Okello on board

In October 2004, the Ministry of Health hired Dr. Velephi Okello as national antiretroviral treatment coordinator. Okello likes to say that as a child, she played doctor during her first day at school—and was hooked. When she got home, she told her mother that she wanted to be physician. She earned her medical degree at Mbarara University of Science and Technology in Uganda in 2000. "I chose Uganda purposely," she says.

I could have gone to South Africa, but I wanted to learn medicine in a country that is not so affluent. I just wanted to understand how to help the really desperate, the low socioeconomic status people in this country, people in the rural areas.[25]

She practiced medicine in Swaziland for several years, but couldn't shake the thought that she could do more to address her country's health problems. "When you start practicing medicine, you realize that [for all the] people I’ve seen today, how many other people are out there?" she says. "That made me start thinking, there must be a way to get out there and touch on a much broader population, which brought me to my interest in HIV."

Dr. Velephi Okello

When she took the helm at the National ART Programme, Okello was feeling her way as a public health official. The Programme’s policy on treatment and prevention initially adhered closely to the 3 by 5 initiative, she says: “We didn’t ask too many questions. We just followed the instructions.” Soon, however, Okello and her staff began to adapt what they were learning to Swaziland's particular context. For example, they came to believe that it would make sense to treat HIV-AIDS patients in dedicated facilities adjacent to existing hospitals and clinics. Opponents argued that this approach would fail because of the stigma attached to AIDS. So the team started small—with one hospital. It worked. Patients came in great numbers, many showing up early to queue. With that early success, the Programme replicated the parallel structure at clinics across rural areas. “People [were] coming in, even in the clinics closer to their homes,” says Okello.

Okello also observed that with most clinics located in larger population hubs, it was difficult to reach patients where they lived, especially in the countryside. So she decided to decentralize services. The Programme placed its HIV facilities in a hub-and-spoke configuration (dubbed mother-and-baby), so that physicians at a “mother” facility could monitor and periodically visit “baby” facilities. The “baby” facilities also sent lab tests to and ordered drugs through the “mothers.”

She also addressed management deficiencies in the national healthcare system that she believed impeded effective treatment for HIV-AIDS patients. As a start, she put in place a National ART Programme management structure parallel to the national system. The National ART Programme’s vertical hierarchy, which also oversaw treatment facilities, made it easier to train and retrain physicians and nurses. The vertical structure also allowed HIV-AIDS facilities to order and stock drugs for themselves rather than working through the existing pharmacy system. In addition, the National ART Programme created its own patient tracking system, critical because the government’s health information management system at the time was deeply flawed, says Okello.

Nurses. Finally, there was a chronic lack of physicians. As a result, clinics in rural and poor areas were often staffed by nurses.  While the nurses  could administer refills of antiretroviral treatments, they could not initiate a course of treatment. Swaziland wasn't the only country facing this problem. Gradually, the public health community in Swaziland and elsewhere decided to train nurses to initiate antiretroviral treatment in clinics in a program dubbed the Nurse Initiated and Managed ART (NIMART). In Swaziland, the program was dubbed Nurse-led ART Initiation In Swaziland (NARTIS).

[25] Author’s interview with Dr. Velephi Okello in Mbabane, Swaziland on May 29, 2014. All further quotes from Okello, unless otherwise attributed, are from this interview.