successes and future collaboration with TLs to reach rural populations with prevention messages. COP 09 activities include HPI technical assistance to the NHTL in finalizing its sector plan to be presented to the South African National AIDS Council (SANAC). In COP 10, HPI will assist the TLs in developing a national implementation plan for the seven provinces of South Africa. The sector operational plans will focus on building the capacity of traditional leaders on implementing activities that address perceptions and standards for men in relation to number of partners, alcohol use, and sexual gender-based violence.

Highlighting gender as a workplace issue by supporting policy champions Since 2003, HPI has collaborated with the Africa Center for HIV and AIDS Management in the Workplace at the University of Stellenbosch (SUN) in offering an accredited Post-graduate diploma in HIV/AIDS Management (PDM) aimed at providing managers with knowledge and skills to manage HIV in the workplace. The program aims to develop students into policy champions. Beginning in 2008, HPI has followed graduates from the PDM course to ascertain the extent to which former students have applied and implemented knowledge and skills gained during their training. HPI conducts a screening of all graduates from a specific year and selects a cadre of policy champions to offer further technical and financial assistance to develop their skills in policy and program development and implementation in the workplace.

Following COP 08 implementation successes, COP 09 implementation will include the selection of twenty policy champions from the 2008 class. Six graduates will be profiled and provided both technical and financial assistance. The remaining 14 will receive technical assistance in the form of structured coaching and mentoring from an expert consultant. In addition, 2009 will include a platform for peer learning through the sharing of experiences. A data base of current graduates will be created to enable HPI to keep in constant communication with graduates.

In COP 10, HPI will select policy champions from the 2009 class and provide three policy champions with both technical and financial assistance. Seventeen graduate champions will be provided with TA in the form of coaching and mentoring. The selection of the technical and financial assistance will focus on the integration of gender related topics into HIV workplace activities to strengthen and create pilots which can be shared nationally and internationally. As a whole, this activity will strengthen the capacity of individuals and organizations in the prevention and mitigation of the impact of HIV and AIDS in the workplace. In addition in COP 10, HPI will continue to update and manage the database of policy champions in collaboration with the University of Stellenbosch so that the database can be sustained within the university as a mechanism to communicate with former graduates.