Supporting HIV-vulnerable children in South Africa: Why health and social system strengthening is key

December 14, 2020
Children play games as part of ChommY, a GCBS-supported program designed to reduce risky behavior and HIV infections among 10-to-14 year olds. (Credit: Tanja Bencun-Roberts/Pact)

South Africa’s HIV rates are among the highest in the world. We know that the country’s children – especially those who are orphaned or otherwise socially vulnerable – are critical to finally controlling the AIDS epidemic here.

This is the focus of the Government Capacity Building Support program, or GCBS, which I lead on behalf of Pact. A partnership between Pact, USAID/PEPFAR and South Africa’s Department of Social Development (DSD), the program has been working since 2013 to build DSD’s capacity to better support orphans and vulnerable children in an effort to reduce new pediatric HIV infections and ensure that all South African children and adolescents who are living with HIV receive the care and support they need to live healthy, positive lives.

Nearly everything we do through GCBS aims to make lasting change. This is why the bulk of our efforts focus on improving health and social services and the systems that ensure their effective delivery. Day in and day out, we are working in true partnership with DSD to strengthen their systems at the national, provincial and district levels to ensure that no child is left behind.

Health systems strengthening involves working closely with government and civil society institutions to obtain results. GCBS is implemented using a “policy to practice” model. This ensures that as policies are developed, such as South Africa’s National Child Protection Policy, implementation approaches are piloted at the social service site level to ensure integrity for provider-friendly and client-friendly implementation. Using this model, national policies become living documents that effectively guide and improve site-level service delivery.

An excellent example of this is the DSD’s “Guidelines for Social Service Providers: Enabling Access to HIV Services for Children and Adolescents,” jointly developed under GCBS and which Pact is helping DSD to roll out. The guidelines ensure that all children access HIV testing services, that those found positive access treatment, and that those on treatment become virally suppressed through adherence to antiretroviral therapy.

How else has GCBS strengthened health and social systems? Specifically, GCBS implements and documents a core package of prevention and early intervention services for vulnerable children and adolescents through DSD and its funded partner organizations. Working with DSD staff, we strengthen the capacities of social service practitioners, including social workers, social auxiliary workers, child and youth care workers, community development practitioners and community caregivers. We also focus on improving coordination and collaboration among them.

This means that when GCBS ends, we will leave behind a strong platform of critical services, a vast network of well trained professionals to provide them, and effective public systems to oversee them. Another area where we are making good progress is in using data, evidence and best practices to improve decision-making, planning, implementation and outcomes of services for orphans and vulnerable children and adolescents.

What does this look like on the ground? Let’s look at Moretele, a municipality in Bojanala district of North West province, where HIV rates are high, along with numbers of orphans and vulnerable children, and access to social services has been limited. One of the major challenges faced by social workers in this rural area is a lack of knowledge about services that can be rendered to children and adolescents living with HIV. To address this gap, the GCBS team partnered with DSD staff in Moretele to help local social workers learn to use the HIVSTAT indicator, which monitors HIV status among OVC, assesses their risk of HIV infection and facilitates access and retention in HIV treatment for those who are HIV-positive. This means comprehensive services for children who need them.

The GCBS team explained why knowing and recording children’s HIV status is so important, and demonstrated how health and social services are connected to ensure overall wellbeing – a fundamental mindset shift.  

Today, all children in the Foster Care Register at the Moretele Service Point have a known HIV status – a significant change from just a year ago. Many more children are receiving services including HIV counseling, disclosure and treatment adherence support, and strong systems are in place to ensure no child “falls through the cracks.”

“Now [DSD social workers] can confidently provide competent care to kids who are positive and follow up on adherence to HIV medication,” Thembi Masilela, a GCBS social worker, recently reported. “The department and its social workers have a better understanding of the importance of knowing HIV status so they can help that child accordingly.”

This doesn’t mean this work has been without its challenges. Systems-level change can be arduous, in that it requires dealing with multiple ecosystems of stakeholders and institutions. There are stakeholders at the national, provincial and district/site levels, each with their own priorities. This means that GCBS’s processes must be extremely consultative to ensure that these myriad interests are integrated into design, implementation and analysis. 

Yet DSD is making remarkable progress. Since 2018, the department has improved its identification of HIV-positive children within the GCBS caseload from 8 percent to 92 percent, and 100 percent of those are now adhering to antiretroviral therapy.

My hope for DSD and the children it reaches is that these critical services continue for as long as they are needed. I am confident they will because of the strong systems we have built together.


Ranahnah Afriye is Pact’s Chief of Party for the Government Capacity Building Support program (GCBS) in South Africa. GCBS is a partnership between Pact, USAID/PEPFAR and South Africa’s Department of Social Development.

Work and intellectual property under GCBS were made possible with support from the American people delivered through the U.S. Agency for International Development (USAID). The contents are the responsibility of Pact under Award No. 674-13-00004 and do not necessarily reflect the opinion of USAID or the U.S. Government.