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US Investments in South Africa and Zambia

In 2014, the United States Government (USG) spent an estimated $5.3 billion on foreign assistance funding for health worldwide. The vast majority of this – about $3.1 billion – went towards slowing the HIV/AIDS epidemic. Throughout the Southern Africa region, the USG also supports projects focused on water supply and sanitation, orphans and vulnerable children, tuberculosis, palliative care, the health workforce, and developing information sharing platforms for evidence-based decision-making and capacity development.  Recently, our study tour delegates got to sit down with USG representatives and local leaders to hear about the impact of US investments in health and see what this funding is achieving.

South Africa: Low, middle income country
South Africa is the second highest recipient of USG assistance for HIV/AIDS assistance worldwide, falling only slightly behind Kenya. Since 2004, PEPFAR has invested $4.2 billion in the South African response to the dual epidemics of HIV/AIDS and tuberculosis, and despite plans to decrease the level of aid going to South Africa, the amount spent has remained fairly steady over the past five years. Even with such significant US support, South Africa funds more than 80% of the budget for antiretroviral therapy and the majority of its own HIV/AIDS programs – spending more than $1 billion annually. In addition to supporting health service delivery, US investments in South Africa promoted greater sustainability of the health system through capacity building, leadership and civil society engagement.

Delegates are briefed by staff at the Trucking Wellness Center in Limpopo. Photo credit: Bright Phiri/MSH.

Delegates are briefed by staff at the Trucking Wellness Center in Limpopo. Photo credit: Bright Phiri/MSH.

Delegates saw this firsthand through their visit to the Corridor Empowerment Project’s Trucking Wellness Center, in Limpopo province. Truck drivers are at significantly higher risk for acquiring HIV, but making time for routine testing or treatment adherence is a challenge for on-the-go drivers. The delegates saw how one organization is addressing this issue by meeting the drivers where they are. The Corridor Empowerment Project participated in our Building Local Capacity in Southern Africa project and is now eligible for USG funding, which allows them to provide HIV testing and counseling through 22 roadside and mobile clinics.

Zambia: Moving out of debt into middle income status
US funding in Zambia also focuses heavily on HIV/AIDS, accounting for 75% of the $174 million in health assistance in 2014. In addition, health funding targets malaria, maternal and child health, family planning and reproductive health, nutrition, and water and sanitation. The US also supports governance, law and policy changes to support people living with HIV/AIDS. Our

Pharmaceutical supplies at a Medical Stores Limited center in Zambia. Photo credit: Zambia Daily Mail.

Pharmaceutical supplies at a Medical Stores Limited center in Zambia. Photo credit: Zambia Daily Mail.

delegates toured Medical Stores Limited (MSL), an autonomous government agency that stores, transports and distributes drugs and medical equipment throughout the country. Through US investment, MSH has helped Zambia build a robust supply chain for medications and equipment, which helps strengthen the overall health system and improves access to high quality essential medicines for people with both chronic and acute health needs.

US support of global health projects in Southern Africa has led to significant improvements in access to care and affordability of life-saving medications. Just as important, South Africa and Zambia now have the human and technological capacity to support and improve their own health systems through domestic resource mobilization and policy reform.

Where the Environment and Business Collide

Delegates concluded their study tour to South Africa and Zambia with a visit to the Lilayi Elephant Nursery in Lusaka. Sponsored by Game Rangers International (GRI), the nursery rehabilitates baby elephants that have been injured or left orphaned due to elephant poaching. GRI works with the local community to show the value of environmental tourism and engages in interdisciplinary capacity building to help protect the endangered animals. Many in the local area haven’t always seen the value of these majestic animals as they can damage crops or hurt people, but GRI is finding mutually beneficial ways to interact with and encourage participation from the community in managing Zambia’s vital, internationally important ecosystems.

Baby elephants at Lilayi. Photo credit: Brigid Boettler/MSH.

Baby elephants at Lilayi. Photo credit: Brigid Boettler/MSH.

History of Poaching
Since the early 1900s, the demand for ivory has decimated the elephant population throughout Africa as ivory is seen as a coveted status symbol and some cultures consider it to have healing properties. In 1800, the elephant population numbered more than 26 million but by 1979, there were only 600,000 elephants left roaming the continent. While a 1989 international ban on ivory sales led to a rebound in the population and a decline in poaching, pressure from Asian and southern African nations led to the Convention on International Trade in Endangered Species sanctioning sales of ivory in 1999 and 2008. Since then, the elephant population has started to decline again as poachers continue to kill and demand from regions like Asia has led to a soaring price for ivory, even surpassing the price of gold. The animals’ slow reproduction rate cannot keep pace with the ivory demand and escalating poaching practices.

Although it had previously banned hunting elephants in 1982, Zambia permitted elephant hunting in four Game Management Areas (GMAs) from 2005 until 2013. The loosening of hunting regulations in GMAs combined with the recent upswing in poaching threatens the elephant population in Zambia.

elephant2 - CS

Orphaned elephants get their 11:30 feeding from their keepers at Lilayi. Photo credit: Cate Sadler/Delegate.

Negative Impacts of Poaching
Poaching has taken a staggering toll on the elephant population, environment, and economy of Zambia.  Tourism in Zambia focuses heavily on the country’s natural wonders, including its safaris and wealth of wildlife. As Zambia’s travel and tourism sector continues to grow, the rapid decline of the country’s elephant population will affect this rising economic sector as ecological tourism will decline with fewer and fewer elephants to see.

Poaching doesn’t just affect Zambian tourism and the elephants. Rangers, anti-poaching advocates, and wildlife conservation staff lose their lives every day across Africa, from Zambia to Sudan to Chad, as they work to protect elephants and other wildlife from poachers. Additionally, while it may seem harmless to all but the elephant to purchase ivory goods, the sales from these goods fund more than the poachers themselves. Militant groups, including the Lord’s Resistance Army (LRA) and Sudan’s janjaweed, garner income from poaching and reports have linked terrorist group al-Shabaab to poaching profits.

The experience of visiting Lilayi Elephant Nursery, hearing from GRI staff, and seeing the orphaned elephants firsthand reinforced the devastating and heart-breaking impacts of elephant poaching, both in Zambia and throughout Africa. Delegates were exposed to the dangers poaching not only poses to the elephants, but to local communities, game rangers, economies and global security. Thankfully, there are organizations like GRI who work tirelessly to protect the elephants and prevent poaching but more work is still needed to prevent these majestic animals from extinction.

Recap: Day 7 – Saturday, February 21

Before heading back to the cold and snow in Washington, DC, the delegates spent their final day in Zambia visiting Chilenje Clinic and the Lilayi Elephant Nursery.

At Chilenje Clinic, located in Lusaka, the delegates learned about key challenges in health equity and service delivery. As they toured the urban clinic, the delegates learned how staff and Zambian health workers work to address these challenges through improvements in pharmaceutical management, quality assurance and capacity building.

Baby elephants (calves) the delegates got to see at the Lilayi Elephant Nursery. Photo credits: Brigid Boettler/MSH.

Baby elephants (calves) the delegates got to see at the Lilayi Elephant Nursery. Photo credits: Brigid Boettler/MSH.

For the last site visit of the study tour, delegates traveled to the Lilayi Elephant Nursery in Lusaka. There, they received a briefing on key environmental issues faced by rural communities and learned how Game Rangers International (GRI), a local wildlife NGO, engages in interdisciplinary capacity building by investing in rural community health efforts. Lilayi Elephant Nursery is home to the youngest members of GRI’s rescued elephant calves. While at Lilayi, the calves receive the dedicated care they need to get through the vital, vulnerable early months and years of rehabilitation they need before they can be released into their new home in Kafue National Park.

After Chilenje Clinic and the Lilayi Elephant Nursery, the delegates reflected on trip experiences, key trends they observed, and the lessons learned from their week in South Africa and Zambia before packing up and departing for home.

Recap: Day 6 – Friday, February 20

The delegates started their second day in Lusaka bright and early with a breakfast discussion with representatives from Zambian non-governmental organizations. The delegates learned about the work of local organizations in improving and expanding access to quality health services in Zambia.

Following the breakfast meeting, the delegates received a quick site visit briefing before departing for Liteta Hospital in Chibombo District, located in Zambia’s Central Province. Chimbobo District is one of Zambia’s largest districts and is about an hour outside of Lusaka. The delegates toured Liteta Hospital, where they got to see a rural, district-level hospital firsthand. While there, they learned about key challenges in health equity and service delivery at the district-level. The hospital staff shared how they address these challenges through improvements in pharmaceutical management, quality assurance, and capacity building of laboratories.

While in Central Province, the delegates also visited Medical Stores, Ltd. (MSL) before returning to Lusaka. The delegates toured the MSL facilities and learned about US-funded pharmaceutical strengthening efforts, from strengthening internal quality control practices to implementing standard operating procedures and improving patient access to essential medicines.

The delegates spent their last evening in Zambia meeting with the National HIV/AIDS/STI/TB Council (NAC) over dinner. NAC is a broad-based corporate body in Zambia comprised of government, private sector, and civil society representatives. The delegates learned how NAC coordinates, monitors, and evaluates inputs, outputs, and the impact of HIV/AIDS, STI, and TB programs and interventions in Zambia.

Stay tuned for our final recap as the delegates visit Chilenje Clinic and the Lilayi Elephant Nursery in Lusaka before departing Zambia to return to Washington, DC.

South Africa’s Health System: From Race-Based to Rights-Based

By: Annette Sheckler

Since 1996, South Africa has been working to build an equitable public health system accessible to all out of the remnants of its apartheid past—essentially racially-based services delivered by a highly fragmented and bureaucratic system. Today’s approach to healthcare is rights-based with the goal of creating a comprehensive and integrated health system. Equitable access to quality medicines and medical products, vaccines and technologies that are safe, efficacious and cost-effective are one of the six building blocks of a proper health system. [i] The South African pharmacist, working alongside partners such as USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS), is playing a key role in building a first-class,  reliable public health system that can serve the needs of the South African people.

Delegates see a store room and learn about pharmaceutical management from SIAPS staff while visiting Mokopane Hospital in Limpopo Province, South Africa. Photo credit: Bright Phiri/MSH.

Delegates see a store room and learn about pharmaceutical management from SIAPS staff while visiting Mokopane Hospital in Limpopo Province, South Africa. Photo credit: Bright Phiri/MSH.

South Africa’s Pharmacists: On the Frontlines of Healthcare Reform
“The central challenge to the stability and well-being of our nation is reducing the deep inequality between rich and poor, between privilege and deprivation. This goes to the heart of South Africa’s future,” said South Africa’s Health Minister Aaron Motsoaledi. [i] The government of South Africa is committed to ensuring access to quality healthcare for all South Africans, regardless of their ability to pay. This is not easy in a country said to have one of the highest rates of inequality in the world.  South Africa’s healthcare system consists of a large, resource-constrained public sector and a small private sector for those able to pay premium prices for premium healthcare. The majority of South Africans, however, are largely uninsured and unable to pay for private healthcare. Although primary healthcare is free, specialized healthcare is available only in the private sector for those who can afford it.

In order to meet the challenge of expanding access to healthcare for all, the South African government has embarked upon an ambitious plan to implement a national health insurance (NHI) system.  Universal health insurance is expected to increase the consumer’s access to healthcare. However, equally challenging will be the quality of healthcare available to the consumer. Since 1994, South Africa has been putting resources in building its healthcare system—its health facility infrastructure, regulatory system, supply chain, and human resources.  In all of these efforts, pharmacists have made significant contributions from national initiatives to community care.

SIAPS in South Africa: Promoting Country Ownership and Sustainability
SIAPS’s systems-strengthening approach is based on a fundamental recognition that, in order to be sustainable, countries must lead the process of building  health systems within the context of country ownership. In South Africa, SIAPS developed a robust partnership with the South African government at all levels, as well as with a number of pharmacy schools and governing bodies such as the South African Pharmacy Council (SAPC).

Good governance drives quality service delivery. Good governance is a function of strong and viable institutions that can deliver public services equitably, transparently and efficiently. SIAPS, in partnership with the government, has worked to develop and implement systems for: standards and accreditation; pharmaceutical licensing; tender management; supply management ; pharmacovigilance; compliance with standard treatment guidelines; and pharmaceutical management information systems. These elements together work to build a unitary, comprehensive, equitable and integrated public health system that can deliver quality health care to all South Africans, regardless of ability to pay.

Delegates learn about pharmaceutical management at Mokopane Hospital from the Pharmaceutical Manager. Photo credit: Bright Phiri/MSH.

Delegates learn about pharmaceutical management at Mokopane Hospital from the Pharmaceutical Manager. Photo credit: Bright Phiri/MSH.

Looking Ahead
South Africa’s commitment to providing access to healthcare for all of its citizens through the NHI is a positive step forward in transforming the public health system. The challenges ahead are maintaining the momentum for building the health system infrastructure, creating the regulatory environment, and improving service delivery.  However, by investing in South Africa’s people with quality healthcare, South Africa will be able to take fulfill its economic, political and socially progressive potential on the global stage. SIAPS will continue to support these efforts.

[i] South Africa Unveils Universal Healthcare Scheme, BBC News (August 12, 2011).
[i] WHO Health Systems Framework


Annette Sheckler is the Communications Manager for the Center for Pharmaceutical Management at Management Sciences for Health.

Recap: Day 5 – Thursday, February 19

Today the delegates traveled to Lusaka, the capital of Zambia.  As one of the fastest growing cities in Southern Africa, Lusaka offers an expansive display of both the commerce and government sectors in Zambia.  The delegates learned more about national and community development projects in Zambia through meetings with key Zambian and United States government officials.

The delegates began their visit to Zambia by visiting the US Embassy in Lusaka, where they gained a deeper understanding of the role of US health and foreign assistance in Zambia.  The delegates met with the US Ambassador and representatives of US government agencies, including the USAID Mission, CDC, Peace Corps, and Defense.  Through these meetings, the delegates discovered how the different agencies coordinate and engage in Zambia’s health and development. Furthermore, the delegates learned more about the progress and challenges facing Zambia’s health systems.

Next, the delegates met with the Zambian Minister of Health and Permanent Secretary to better understand the Ministry of Health’s (MoH) priorities and health policy objectives.  Following their meeting at the MoH, the delegates met with the Permanent Secretary and Ministry of Community Development, Mother & Child Health (MCDMCH) representatives to learn about MCDMCH priorities. As the implementation arm of the national health system, MCDMCH plays a vital role in health systems delivery. Through these meetings, the delegates gained insight into the perspective of the Zambian government as a health system implementer and key policy initiatives related to the national health system.

The day concluded with a dinner and discussion with the Directors of the MoH and MCDMCH.  The dinner roundtable discussion centered on technical issues, including disease surveillance, human resources for health, and maternal child health in Zambia.

Recap: Day 4 – Wednesday, February 18

The delegates spent their last day in South Africa gaining a better understanding of capacity building and community development from a national level. While in Pretoria, delegates started their day with a briefing with US Embassy and USAID Mission staff. During this interagency briefing, delegates learned how different US government agencies coordinate and engage in South Africa’s health and development.

After meeting with Embassy and USAID staff, the delegates traveled to the National Department of Health to meet with Chief Director Gavin Steel and Deputy Director General Terrance Carter. Steel and Carter updated the delegates on the National Department of Health’s 2030 plan, which includes creating a national health plan; increasing life expectancy; reducing maternal, newborn and child morbidity; addressing non-communicable diseases; and reducing accidents and violence. Delegates also learned how the National Department of Health is addressing health systems strengthening and donor partnerships and investments.

The delegates’ final day in South Africa concluded with a Public Private Partnership Reception. During this reception, delegates conversed with public and private sector leaders and implementers and celebrated the importance of interdisciplinary and multisectoral partnerships for health and development.

Clockwise from top left: MSH Country Representative Bada Pharasi opens the reception; guests engage in conversation; delegates and US Embassy Deputy Chief of Mission Catherine Hill-Herndon. Photo credits: Johanna Theunissen & Bright Phiri/MSH.

Clockwise from top left: MSH Country Representative Bada Pharasi opens the reception; guests engage in conversation; delegates and US Embassy Deputy Chief of Mission Catherine Hill-Herndon. Photo credits: Johanna Theunissen & Bright Phiri/MSH.

MSH Country Representative Bada Pharasi, delegates and MSH Policy & Advocacy Director Crystal Lander. Photo credit: Johanna Theunissen/MSH.

MSH Country Representative Bada Pharasi, delegates and MSH Policy & Advocacy Director Crystal Lander. Photo credit: Johanna Theunissen/MSH.

Stay tuned for tomorrow’s update as the delegates head to Lusaka, Zambia for the remainder of the study tour!

Recap: Day 3 – Tuesday, February 17

While colleagues back home in Washington, DC were snowed in, the delegates visited more sites in Limpopo province, from the South Africa-Zimbabwe border to Vhembe and back to Polokwane, before returning to Pretoria.

truckstop

Truck stop on South Africa-Zimbabwe border where the Trucking Wellness Center is located. Photo credit: Bright Phiri/MSH.

The day started with a visit to a Trucking Wellness Center, which is supported by the Corridor Empowerment Project, at a truck stop on the South Africa-Zimbabwe border. Southern Africa has a long history of cross-border migration and internal migration. People migrate for political, social, and economic reasons. Highly mobile workers include cross-border traders and truck drivers, among many others. Although data on HIV prevalence among mobile workers and migrant populations is scarce, existing data shows that HIV prevalence among these populations is considerably higher than in national adult populations. Migrants and mobile communities are therefore identified as one of the priority populations needing targeted HIV prevention interventions. As they toured the Trucking Wellness Center, delegates learned how civil society organizations in the Migration Corridor use US funding to provide vital health services to long-distance truck drivers, female sex workers, and border communities. By bringing health services to the truck stop, larger populations can be reached to have a greater impact.

After visiting the Trucking Wellness Center, the delegates traveled to Vhembe in Limpopo to visit the Tshikuwi Clinic. There, they learned about pharmaceutical management at the local level as they viewed the primary healthcare clinic’s pharmacy and met with the clinic’s Community Service Pharmacist (CSP) and her mentor to discuss the clinic’s stock management challenges and the strategies they implement to improve management capacity.

Delegates and staff from the Tshikuwi Clinic in Vhembe, South Africa. Photo credit: Bright Phiri/MSH.

Delegates and staff from the Tshikuwi Clinic in Vhembe, South Africa. Photo credit: Bright Phiri/MSH.

Before returning to Pretoria for the night, the delegates visited a loveLife Support Site with MSH

loveLife peer counselors brief delegates at the loveLife support site. Photo credit: Bright Phiri/MSH.

loveLife peer counselors brief delegates at the loveLife support site. Photo credit: Bright Phiri/MSH.

staff from the USAID-funded Building Local Capacity for the Delivery of HIV Services in Southern Africa (BLC) project. loveLife is South Africa’s largest national HIV prevention initiative for young people. It combines a sustained high-powered campaign with nationwide community-level outreach and support programs to promote healthy, HIV-free living among South African teens. At loveLife, delegates met with organization leaders and peer counselors to learn how loveLife provides leadership development and educational opportunities for youth capacity in the Migration Corridor.

Recap: Day 2 – Monday, February 16

The delegates departed Pretoria bright and early on Monday to drive to Limpopo, South Africa’s northern-most province which shares its border with Botswana, Zimbabwe, and Mozambique.

During the drive to Limpopo, delegates received a briefing with MSH staff from the USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) project on the innovative RxSolution pharmaceutical management system. RxSolution enables integrated stock management and ensures patients have access to essential medicines in South Africa.

Delegates learn about pharmaceutical management at Mokopane Hospital from the Pharmaceutical Manager. Photo credit: Bright Phiri/MSH.

Delegates learn about pharmaceutical management at Mokopane Hospital from the Pharmaceutical Manager. Photo credit: Bright Phiri/MSH.

Once in Limpopo, the first stop was a site visit to Mokopane Hospital in the town of Mokopane. There, delegates learned about pharmaceutical management at the regional level as they toured the hospital pharmacy and met with the Pharmaceutical Manager. The Manager discussed the hospital’s implementation of RxSolution through the Pharmaceutical Leadership Development Programme (PLDP).

After visiting Mokopane Hospital, the delegates learned about pharmaceutical management at the provincial level as they toured the Limpopo Pharmaceutical Depot in Polokwane, Limpopo province’s capitol city. There, they met with depot managerial and local government staff to discuss challenges and innovative strategies for building pharmaceutical capacity, including PLDP and the Community Service Pharmacist Program (CSP).

Delegates, MSH staff, and staff from the Limpopo Pharmaceutical Depot. Photo credit: Bright Phiri/MSH.

Delegates, MSH staff, and staff from the Limpopo Pharmaceutical Depot. Photo credit: Bright Phiri/MSH.

The day concluded with an intimate dinner and discussion with local implementers in Musina, the northern-most town in Limpopo province. Delegates discussed the progress made and challenges faced in strengthening delivery of and improving access to prevention, care, treatment, and support services for vulnerable populations with local civil society organization leaders.