PEPFAR/South Africa Landscape Analysis: Current and Potential Role of South African Faith-Based and Traditional Structures to Support the HIV Response

Objective:

With the world’s largest antiretroviral therapy (ART) program, South Africa has seen significant improvements in HIV morbidity and mortality, as well as in quality of life over the last two decades. However, South Africa realized it could only reach its 90-90-90 targets by 2020 through effectively engaging respected and trusted community-based entities (such as faith-based organizations [FBOs], traditional leaders, traditional healers, and unions) who are uniquely positioned to support their communities with prevention, treatment, and care services.

USAID/South Africa, through FHI360, commissioned Khulisa to conduct a comprehensive landscape analysis of FBOs, traditional structures (TSs), and unions that were currently engaged in, or who could potentially be engaged in, the HIV response in South Africa, especially those who operate in high-priority districts supported by USAID and PEPFAR.

The objectives of the landscape analysis were to:

1. Identify FBOs/TSs/unions offering HIV services or programs in 10 high-priority districts of South Africa.

2. Determine the extent to which FBOs/TSs/unions could:

• Mobilize demand for ART;
• Actively link people living with HIV (PLHIV) to ART;
• Support ART adherence and retention; and
• Increase demand for HIV services.

3. Identify gaps and needs of FBOs/TSs/unions in scaling-up ART among PLHIV and among their constituents or in their communities.

Approach:

Khulisa initially identified approximately 60 FBOs/TSs/unions operating in South Africa and shortlisted these by their likely ability to succeed if engaged by USAID to implement an HIV program. The shortlisting approach was designed against several criteria based on discussions with USAID and FHI360:

1. The organization was currently implementing an HIV program in South Africa, and the current HIV program:
2. Worked with adolescent girls and men aged 19-45 in some capacity;
3. Worked in one of the 10 priority PEPFAR districts;
4. Had technical and management capacity to expand its activities to referring PLHIV to health facilities for ART (if not already doing so) and supporting PLHIV on ART to stay on ART;
5. Had established indicators for reporting on program outputs, a track record of regular reporting, and a functional data management/M&E system;
6. Had a track record of managing donor funds and had adequate financial systems in place to account for external financing; and
7. Appeared interested in expanding into PLHIV treatment support activities.

Khulisa undertook three separate data collection activities to identify the final shortlist of organizations:

• Phase 1: Brief telephone interviews (less than 20 minutes) focused on identifying the existence of any HIV-related program, the main activities, the main target groups for those activities, the districts where the HIV program was operating, and contact details for key HIV program respondents. Interviewers also identified names of other FBOs/TSs/union organizations that were implementing HIV programs. Based on the results of this phase, a preliminary shortlist of organizations was created for phase 2.
• Phase 2: Key informant interviews with head office staff or the FBO, TS, or union in the preliminary shortlist. The interviews, which were no more than two hours and conducted face-to-face or telephonically, focused on obtaining more detailed information about the HIV program’s: 1) activities, target groups, partnership structures, approaches to engaging communities in HIV prevention and PLHIV support services, and operating locations; 2) program and organizational management structures, including staffing profiles, use of volunteers, and how volunteers are supported; 3) funding profile and financial management structures; and 4) names of other FBOs/TSs/union organizations that were implementing HIV programs. Based on the results of this phase, a further shortlist was created for Phase 3.
• Phase 3: In-depth, full-day assessments at head offices and/or implementation sites, focusing on assessing five key areas of organizational capacity (measuring 20 different elements of program design and management) using an adaptation of the McKinsey NGO organizational assessment tool. Organizations were scored against 20 capacity elements using a rubric describing organizational capacity.

Impact: 

Landscape analysis findings provided a final shortlist of potential organizations that PEPFAR could engage for supporting South Africa’s ART program. The landscape analysis also offered additional recommendations for enhancing community-level interventions to assist South Africa in reaching the 90-90-90 goals:

• Leverage the influence of traditional and religious leaders to address HIV-related stigma and improve the uptake of HIV services;
• Increase HIV and ART literacy among PLHIV, community cadres, and stakeholders to improve early ART enrollment;
• Strengthen and expand community-level (especially FBO) adherence support groups and ARV dispensing points;
• Strengthen relationships between community entities and the Department of Health/Government;
• Harmonize stakeholder implementation and support collaboration;
• Better target male and other key population groups; and
• Create guidelines for community-level activities around the 2^nd and 3^rd 90s.