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

Beijing HSR Symposium, October 2012

Background

• Part of multi country study on the effects of GHIs on health Sytems in recipient countries

• The study was initiated in response to – increases in the amount of

funding from GHIs

– observed changes in the way donors, NGOs and other service provider worked with the government in HIV programmes

• In 2007, donor funding accounted for 1% of all health system expenditure and 36% of all HIV-related government spending

– Public sector antiretroviral therapy (ART) introduced in 2003

• 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

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 and AIDS: 1997-2008

• National Health Insurance Builds on re-engineering of PHC– Provide a ‘comprehensive

package of care’, of which ART is part

– Promotes idea of equity of access and of services ( between private and public)

– Present discussions on financing focused on curative care (especially hospitals), to detriment of notion of PHC

– Policy document does not explicitly address inequalities between rural and urban areas

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 (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 were 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

• Sustainability

Facility and 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

GHIs’ contribution to health financing

9

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 impede 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),

• GHIs/NGO support made it possible for poor resourced facilities to be accredited for ART

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

Source:Larson et.al. 2012

Distribution of PEPFAR funded ART NGOs in KZN, 2008

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

by general health system capacity (M&E, HRH, pharmacy and infrastructure)– Rapid scale up of ART programme, increased from 324,754 in 2006 to

1.8 million by mid-2011 (NDOH, 2011)

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

– an issue for PHC provision as over time patients on ART often require comprehensive PHC services (for diabetes, hypertension, etc)

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

Concluding remarks• GHIs’ reliance on emergency/project response model meant they

did not fund recurrent costs; this is seen as a government responsibility– Continual problem at local level where facilities have few resources and NGO

support re-directs available resources towards ART provision

• GHI-financed NGOs were a catalyst for service provision, but this is a problem in areas where government cannot sustain services

• Separate funding for HIV, HIV-related TB, PMTCT was maintained by both government and GHIs/NGOs; PHC services continue to be underfunded though burden of HIV disease affects all services – Complexity of service access for HIV+ patients with other health conditions – Selective strengthening of health services ties in with NHI discussions focusing

on curative care

Acknowledgements

EU funding: INCO-DEV project

National and provincial health and treasury departments

Municipal and district health authorities

All the Study Participants