GHIs in South Africa


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

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  • Sources: National Department of Health HIV and Syphilis Survey 2009/2010, District Health Barometer 2008/2009, South African Health Review 2010
  • Delays in GFATM grant in 2008/9 exemplified problem: TAC forced to cut 20% of staff & ART literacy programme PEPFAR funding in particular is a main source of funding for service-delivery NGOs: though Treatment and Care funding not cut, in reality delays and flatlining in funding mean constraints on surveyed NGOs
  • Overall, GHI funding is a small percentage of South Africa’s health spending, but its influence on HIV and ART is disproportionate In FY2008, PEPFAR’s allocation for HIV treatment = 83% of the 2008/9 National Conditional Grant for HIV and AIDS and 57% of all expenditure on provincial health services HIV and AIDS sub programmes
  • Elysia Larson, Heidi O'Bra, J W Brown, Thobile Mbengashe, Jeffrey D Klausner: Supporting the massive scale-up of antiretroviral therapy: the evolution of PEPFAR-supported treatment facilities in South Africa, 2005-2009. BMC Public Health 2012, 12:173 doi:10.1186/1471-2458-12-173
  • Is this sustainable?? Get support to write good quality proposal but built capacity to implement and supervise.
  • NGO training on HIV increase staff mobility as they have skills in demand Figures from Sanders et al 2009 HR interventions reactive to HR challenges Staff patient ratio going down from 251nurses/100 000 in 1994 to 110/100 000 in 2007 Largest gaps are for pharmacy, lab specialist, doctors in public facilities
  • Training for clinical staff only in specific programme areas Rural nurses and doctors faced challenges in accessing training Found a lack of management/coordination of HR training (duplication of training, staff attended more than one course) NGOs ran the HIV-related trainings and lacked standardization (EC particularly) Built capacity among facility level programme staff and NGO staff (TB/HIV management and M&E) MEPI started recently. See Lancet article in about March/April 2011. I think that 2 SA med schools benefit, but am not sure. In Eastern Cape: Professional Nurses: 1996-2010 28%enrolled 59%, auxiliaries 23% 46% WF is >50yrs and 16% already reached 60 yrs 51, 200 PN need to qualify in the next 10 yrs Lack of HIV knowledge and skills among clinical staff: n= 215 providers in PHC facilities, ~>50% received training in clinical aspects of HIV/AIDS, 40% had been trained in counselling but only 10% had received training in both clinical aspects of HIV/AIDS and management (Modiba et al.,2003)
  • Presence of PEPFAR-funded NGO helped local government in EC and WC bypass internal bureaucratic employment processes for HR, but also meant lack of absorption/sustainability plans Lack of participation of other stakeholders in policy development (e.g. professional unions), resistance of labour unions Task shifting not supported by regulation changes, e.g. aasisstant pharmacists not allowed to prescribe some drugs
  • i.e. KZN consistently under-estimated ART uptake – health system does not have the capacity to sustain scale up If the NGO leaves, what happens? NGOs are 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 maintained by both government and GHIs/NGOs; PHC services continue to be underfunded though burden of "Some officials seem to believe government money from the budget ... and donor money are separate. Donor money was considered a luxury ... And we don't think that was correct.“ (Minister of Health, Reuters: 21/1/2011)
  • It was unclear who should enforce the Paris Declaration There were fragmented coordination units among donors and NGOs e.g. EU Plus Forum, but few routine meetings etc Harmonization or alignment was particularly absent at the local level among service-delivery NGOs Different indicators were used by different NGOs/GHIs Was little sharing of reports, data among NGOs/GHIs Presence of PEPFAR-funded NGO helped local government in EC and WC bypass internal bureaucratic employment processes for HR, but also meant lack of absorption/sustainability plans GHI and NGO M&E requirements had knock-on effects on government practices, i.e. in WC with ART Government/NGO/GHI meetings were often reactive, not proactive (i.e. in reaction to unfunded mandate demands Exacerbated by lack of government management at local level Leadership, power dynamics Collaboration and management capacity was uneven across provinces
  • NGOs were only able to offer specific assistance to districts/facilities on the basis of the funding agreement with PEPFAR
  • Look at Umgungunlovu with highest ANC prevalence in 2008 – but fewer projects than Umkhanyakude, which also had about a third less uninsured population in 2007. Note that deprivation index does not include population density; not included for this presentation but even when taken into account there is disparity between that and number of projects (i.e. in 2007 Uthukela had almost a third more uninsured people accessing public health services in 2007 compared to Sisonke, a higher ANC HIV prevalence, but only 3 compared to 11 PEPFAR funded projects). Adding ANC prevalence suggests that projects should be concentrated on right, but still not quite right – look at Umgungunlovu with highest ANC prevalence in 2008
  • GHIs in South Africa

    1. 1. Global Health Initiatives andthe 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. 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. 3. South Africa National HIV Funding
    4. 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. 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. 6. Sampled provinces Eastern KwaZulu- Western National Cape Natal CapePopulation, 2008 (DHIS) 7,084,923 9,894,761 4,945,733 48,272,35Est. adult HIV prevalence, 18.5% 25.0% 6.2% 3 17.8%2009 (UNAIDS)Public sector ART 113,927 330,897 77,990 1,049,754patients initiated as ofMay 2010TB cure rate, 2007 (DHB) 62.0% 55.4% 77.7% 64.0%MMR per 100,000 live - - - 410births, 2008 (UN)Est. IMR per 1,000 live 60.3 60.0 25.3 46.1births, 2007 (SAHR)
    7. 7. Findings• Health system financing• Selective Health System Strengthening• HRH• Accountability• Financial sustainability
    8. 8. Flow of ART funding and GHIsGlobal Fund to U.S. President’sfight AIDS, TB Emergency Plan and Malaria For AIDS Relief Service Government (national, provincial) delivery NGOs Community-level ART services
    9. 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 9
    10. 10. GHIs’ contribution to health financing 10
    11. 11. Distribution of PEPFAR-supported facilities in SouthAfrica, by province: October 2005, September 2009Source:Larson 2012
    12. 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. 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. 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 14
    15. 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. 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. 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. 18. AcknowledgementsEU funding: INCO-DEV projectNational and provincial health and treasury departmentsMunicipal and district health authoritiesAll the Study Participants
    19. 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. 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. 21. Finding 2: Donor coordination (3)Distribution of PEPFAR funded ART NGOs in KZN, 2008
    22. 22. rce: Kelly et al. 2008