Global Health Initiatives and the South African health system

Dr Thubelihle Mathole

Annie Neo ParsonsDr Johann Cailhol

Prof David Sanders

School of Public Health University of the Western

Cape

Global Health Forum, 23 April 2012

Background• Middle-income country but highest number of people living with

HIV in the world (around 5 million)• History of inequitable distribution of resources

– Apartheid pre-1994, national economic policies post-1994

– Provincial autonomy in allocation of finances, policy implementation

• Denialist national government stance on HIV treatment: 1997-2008

• Public sector antiretroviral therapy (ART) introduced in 2003 – Ring-fenced national Conditional Grant HIV and AIDS since 2006 (ARVs,

clinical ART staff and laboratory tests)

• Public health expenditure as % of GDP in 2009 was 3.7%• Two GHIs active in South Africa – focused on HIV programmes

– Global Fund for AIDS, Tuberculosis and Malaria (GFATM) since 2002

– US President’s Emergency Plan For AIDS Relief (PEPFAR) since 2004

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South Africa National HIV Funding

Aims and objectives

• To assess the impact of GHIs on: – Country-level and sub-national decision-making and planning

processes

– HR policies, planning, management, service delivery

– Development assistance for health practices.

• To identify useful lessons that improve the coherence of development assistance and the co-ordination and efficacy of the health system

• To understand how GHIs and other donors operate in South Africa

Methodology• Mostly relied on descriptive qualitative research (~230

interviews)• Some quantitative research (Questionnaires and Document

Analysis), but limited by information availability• Phased national (University of Pretoria) and sub-national level

research (2008-2010)• Study relied on purposive sampling and snowballing of senior

government officials, GHI/ Donor country/ NGO representatives

• 3 provinces were sampled according to GHI activity in the last eight years, with a minimum of 2 districts and 2 facilities in each district

• Data was thematically analysed

Sampled provinces

Eastern Cape

KwaZulu-Natal

Western Cape

National

Population, 2008 (DHIS) 7,084,923 9,894,761 4,945,733 48,272,353

Est. adult HIV prevalence, 2009 (UNAIDS)

18.5% 25.0% 6.2% 17.8%

Public sector ART patients initiated as of May 2010

113,927 330,897 77,990 1,049,754

TB cure rate, 2007 (DHB) 62.0% 55.4% 77.7% 64.0%

MMR per 100,000 live births, 2008 (UN)

- - - 410

Est. IMR per 1,000 live births, 2007 (SAHR)

60.3 60.0 25.3 46.1

Findings

• Health system financing

• Selective Health System Strengthening

• HRH

• Accountability

• Financial sustainability

Community-level ART services

Flow of ART funding and GHIs

Service delivery

NGOs

Government (national, provincial)

Global Fund to fight AIDS, TB

and Malaria

U.S. President’s Emergency Plan For AIDS Relief

Dependency on GHI funding?

• In 2007, donor funding accounted for 1% of all health system expenditure and 26% of all HIV-related government spending

• National governments historically failed to acknowledge the extent of GHI support for ART services: the general discourse was donor funding is insignificant

• However, the project found GHI-supported service delivery through government (KZN, WC) and service-delivery NGOs (EC, KZN & WC) essential to ART roll-out

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GHIs’ contribution to health financing

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Distribution of PEPFAR-supported facilities in South Africa, by province: October 2005, September 2009

Source:Larson et.al. 2012

Selective Approach to HSS

• Weak health system identified as major barrier to success of programmes– GHIs focus on disease specific interventions, e.g. vertical

TB, HIV (measurable short term outputs)

– HSS services a means to deliver targeted interventions e.g. Improved HIS (NGO data capturer/software), drug supply, seconded staff.

– Don’t address the root causes of the health system weaknesses, but only constraints that impedes progress e.g. use of expatriate staff to write proposals

HRH Supply

• On GHIs’ entry and ART initiation, South Africa faced HR shortages and distribution challenges

– Vacancy rates in facilities ranged between 20-70% – 39% of GPs & 44% of nurses served 80% of the population in the

public sector, vs 63% of GPs & 56% of nurses for 20% in the private sector (2008)

• NGOs and government responded with:– Task shifting (Nurse Initiated and Managed ART, training of

Pharmacist Assistants, increasing CHWs numbers)– NGO secondment of staff to public sector facilities with a focus on

HR for ART services (as part of an emergency response),

• HR production did not match the increasing burden of disease and demands of the ART roll out programme

HRH Training and Management

• Limited pre-service training on HIV/TB Management– New graduates still require in-service training in HIV/TB management– New PEPFAR Initiative on Strengthening Medical Schools (2011)

• NGOs supported short-term in-service training for ART/PMTCT

• Government HR planning and forecasting affected by a lack of information on NGO staff seconded staff– Government HR management unable to track NGO seconded staff:

exposed existing weaknesses in government HR HIS– HR planning not linked to disease profile e.g. ART scale up

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HRH Sustainability

• HRH sustainability differed according to GHI funding source – GFATM: posts were created within the health service; only

the funds were external and posts themselves were permanent

– PEPFAR: NGOs were told that health services would absorb staff BUT usually without HR consultation (recruitment did not meet HR criteria and posts not created in system)

• Policy and practice gaps around HR initiatives mean continual ART scale-up is problematic– i.e. Task shifting not supported by regulation changes, e.g.

assistant pharmacists not allowed to prescribe some drugs

Scale-up sustainability• Service integration of ART into general services constrained by general

health system capacity (M&E, HRH, pharmacy) and infrastructure (buildings, funding)– Expanded access to ARV treatment – 1163 512 people were enrolled ART by

August 2010, almost doubled its December 2008 total (NDOH, 2010)

– Service delivery NGO and government targets focus on the recruitment of new patients, not the follow-up of ‘old’ patients

– ART as an emergency response justified building of vertical service: at what point does an epidemic become endemic?

– National/provincial plans for sustainability tied to global economic changes (i.e. Economic improvement? Access to cheaper 2nd/3rd line ARVs?)

• Financial support was selective – focused on GHI financed programmes (HIV, TB, PMTCT)- while HIV disease affects all services

Harmonization & Alignment

• NGOs’ reliance on performance based funding model meant competition for limited resources and disincentive for communication/collaboration

• The use of diverse Health Information Systems among NGOs/GHIs increased problems of harmonization

• Denialism contributed to a lack of alignment– GFATM worked directly with WC and KZN when they came in– PEPFAR subcontracted NGOs, and in some areas by-passed

government institutions• GFATM, PEPFAR increasingly demanding NGO/government

collaboration as part of growing sustainability drive

Acknowledgements

EU funding: INCO-DEV project

National and provincial health and treasury departments

Municipal and district health authorities

All the Study Participants

Finding 2: Donor coordination (4)

• “Hmm, yeah, everyone got their own plans, everyone wants to manage their own budgets, everyone wants to have their own performance indicators, everyone wants their own ‘in and outs’. So it’s impossible to coordinate with that.” (NDOF2)

• Accountable to Funding institutions, not flexible

Financial accountability• GHI funding emphasised financial accountability (linking

money spent to meeting targets) • Tight financial accountability requirements led to vertical

systems and hierarchical management, BUT in turn:– Facilitated the rapid rollout of ART

• Failure to align and consult ‘Beneficiaries’ by service-delivery NGOs policy or planning process – a loophole

• Government lacked the authority to enforce decisions or policy on NGOs as it did not control the finances and was unwilling to sanction – Related to reliance on service delivery NGOs for ART roll-out

Finding 2: Donor coordination (3)Distribution of PEPFAR funded ART NGOs in KZN, 2008

Source: Kelly et al. 2008