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Global Health Initiatives and the South African health system


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presentation given my Thubelihle Mathole and HSR Symposium Beijing 2012

presentation given my Thubelihle Mathole and HSR Symposium Beijing 2012

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  • there have been shifts in GHI policies and practice during the period of the study
  • Sources: National Department of Health HIV and Syphilis Survey 2009/2010, District Health Barometer 2008/2009, South African Health Review 2010
  • 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
  • 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
  • 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
  • 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
  • Service delivery NGO and government targets focus on the recruitment of new patients, not the follow-up of ‘old’ patients [This is an issue for PHC provision as over time patients on ART often require comprehensive PHC services (for diabetes, hypertension, etc)] Expanded access to ARV treatment – 1163 512 people were enrolled ART by August 2010, almost doubled its December 2008 total (NDOH, 2010) 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)
  • Example: one urban KZN, NGO-supported government clinic initiating ART (with 1 ART doctor, 2 ART professional nurses and 1 ART pharmacist on duty) and a monthly outpatient load of 37,000 people can no longer down-refer 'stable' ART patients to its satellite primary care clinics (with 2 professional PHC nurses on duty) as each is at full capacity of 3,000 people
  • Transcript

    • 1. Global Health Initiatives andthe 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 CapePopulation, 2008 (DHIS) 7,084,923 9,894,761 4,945,733 48,272,35 3Est. adult HIV prevalence, 18.5% 25.0% 6.2% 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. 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 NGOsFacility 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 SouthAfrica, by province: October 2005, September 2009Source:Larson 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. AcknowledgementsEU funding: INCO-DEV projectNational and provincial health and treasury departmentsMunicipal and district health authoritiesAll the Study Participants