Report of Thubelihle Mathole (UWC) presented at the COHRED forum 2012 on the INCO-GHI research project

1. Global Health Initiatives and
the South African health system
Global Health Forum, 23 April 2012
School of Public Health
University of the Western Cape
Dr Thubelihle Mathole
Annie Neo Parsons
Dr Johann Cailhol
Prof David Sanders

2. 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
2

3. South Africa National HIV Funding

4. 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

5. 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

6. Sampled provinces
Eastern KwaZulu- Western National
Cape Natal Cape
Population, 2008 (DHIS) 7,084,923 9,894,761 4,945,733 48,272,35
Est. adult HIV prevalence, 18.5% 25.0% 6.2% 3
17.8%
2009 (UNAIDS)
Public sector ART 113,927 330,897 77,990 1,049,754
patients initiated as of
May 2010
TB cure rate, 2007 (DHB) 62.0% 55.4% 77.7% 64.0%
MMR per 100,000 live - - - 410
births, 2008 (UN)
Est. IMR per 1,000 live 60.3 60.0 25.3 46.1
births, 2007 (SAHR)

7. Findings
• Health system financing
• Selective Health System Strengthening
• HRH
• Accountability
• Financial sustainability

8. Flow of ART funding and GHIs
Global Fund to U.S. President’s
fight AIDS, TB Emergency Plan
and Malaria For AIDS Relief
Service
Government (national, provincial)
delivery
NGOs
Community-level ART services

9. 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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10. GHIs’ contribution to health financing
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11. Distribution of PEPFAR-supported facilities in South
Africa, by province: October 2005, September 2009
Source:Larson et.al. 2012

12. 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

13. 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

14. 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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15. 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

16. 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

17. 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

18. Acknowledgements
EU funding: INCO-DEV project
National and provincial health and treasury
departments
Municipal and district health authorities
All the Study Participants

19. 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

20. 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

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

22. rce: Kelly et al. 2008