presentation given my Thubelihle Mathole and HSR Symposium Beijing 2012

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

2. Background
• Part of multi country • In 2007, donor funding
accounted for 1% of all health
study on the effects of system expenditure and 36%
GHIs on health Sytems in of all HIV-related government
spending
recipient countries – Public sector antiretroviral
therapy (ART) introduced in 2003
• The study was initiated in • Public health expenditure as %
response to of GDP in 2009 was 3.7%
– increases in the amount of • Two GHIs active in South
funding from GHIs Africa – focused on HIV
programmes
– observed changes in the way – Global Fund for AIDS,
donors, NGOs and other Tuberculosis and Malaria (GFATM)
since 2002
service provider worked with – US President’s Emergency Plan
the government in HIV For AIDS Relief (PEPFAR) since
programmes 2004

3. Background
• Middle-income country but • National Health Insurance
highest number of people Builds on re-engineering of
living with HIV in the world
(around 5 million) PHC
– Provide a ‘comprehensive
• History of inequitable
package of care’, of which ART
distribution of resources is part
– Apartheid pre-1994, – Promotes idea of equity of
national economic access and of services
policies post-1994 ( between private and public)
– Provincial autonomy in – Present discussions on
allocation of finances, financing focused on curative
policy implementation care (especially hospitals), to
• Denialist national detriment of notion of PHC
government stance on HIV – Policy document does not
and AIDS: 1997-2008 explicitly address inequalities
between rural and urban areas

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 (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

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
3
Est. adult HIV prevalence, 18.5% 25.0% 6.2% 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
• 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
Facility and Community-level ART services

9. GHIs’ contribution to health financing
9

10. 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

11. 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

12. Distribution of PEPFAR-supported facilities in South
Africa, by province: October 2005, September 2009
Source:Larson et.al. 2012

13. Distribution of PEPFAR funded ART NGOs in KZN, 2008

14. 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?)

15. 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

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