The South African Government (SAG) and its development partners have mounted a formidable response to the world’s largest HIV epidemic and a persistent burden of tuberculosis (TB), the country’s leading killer. Nearly 4 million South Africans initiated antiretroviral therapy (ART) by the end of financial year 2016/17, helping to curtail new infections and reduce the number of annual HIV-related deaths. Mortality from TB has also declined thanks, in part, to improved treatment success.
Despite progress, challenges remain. Roughly 3 million people living with HIV (PLHIV) lack treatment, and each year more than a quarter million are newly infected. Moreover, nearly a half million South Africans contract TB every year, with an increasing share affected by drug-resistant strains.
To effectively plan and steward the health system, the SAG routinely monitors programmatic and financial performance of the response to HIV and TB, including by tracking expenditure. Analysis of spending, including trends in sources, levels, geographic and programmatic distribution and cost drivers can help policymakers to assess whether resources are reaching priority populations, interventions, and hotspot geographies; to identify potential opportunities to improve allocative and technical efficiency; and to stimulate more productive dialogue at multiple levels of the system.
This review of HIV and TB expenditure in South Africa is an input to policy, planning and management processes within and amongst spheres of government and between government and development partners. The data have been especially useful to national and provincial programme managers as they perform their oversight functions, leading to improved spending of available resources. With 52 annexes, it also serves as an authoritative reference document detailing levels and trends in HIV and TB spending by the three main funders of the disease responses: the SAG, the United States Government (USG), primarily via the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund). The findings have informed South Africa’s report to the UNAIDS Global AIDS Monitor and the country’s forthcoming funding request to the Global Fund.
Capital Investment in Health Systems: What is the latest thinking?HFG Project
Capital investment in health typically refers to large expenditures in construction of hospitals and other facilities, investment in diagnostic and treatment technologies, and information technology platforms. These investments are characterized by their longevity and they are critical to efforts to improve healthcare quality and efficiency. Contrary to developed countries where there is well documented experience on capital investment in the health sector, including use of public private partnerships for the investment; there is little evidence on capital investment in health from low and middle income countries.
This work was undertaken to add to the HFG’s knowledge and learning strategy by clarifying what good practice guidance exists in capital benchmark in LMICs health sectors, as well as the HFG project’s experience in the area. This brief will be of value to all those interested in the planning and financing the capital investment in the health sector. This includes politicians, planners, managers, health professionals, architects, designers, and researchers in both the public and private sectors.
Integrating the HIV Response at the Systems LevelHFG Project
The global response to combat the acquired immunodeficiency syndrome (AIDS) epidemic scaled up considerably in the early 2000s with the establishment of key institutions, notably the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) (AIDS.gov 2018). In response to high global rates of AIDS-related morbidity and mortality, the internationally supported rapid scale-up of human immunodeficiency virus (HIV) prevention, testing, treatment, and drug development is widely credited with curtailing a global epidemic, thereby limiting the human and financial costs of the virus (Bekker et al. 2018). Still the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 1.8 million people were infected with HIV in 2017, and there are nearly 37 million people living with HIV (PLWHIV) worldwide (UNAIDS 2018a). In many countries, financing and governance of HIV services is transitioning from international donors to national governments.
This funding transition has major implications for the governance, management, and implementation of the HIV response. Governments undergoing funding transitions for the HIV response are integrating aspects of the response into systems and processes for governing, managing, financing, and delivering other essential
health services. But this phenomenon has not been systematically studied, and documentation on how governments achieve this is limited. Understanding how some governments are navigating an HIV funding transition may help other countries and the global health community to better design and plan future or ongoing efforts to transition national HIV responses to domestic resources for health. USAID’s HFG project is helping to fill this gap. In particular, this study helps build an evidence base by exploring whether and how four countries in the process of transitioning to greater domestic financing of their HIV response are integrating HIV programming with local systems and processes for other essential health services.
This study applies the concept of system integration to examine the alignment of rules, policies, and support systems to address HIV and other essential health services in four low and middle-income countries (LMICs). Specifically, the study explores the current extent of integration, the decisions faced by policymakers, and potential barriers/facilitators to integration in four countries. The analysis allows HFG to share lessons learned by each of these countries attempting to optimize rules, policy, and support systems for HIV and other essential health services.
HFG began working in Namibia in 2013, closely partnering with the Namibian Ministry of Health and Social Services and going on to collaborate with key government agencies, such as the Namibian Social Security Commission and the Universal Health
Coverage Advisory Committee of Namibia. The overarching aim of our technical assistance has been to support Namibia’s progress toward UHC to ensure all can access necessary, quality health care without financial struggle. We emphasized a government-led and -owned approach as we supported the Namibian government in addressing some of the key challenges it faced at the start of the project.
HFG’s support has helped strengthen the government’s capacity to mobilize and manage resources; improve efficiency, quality, and equity of health services; expand access to health care; sustain key health interventions, especially the HIV/AIDS prevention, care, and treatment program; and, ultimately, identify sustainable financing for UHC. We provided technical support to the Namibian government’s Health Accounts team, equipping them with tools and know-how to lead and implement four Health Accounts exercises and analyze and present data for better policy analysis and evidence-based decision making. Our support has helped institutionalize Health Accounts in Namibia and provided the country’s policymakers with evidence to examine health financing options for UHC, advocate for greater resources, and explore financial risk protection options.
Strengthening the larger health system and generating fiscal space through improved efficiency of health services was another important goal for HFG.
Findings of the health facility costing and district hospital efficiency study we undertook will enable the government to identify where it can save resources, how it can improve equity in service distribution, and what Namibia’s total financing requirement is for UHC.
This report highlights some of the major contributions HFG and its key partners have made toward more efficient use of limited health resources, improved sustainability of
health programs, and progress toward UHC in Namibia.
Capital Investment in Health Systems: What is the latest thinking?HFG Project
Capital investment in health typically refers to large expenditures in construction of hospitals and other facilities, investment in diagnostic and treatment technologies, and information technology platforms. These investments are characterized by their longevity and they are critical to efforts to improve healthcare quality and efficiency. Contrary to developed countries where there is well documented experience on capital investment in the health sector, including use of public private partnerships for the investment; there is little evidence on capital investment in health from low and middle income countries.
This work was undertaken to add to the HFG’s knowledge and learning strategy by clarifying what good practice guidance exists in capital benchmark in LMICs health sectors, as well as the HFG project’s experience in the area. This brief will be of value to all those interested in the planning and financing the capital investment in the health sector. This includes politicians, planners, managers, health professionals, architects, designers, and researchers in both the public and private sectors.
Integrating the HIV Response at the Systems LevelHFG Project
The global response to combat the acquired immunodeficiency syndrome (AIDS) epidemic scaled up considerably in the early 2000s with the establishment of key institutions, notably the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) (AIDS.gov 2018). In response to high global rates of AIDS-related morbidity and mortality, the internationally supported rapid scale-up of human immunodeficiency virus (HIV) prevention, testing, treatment, and drug development is widely credited with curtailing a global epidemic, thereby limiting the human and financial costs of the virus (Bekker et al. 2018). Still the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 1.8 million people were infected with HIV in 2017, and there are nearly 37 million people living with HIV (PLWHIV) worldwide (UNAIDS 2018a). In many countries, financing and governance of HIV services is transitioning from international donors to national governments.
This funding transition has major implications for the governance, management, and implementation of the HIV response. Governments undergoing funding transitions for the HIV response are integrating aspects of the response into systems and processes for governing, managing, financing, and delivering other essential
health services. But this phenomenon has not been systematically studied, and documentation on how governments achieve this is limited. Understanding how some governments are navigating an HIV funding transition may help other countries and the global health community to better design and plan future or ongoing efforts to transition national HIV responses to domestic resources for health. USAID’s HFG project is helping to fill this gap. In particular, this study helps build an evidence base by exploring whether and how four countries in the process of transitioning to greater domestic financing of their HIV response are integrating HIV programming with local systems and processes for other essential health services.
This study applies the concept of system integration to examine the alignment of rules, policies, and support systems to address HIV and other essential health services in four low and middle-income countries (LMICs). Specifically, the study explores the current extent of integration, the decisions faced by policymakers, and potential barriers/facilitators to integration in four countries. The analysis allows HFG to share lessons learned by each of these countries attempting to optimize rules, policy, and support systems for HIV and other essential health services.
HFG began working in Namibia in 2013, closely partnering with the Namibian Ministry of Health and Social Services and going on to collaborate with key government agencies, such as the Namibian Social Security Commission and the Universal Health
Coverage Advisory Committee of Namibia. The overarching aim of our technical assistance has been to support Namibia’s progress toward UHC to ensure all can access necessary, quality health care without financial struggle. We emphasized a government-led and -owned approach as we supported the Namibian government in addressing some of the key challenges it faced at the start of the project.
HFG’s support has helped strengthen the government’s capacity to mobilize and manage resources; improve efficiency, quality, and equity of health services; expand access to health care; sustain key health interventions, especially the HIV/AIDS prevention, care, and treatment program; and, ultimately, identify sustainable financing for UHC. We provided technical support to the Namibian government’s Health Accounts team, equipping them with tools and know-how to lead and implement four Health Accounts exercises and analyze and present data for better policy analysis and evidence-based decision making. Our support has helped institutionalize Health Accounts in Namibia and provided the country’s policymakers with evidence to examine health financing options for UHC, advocate for greater resources, and explore financial risk protection options.
Strengthening the larger health system and generating fiscal space through improved efficiency of health services was another important goal for HFG.
Findings of the health facility costing and district hospital efficiency study we undertook will enable the government to identify where it can save resources, how it can improve equity in service distribution, and what Namibia’s total financing requirement is for UHC.
This report highlights some of the major contributions HFG and its key partners have made toward more efficient use of limited health resources, improved sustainability of
health programs, and progress toward UHC in Namibia.
South Africa HIV and TB Expenditure Review 2014/15 - 2016/17 Full ReportHFG Project
The South African Government (SAG) and its development partners have mounted a formidable response to the world’s largest HIV epidemic and a persistent burden of tuberculosis (TB), the country’s leading killer. Nearly 4 million South Africans initiated antiretroviral therapy (ART) by the end of financial year 2016/17, helping to curtail new infections and reduce the number of annual HIV-related deaths. Mortality from TB has also declined thanks, in part, to improved treatment success.
Despite progress, challenges remain. Roughly 3 million people living with HIV (PLHIV) lack treatment, and each year more than a quarter million are newly infected. Moreover, nearly a half million South Africans contract TB every year, with an increasing share affected by drug-resistant strains.
To effectively plan and steward the health system, the SAG routinely monitors programmatic and financial performance of the response to HIV and TB, including by tracking expenditure. Analysis of spending, including trends in sources, levels, geographic and programmatic distribution and cost drivers can help policymakers to assess whether resources are reaching priority populations, interventions, and hotspot geographies; to identify potential opportunities to improve allocative and technical efficiency; and to stimulate more productive dialogue at multiple levels of the system.
This review of HIV and TB expenditure in South Africa is an input to policy, planning and management processes within and amongst spheres of government and between government and development partners. The data have been especially useful to national and provincial programme managers as they perform their oversight functions, leading to improved spending of available resources. With 52 annexes, it also serves as an authoritative reference document detailing levels and trends in HIV and TB spending by the three main funders of the disease responses: the SAG, the United States Government (USG), primarily via the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund). The findings have informed South Africa’s report to the UNAIDS Global AIDS Monitor and the country’s forthcoming funding request to the Global Fund.
Health Trends in the Middle East and North AfricaHFG Project
In the past several decades, countries in the Middle East and North Africa have made significant improvements in developing their health systems and improving the health status of their populations. However, the region continues to face substantial and diverse political, economic, social, and health challenges: a rise in the burden of noncommunicable diseases, ongoing conflicts in several countries, and refugee crises. To inform future USAID health investments in the Middle East and North Africa, the Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project and the Health Financing and Governance (HFG) project conducted an analysis of the private health sector and the health financing landscape from January 2017 to April 2018. The countries included in this analysis are Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Syria, Tunisia, the West Bank and Gaza, and Yemen.
Modeling the impact of the health finance and governance projectHFG Project
Over its six-year life (2012-2018), the project worked with more than 40 partner countries to increase their domestic resources for health, manage resources more effectively, and reduce system bottlenecks in order to increase access to and use of priority health services and strengthen health systems overall. HFG provided state-of-the-art and country-specific technical assistance to remove obstacles that impede effective health system functioning and essential reforms. Recognizing the importance of measuring its impact, HFG quantified its return on investment for HFG health systems strengthening efforts.
HFG and its partner Avenir Health conducted a rigorous exercise to estimate the impact of the project’s health systems strengthening activities on its overall goal: increased use of priority health services. We used Spectrum, a suite of modeling tools developed by Avenir Health and partners, to quantify impact on mortality and morbidity based on changes in the coverage of specific priority health services due to the project’s activities aimed at improving access, quality, and use of health care. Given the diverse activities of HFG and the challenge of establishing a measurable causal link between project activities and coverage effects, we adopted a conservative approach and chose for this impact modeling exercise a subset of HFG activities for which a direct link was apparent. Based on these parameters, the exercise was conducted for eight country programs: Bangladesh, Cote d’Ivoire, Cameroon, Ethiopia, Haiti, Nigeria, Senegal, and Vietnam.
Using a methodical approach, we analyzed individual project activities in these countries and the expected effects on service coverage to estimate the impact on morbidity and mortality. We examined how our activities, including implementing strategies for improved human resources for health, operationalizing health insurance schemes, rolling out packages of health services, and using costed plans and packages to advocate for more financial resources, will increase access to health services, which in turn will lead to greater coverage of health services among targeted populations and ultimately to reduced morbidity and mortality. We modeled the impact of HFG’s activities by quantifying the number of deaths that were averted as a result of HFG-supported strategies and reforms.
The modeling results indicate that continued implementation of health systems strengthening strategies like those HFG supported would bring significant expansion of health care coverage and enhanced health outcomes.
This report presents country- and activity-specific results and the methodology for estimating coverage changes and impact. We hope this modeling exercise adds to the global understanding of how the impact of health systems strengthening can be measured. It provides powerful evidence on why investment and effort in strengthening health systems must continue.
The Health Finance and Governance Briefing KitHFG Project
Resource Type: Brief
Authors: Megan Meline, Lisa Tarantino, Jeremy Kanthor, and Sharon Nakhimovsky
Published: September 2015
Resource Description: Getting access to affordable, quality health care is a universal story that touches virtually every family in the world. At the same time, providing quality health services and access to trained health professionals is a challenge for governments. The World Health Organization (WHO) estimates that 150 million people worldwide face “catastrophic expenditure” because of high costs of health care. In other words, they may have to forgo paying for basic needs, such as food, housing, or education to pay for medical treatment instead. These costs include transportation, doctors’ fees, medicine, hospitalization bills, and days lost from work.
Behind these sobering statistics lies a wealth of news and feature stories waiting for the media to investigate and share with national leaders and policymakers as well as civil society groups who can advocate for changes to health budgets and policies. At the heart of these stories are important questions about the financing of health care and the quality of governance that ensures responsive and effective management of those resources and services.
But writing health finance and governance stories can be challenging. Health finance is riddled with complex language, technical economic terms, and numbers – not necessarily a journalist’s comfort zone. The right sources for these stories can be difficult to identify and unwilling to talk. Data may be difficult to locate or to understand. And while corruption makes for splashy headlines, the broader systemic challenges of health governance are not widely understood — and yet they are important.
The Health Finance and Governance Briefing Kit is designed to help journalists and their editors uncover and tell these important health stories that affect people all around the world.
Budget matters for health: key formulation and classification issuesHFG Project
This policy brief aims to raise awareness on the role of public budgeting – specifically aspects of budget formulation – for non-PFM specialists working in health. As part of an overall WHO programme of work on Budgeting in Health, it will help clarify the characteristics and implications of various budgeting approaches for the health sector.
Extending health insurance coverage to the informal sector: Lessons from a pr...HFG Project
As a growing number of low‐ and middle-income countries commit to achieving universal health coverage, one key challenge is how to extend coverage to informal sector workers. Micro health insurance (MHI) provides a potential model to finance health services for this population. This study presents lessons from a pilot study of a mandatory MHI plan offered by a private insurance company and distributed through a microfinance bank to urban, informal sector workers in Lagos, Nigeria.
Public Financial Management, Health Governance, and Health SystemsHFG Project
While the importance of governance in a health system is well recognized, there is an overall lack of evidence and understanding of the dynamics of how improved governance can influence health system performance and health outcomes. There is still considerable debate on which governance interventions are appropriate for different contexts. This lack of evidence can result in avoidance of health governance efforts or an over-reliance on a limited set of governance interventions. As development partners and governments are increasing their emphasis on improving accountability and transparency of health systems and strengthening country policies and institutions to move towards universal health coverage (UHC), the need of this evidence is ever rising.
To address this evidence gap, the USAID’s Office of Health Systems (USAID/GH/OHS), the World Health Organization (WHO), and the Health Finance and Governance (HFG) Project launched an initiative in September 2016 to ‘Marshall the Evidence’ on how governance contributes to health system performance and improves health outcomes.
The overall objective of the initiative was to increase awareness and understanding of the evidence of what works and why in how governance contributes to health system performance, and how the field of health governance is evolving at the country level. This report provides a synthesis of the findings across the four themes. This report presents the findings of the Public Financial Management.
Entry Point Mapping: A Tool to Promote Civil Society Engagement on Health Fin...HFG Project
ivil society organizations (CSOs), particularly those working in the health sector, frequently seek opportunities to influence public health policy or share feedback on the quality or accessibility of health services. While these organizations may have important contributions to make, they often are not aware of the most effective and accessible entry points to use. Entry Point Mapping provides a methodology for systemic review and identification of mechanisms, forums and public platforms by which civil society organizations can participate in health sector policy formulation, program implementation, and oversight.
This paper presents an Entry Point Mapping Tool designed for CSOs with advocacy experience and public health officials seeking to expand civil society participation and contains a step-by-step guide for researching and analyzing legal entry points for civil society participation in governance of public health care facilities. Because CSOs have varied interests, the tool includes a series of steps for individual CSOs to determine the level of government at which to pursue their specific advocacy interest and the process of collecting targeted information on legally required points of entry for their civic engagement.
In addition, the Entry Point Mapping Tool offers guidance on analyzing the effectiveness on these entry points and coaches CSOs through the negotiation process of activating or expanding existing entry points, creating new ones, and winning overall collaboration with health officials on improving health policy and service delivery. This tool also documents the experience of CSOs implementing the entry point mapping methodology in Bangladesh and Cote d’Ivoire to demonstrate how the tool can promote increased civil society engagement on issues of health finance and governance.
Championing Sustainability, Namibia Funds Health AccountsHFG Project
In Namibia, donor funding for health dropped by 47 percent between 2009 and 2013. This sharp decline could have broad implications for the health sector—particularly Namibia’s HIV and AIDS response which relies heavily on donor resources. In light of declining donor resources for health, the Government of Namibia (GRN) is positioning itself to sustain health sector progress to-date, through investing in Health Accounts.
South Africa HIV and TB Expenditure Review 2014/15 - 2016/17 Full ReportHFG Project
The South African Government (SAG) and its development partners have mounted a formidable response to the world’s largest HIV epidemic and a persistent burden of tuberculosis (TB), the country’s leading killer. Nearly 4 million South Africans initiated antiretroviral therapy (ART) by the end of financial year 2016/17, helping to curtail new infections and reduce the number of annual HIV-related deaths. Mortality from TB has also declined thanks, in part, to improved treatment success.
Despite progress, challenges remain. Roughly 3 million people living with HIV (PLHIV) lack treatment, and each year more than a quarter million are newly infected. Moreover, nearly a half million South Africans contract TB every year, with an increasing share affected by drug-resistant strains.
To effectively plan and steward the health system, the SAG routinely monitors programmatic and financial performance of the response to HIV and TB, including by tracking expenditure. Analysis of spending, including trends in sources, levels, geographic and programmatic distribution and cost drivers can help policymakers to assess whether resources are reaching priority populations, interventions, and hotspot geographies; to identify potential opportunities to improve allocative and technical efficiency; and to stimulate more productive dialogue at multiple levels of the system.
This review of HIV and TB expenditure in South Africa is an input to policy, planning and management processes within and amongst spheres of government and between government and development partners. The data have been especially useful to national and provincial programme managers as they perform their oversight functions, leading to improved spending of available resources. With 52 annexes, it also serves as an authoritative reference document detailing levels and trends in HIV and TB spending by the three main funders of the disease responses: the SAG, the United States Government (USG), primarily via the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund). The findings have informed South Africa’s report to the UNAIDS Global AIDS Monitor and the country’s forthcoming funding request to the Global Fund.
Health Trends in the Middle East and North AfricaHFG Project
In the past several decades, countries in the Middle East and North Africa have made significant improvements in developing their health systems and improving the health status of their populations. However, the region continues to face substantial and diverse political, economic, social, and health challenges: a rise in the burden of noncommunicable diseases, ongoing conflicts in several countries, and refugee crises. To inform future USAID health investments in the Middle East and North Africa, the Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project and the Health Financing and Governance (HFG) project conducted an analysis of the private health sector and the health financing landscape from January 2017 to April 2018. The countries included in this analysis are Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Syria, Tunisia, the West Bank and Gaza, and Yemen.
Modeling the impact of the health finance and governance projectHFG Project
Over its six-year life (2012-2018), the project worked with more than 40 partner countries to increase their domestic resources for health, manage resources more effectively, and reduce system bottlenecks in order to increase access to and use of priority health services and strengthen health systems overall. HFG provided state-of-the-art and country-specific technical assistance to remove obstacles that impede effective health system functioning and essential reforms. Recognizing the importance of measuring its impact, HFG quantified its return on investment for HFG health systems strengthening efforts.
HFG and its partner Avenir Health conducted a rigorous exercise to estimate the impact of the project’s health systems strengthening activities on its overall goal: increased use of priority health services. We used Spectrum, a suite of modeling tools developed by Avenir Health and partners, to quantify impact on mortality and morbidity based on changes in the coverage of specific priority health services due to the project’s activities aimed at improving access, quality, and use of health care. Given the diverse activities of HFG and the challenge of establishing a measurable causal link between project activities and coverage effects, we adopted a conservative approach and chose for this impact modeling exercise a subset of HFG activities for which a direct link was apparent. Based on these parameters, the exercise was conducted for eight country programs: Bangladesh, Cote d’Ivoire, Cameroon, Ethiopia, Haiti, Nigeria, Senegal, and Vietnam.
Using a methodical approach, we analyzed individual project activities in these countries and the expected effects on service coverage to estimate the impact on morbidity and mortality. We examined how our activities, including implementing strategies for improved human resources for health, operationalizing health insurance schemes, rolling out packages of health services, and using costed plans and packages to advocate for more financial resources, will increase access to health services, which in turn will lead to greater coverage of health services among targeted populations and ultimately to reduced morbidity and mortality. We modeled the impact of HFG’s activities by quantifying the number of deaths that were averted as a result of HFG-supported strategies and reforms.
The modeling results indicate that continued implementation of health systems strengthening strategies like those HFG supported would bring significant expansion of health care coverage and enhanced health outcomes.
This report presents country- and activity-specific results and the methodology for estimating coverage changes and impact. We hope this modeling exercise adds to the global understanding of how the impact of health systems strengthening can be measured. It provides powerful evidence on why investment and effort in strengthening health systems must continue.
The Health Finance and Governance Briefing KitHFG Project
Resource Type: Brief
Authors: Megan Meline, Lisa Tarantino, Jeremy Kanthor, and Sharon Nakhimovsky
Published: September 2015
Resource Description: Getting access to affordable, quality health care is a universal story that touches virtually every family in the world. At the same time, providing quality health services and access to trained health professionals is a challenge for governments. The World Health Organization (WHO) estimates that 150 million people worldwide face “catastrophic expenditure” because of high costs of health care. In other words, they may have to forgo paying for basic needs, such as food, housing, or education to pay for medical treatment instead. These costs include transportation, doctors’ fees, medicine, hospitalization bills, and days lost from work.
Behind these sobering statistics lies a wealth of news and feature stories waiting for the media to investigate and share with national leaders and policymakers as well as civil society groups who can advocate for changes to health budgets and policies. At the heart of these stories are important questions about the financing of health care and the quality of governance that ensures responsive and effective management of those resources and services.
But writing health finance and governance stories can be challenging. Health finance is riddled with complex language, technical economic terms, and numbers – not necessarily a journalist’s comfort zone. The right sources for these stories can be difficult to identify and unwilling to talk. Data may be difficult to locate or to understand. And while corruption makes for splashy headlines, the broader systemic challenges of health governance are not widely understood — and yet they are important.
The Health Finance and Governance Briefing Kit is designed to help journalists and their editors uncover and tell these important health stories that affect people all around the world.
Budget matters for health: key formulation and classification issuesHFG Project
This policy brief aims to raise awareness on the role of public budgeting – specifically aspects of budget formulation – for non-PFM specialists working in health. As part of an overall WHO programme of work on Budgeting in Health, it will help clarify the characteristics and implications of various budgeting approaches for the health sector.
Extending health insurance coverage to the informal sector: Lessons from a pr...HFG Project
As a growing number of low‐ and middle-income countries commit to achieving universal health coverage, one key challenge is how to extend coverage to informal sector workers. Micro health insurance (MHI) provides a potential model to finance health services for this population. This study presents lessons from a pilot study of a mandatory MHI plan offered by a private insurance company and distributed through a microfinance bank to urban, informal sector workers in Lagos, Nigeria.
Public Financial Management, Health Governance, and Health SystemsHFG Project
While the importance of governance in a health system is well recognized, there is an overall lack of evidence and understanding of the dynamics of how improved governance can influence health system performance and health outcomes. There is still considerable debate on which governance interventions are appropriate for different contexts. This lack of evidence can result in avoidance of health governance efforts or an over-reliance on a limited set of governance interventions. As development partners and governments are increasing their emphasis on improving accountability and transparency of health systems and strengthening country policies and institutions to move towards universal health coverage (UHC), the need of this evidence is ever rising.
To address this evidence gap, the USAID’s Office of Health Systems (USAID/GH/OHS), the World Health Organization (WHO), and the Health Finance and Governance (HFG) Project launched an initiative in September 2016 to ‘Marshall the Evidence’ on how governance contributes to health system performance and improves health outcomes.
The overall objective of the initiative was to increase awareness and understanding of the evidence of what works and why in how governance contributes to health system performance, and how the field of health governance is evolving at the country level. This report provides a synthesis of the findings across the four themes. This report presents the findings of the Public Financial Management.
Entry Point Mapping: A Tool to Promote Civil Society Engagement on Health Fin...HFG Project
ivil society organizations (CSOs), particularly those working in the health sector, frequently seek opportunities to influence public health policy or share feedback on the quality or accessibility of health services. While these organizations may have important contributions to make, they often are not aware of the most effective and accessible entry points to use. Entry Point Mapping provides a methodology for systemic review and identification of mechanisms, forums and public platforms by which civil society organizations can participate in health sector policy formulation, program implementation, and oversight.
This paper presents an Entry Point Mapping Tool designed for CSOs with advocacy experience and public health officials seeking to expand civil society participation and contains a step-by-step guide for researching and analyzing legal entry points for civil society participation in governance of public health care facilities. Because CSOs have varied interests, the tool includes a series of steps for individual CSOs to determine the level of government at which to pursue their specific advocacy interest and the process of collecting targeted information on legally required points of entry for their civic engagement.
In addition, the Entry Point Mapping Tool offers guidance on analyzing the effectiveness on these entry points and coaches CSOs through the negotiation process of activating or expanding existing entry points, creating new ones, and winning overall collaboration with health officials on improving health policy and service delivery. This tool also documents the experience of CSOs implementing the entry point mapping methodology in Bangladesh and Cote d’Ivoire to demonstrate how the tool can promote increased civil society engagement on issues of health finance and governance.
Championing Sustainability, Namibia Funds Health AccountsHFG Project
In Namibia, donor funding for health dropped by 47 percent between 2009 and 2013. This sharp decline could have broad implications for the health sector—particularly Namibia’s HIV and AIDS response which relies heavily on donor resources. In light of declining donor resources for health, the Government of Namibia (GRN) is positioning itself to sustain health sector progress to-date, through investing in Health Accounts.
Sustaining the HIV/AIDS Response in Dominica: Investment CaseHFG Project
Dominica is an upper-middle-income country in the eastern Caribbean with a population of approximately 72,293. HIV prevalence is estimated at 0.75%. The epidemic is male-dominated, with 70% of those infected being male. While data indicates that the adults aged 25-49 are most affected by HIV and AIDS, incidence trends indicate a higher rate of infection among those over 50. HIV prevalence has shown to be much higher among key populations such as men who have sex with men (MSMs). Further studies are required to produce evidence regarding trends in HIV prevalence among other vulnerable groups such as commercial sex workers (CSW), migrants, and indigenous populations. To date, the following populations have been assigned priority for the HIV/AIDS Response: MSMs and their partners, young people, CSWs, the indigenous population, and prisoners.
The National HIV and AIDS Response Program has continued to reinforce prevention efforts through the scaling-up of HIV counseling and rapid testing sites in additional districts and with non-governmental organization (NGO) partners. Challenges related to retaining those with HIV and AIDS in care and treatment, stigma and discrimination of target groups, and surveillance have been addressed in Dominica’s National HIV and AIDS Strategic Plan 2015-2019. The Strategic Plan was developed during a series of participatory stakeholder workshops in 2014 and includes objectives related to prevention, treatment and care, policy and sustaining the HIV/AIDS response.
Sustaining the HIV and AIDS Response in St. Vincent and the Grenadines: Inves...HFG Project
National surveillance reports estimate that there were about 649 persons living with HIV in St. Vincent and the Grenadines at the end of 2011, which translates to 1.2% of the adult population (15-49 years) or 0.7% of the total population. The epidemic is male-dominant, illustrated by the fact that the cumulative case reporting from 1984-2013 indicates that 60.6% of new cases are reported among males and 38.1% females (1.3% unknown). In response to the growing epidemic, the country quickly scaled up its national HIV/AIDS program in 2004. While care and treatment remains a high priority, St. Vincent and the Grenadines has devoted significant resources to preventative activities, including HIV counseling and rapid testing, education and workplace programs, and other behavioral interventions.
Despite a marked decline in HIV and AIDS cases, significant challenges for the country’s response remain. Close to 20% of persons with advanced HIV infection discontinue treatment within 12 months of initiation, suggesting the need to reinforce adherence and retention to care. The country also faces an imminent decline in donor funding and domestic reprioritization of chronic and non-communicable diseases; without renewed sources of external funding or greater domestic resources allocated to HIV/AIDS, progress made since 2004 could regress.
In response to these challenges, key priorities outlined in the country’s strategic framework (2014-2025) include: 1) institutionalizing HIV education through collaborative programs with different sectors, 2) targeting high risk groups, 3) strengthening HIV testing and counseling, including routine testing for pregnant women and, 4) ensuring access and retention to care and treatment for those with HIV and AIDS and TB. St. Vincent and the Grenadines has also taken steps to integrate HIV and AIDS services into the broader health system and included the HIV and AIDS program as part of the Ministry of Health, Environment and Wellness’ overall health framework. These actions are the beginning of efforts to improve access to care, reduce costs, and improve efficiencies.
Two Nigerian States See Increased Budget Allocations for HIV and AIDS ProgramsHFG Project
In Nigeria an estimated 3.5 million people are living with HIV, but only half of them receive care and treatment. Donor funding accounts for more than 70% of the country's HIV and AIDS response, but more resources are needed to sustain and expand this care. To remedy the coverage gap, Nigeria will need to mobilize more of its own resources.
With support from USAID/Nigeria, HFG, and the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) project, four of Nigeria's State Agencies for the Control of AIDS (SACA) have developed domestic resource mobilization strategies for the HIV and AIDS response. These strategies are designed to stimulate government financing for HIV and AIDS programs in the state, and outline potential new funding sources, including those from the private sector.
Rivers, Cross River, Lagos, and Akwa Ibom states are at different stages of implementing strategies aimed at stimulating both public and private spending for HIV and AIDS. The strategies include ways to effectively govern the allocation and use of funds.
Despite wider economic challenges, including the impact of low oil prices, Cross River state has seen a 300 percent (additional $1 million) increase in budgetary allocation for HIV programs by the state government, with a sustained 24 percent (additional $400k) increase in 2016. HFG’s collaboration with SACA also led to increased budgetary allocations for 2016 in Lagos state, with a 38 percent increase ($92,000) from the 2015 budgetary allocation for HIV and AIDS.
Sustaining the HIV and AIDS Response in the Countries of the OECS: Regional I...HFG Project
In 2014, the six countries of the Organization of Eastern Caribbean States (OECS) of Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia and St. Vincent and the Grenadines developed HIV and AIDS Investment Case Briefs, with the support of USAID’s Health Finance and Governance (HFG) and Strengthening Health Outcomes through the Private Sector (SHOPS) projects. This document provides a summary of the findings of these briefs, which includes an analysis of the costs of HIV and AIDS programs that respond to the disease in the six countries, the resources that are available, the funding gaps, and the potential impact of different levels of investment in programming on the progression of the disease in the region.
Follow the Money: Making the Most of Limited Health ResourcesHFG Project
Worldwide, health systems are being asked to do more with less. In many countries, donor funds have stagnated or are declining. This sharp decline could have broad implications for the health sector— particularly Namibia’s HIV and AIDS response which relies heavily on donor resources. New and emerging threats, such as Zika and Ebola, are also testing weak and fragile health systems, such as those in Guinea and Liberia. And costly noncommunicable diseases, like diabetes and cancers, are on the rise in low- and middle-income countries (LMICs).
With the end of the MDGs and start of the new SDGS, momentum is growing for countries around the world to pursue Universal Health Coverage (UHC) reforms and to expand affordable access to health care services, without risk of financial hardship, while facing real resource constraints in the aftermath of the global economic crisis.
In short, countries need to make their limited health resources go a long way. It is a financing challenge as well as a governance one. Countries cannot manage what they cannot measure. Countries need to measure their health spending – know where the money comes from, how much is spent and where, and how it can be spent more efficiently and equitably.
Policymakers can influence public and private health spending to improve efficiency, quality, equity, and expand access to life-saving health services. To succeed, however, governments need evidence around their health financing landscape. More and more, policymakers are appreciating the value of health resource tracking –that is, a range of methods, data collection initiatives, and estimation tools aimed at measuring the flow of funds to and through the health system.
Follow the Money: Making the Most of Limited Health ResourcesHFG Project
Worldwide, health systems are being asked to do more with less. In many countries, donor funds have stagnated or are declining. This sharp decline could have broad implications for the health sector— particularly Namibia’s HIV and AIDS response which relies heavily on donor resources. New and emerging threats, such as Zika and Ebola, are also testing weak and fragile health systems, such as those in Guinea and Liberia. And costly noncommunicable diseases, like diabetes and cancers, are on the rise in low- and middle-income countries (LMICs).
With the end of the MDGs and start of the new SDGS, momentum is growing for countries around the world to pursue Universal Health Coverage (UHC) reforms and to expand affordable access to health care services, without risk of financial hardship, while facing real resource constraints in the aftermath of the global economic crisis.
In short, countries need to make their limited health resources go a long way. It is a financing challenge as well as a governance one. Countries cannot manage what they cannot measure. Countries need to measure their health spending – know where the money comes from, how much is spent and where, and how it can be spent more efficiently and equitably.
HFG Project Brief - Improving Health Finance and Governance Expands Access to...HFG Project
A functional health system delivers the quality health care people need, where they need it, at
prices they can afford. The United States Agency for International Development’s Health Finance
and Governance (HFG) Project collaborates with partners in lower middle-income countries to
increase their domestic resources for health, manage those precious resources more effectively,
and make wise purchasing decisions. Effective health finance is linked closely to robust health
governance. When the governance of the health sector and its resources is weak, then investments
in technical areas are far less likely to achieve their intended results or yield better health
outcomes. Strong health governance ensures that health sector resources and funds achieve their
goals. Building more financial sustainability into health services, such as HIV and AIDS programs,
helps ensure that more people can get the health care they need to lead productive lives.
Active in more than 25 countries, USAID’s HFG Project partners with health stakeholders to
protect families from catastrophic health care costs, expand access to priority services – such as
maternal and child health care – and ensure equitable population coverage. These three pillars are
at the crux of the global movement for Universal Health Coverage (UHC).
Learn more: www.hfgproject.org
1. Directly respond to at least one classmate in a way that extends .docxketurahhazelhurst
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* A thriving global health program requires many things, such as sufficient funds, leaders and managers, and necessary resources. According to the Center for Global Development (n.d.), "good health service delivery requires that trained and motivated workers are in place and have the supplies, equipment, transportation, and supervision to do their job well" (para 5). Funding is needed to be sure the program continues to be successful, and managers and leaders are beneficial to make sure the program is well supervised. Innovative technology is inevitable and can make a program work more efficiently.
New products alone will not lead to success, but technologies must require successful distribution throughout the target population (Center for Global Development, n.d., para 3). Funding challenges tend to be at the top of the list of potential barriers when creating a global health program. Insufficient financial support from domestic sources, funding issues resulting in agencies focusing on their survival and on producing quick results, rather than on strategic planning and careful program evaluation, and insufficient international financial support are just a few individual barriers (Weiss and Pollack, 2017). Financial support is needed to fund new resources that will make a global health program work.
I think it is appropriate to say that COVID-19 has changed the world, but it has also positively affected the field of Epidemiology. The CDC has worked 24/7 to create a sufficient foundation to detect and fight this virus worldwide. "Field Epidemiology Training Program (FETP) has trained 18,000 field epidemiologists, or “disease detectives,” in more than 80 countries to help track, contain, and eliminate outbreaks at their source," Centers for Disease Control and Prevention (2020) states. Along with partnering with health agencies around the world, this program has impacted current students and graduates by providing them with the knowledge of successful global health programs.
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South Africa HIV and TB Expenditure Review 2014/15 - 2016/17. Executive Summary
1. CONSOLIDATED SPENDING ON
HIV AND TB IN SOUTH AFRICA
(2014/15–2016/17)
EXECUTIVE SUMMARY
August 2018
This publication was produced for review by the Government of South Africa, the United States Agency for International
Development, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. It was prepared by Teresa Guthrie, Kavya
Ghai and Michael Chaitkin of the Health Finance and Governance Project; Nthabiseng Khoza, Nomkhosi Mbukiso Zulu,
and Vincent Madisha of the National Department of Health; Nhlanhla Ndlovu, Silindile Shezi, Joshua Karume, Portia
Motsoeneng and Siphethelo Simelane of the Centre for Economic Governance and Accountability in Africa; and Gesine
Meyer-Rath, Sithabiso Masuku and Lise Jamieson of the Health Economics and Epidemiology Research Office at the
University of the Witwatersrand
Health Economics and Epidemiology Research Office
Wits Health Consortium
University of the Witwatersrand
HE RO
2
2. The Health Finance and Governance Project
USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by
expanding people’s access to health care. Led by Abt Associates, the project team works with partner countries to
increase their domestic resources for health, manage those precious resources more effectively, and make wise
purchasing decisions. The six-year, $209 million global project is intended to increase the use of both primary and
priority health services, including HIV/AIDS, tuberculosis, malaria, and reproductive health services. Designed to
fundamentally strengthen health systems, HFG supports countries as they navigate the economic transitions
needed to achieve universal health care.
August 2018
Cooperative Agreement No: AID-OAA-A-12-00080
Submitted to: Scott Stewart, AOR
Office of Health Systems
Bureau for Global Health
Recommended Citation: Guthrie T, Chaitkin M, Khoza N, Zulu N, Madisha V, Ndlovu N, Shezi S, Karume J,
Motsoeneng P, Simelane S, Meyer-Rath G, Masuku S, Jamieson L, and Ghai K. 2018. Consolidated Spending on HIV
and TB in South Africa (2014/15–2016/17). Pretoria: National Department of Health; Washington, DC: Health
Finance & Governance Project, Results for Development Institute.
Abt Associates Inc. | 6130 Executive Boulevard | Rockville, Maryland 20853
T: 301.347.5000 | F: 301.652.3916 | www.abtassociates.com
Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) |
| Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D)
| RTI International | Training Resources Group, Inc. (TRG)
3. CONSOLIDATED SPENDING ON
HIV AND TB IN SOUTH AFRICA
(2014/15–2016/17)
EXECUTIVE SUMMARY
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for
International Development (USAID) or the United States Government.
The views described herein are the views of this institution, and do not represent the views or opinions of the Global Fund
to Fight AIDS, Tuberculosis and Malaria, nor is there any approval or authorization of this material, express or implied, by
the Global Fund to Fight AIDS, Tuberculosis and Malaria.
6. vi
EXECUTIVE SUMMARY
Background and Purpose
The South African Government (SAG) and its development partners have mounted a formidable
response to the world’s largest HIV epidemic and a persistent burden of tuberculosis (TB), the country’s
leading killer. Nearly 4 million South Africans initiated antiretroviral therapy (ART) by the end of
financial year 2016/17, helping to curtail new infections and reduce the number of annual HIV-related
deaths. Mortality from TB has also declined thanks, in part, to improved treatment success.
Despite progress, challenges remain. Roughly 3 million people living with HIV (PLHIV) lack treatment,
and each year more than a quarter million are newly infected. Moreover, nearly a half million South
Africans contract TB every year, with an increasing share affected by drug-resistant strains.
To effectively plan and steward the health system, the SAG routinely monitors programmatic and
financial performance of the response to HIV and TB, including by tracking expenditure. Analysis of
spending, including trends in sources, levels, geographic and programmatic distribution and cost drivers
can help policymakers to assess whether resources are reaching priority populations, interventions, and
hotspot geographies; to identify potential opportunities to improve allocative and technical efficiency;
and to stimulate more productive dialogue at multiple levels of the system.
This review of HIV and TB expenditure in South Africa is an input to policy, planning and management
processes within and amongst spheres of government and between government and development
partners. The data have been especially useful to national and provincial programme managers as they
perform their oversight functions, leading to improved spending of available resources. With 52 annexes,
it also serves as an authoritative reference document detailing levels and trends in HIV and TB spending
by the three main funders of the disease responses: the SAG, the United States Government (USG),
primarily via the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight
AIDS, Tuberculosis, and Malaria (the Global Fund). The findings have informed South Africa’s report to
the UNAIDS Global AIDS Monitor and the country’s forthcoming funding request to the Global Fund.
Approach and Methods
Through a process of capacity building and technical support led by Results for Development (R4D), via
the United States Agency for International Development’s (USAID’s) Health Finance and Governance
project, a consortium produced this analysis, including officials from the National Department of Health
(NDOH) and researchers from the Centre for Economic Governance and Accountability in Africa
(CEGAA) and the Health Economics and Epidemiology Research Office (HE2RO) at the University of
Witwatersrand, via USAID’s Innovations Research on AIDS Program (INROADS) and Financial Capacity
Building and Technical Support Project (FIN-CAP). Other agencies provided essential data or funding (or
both), including the National Departments of Basic Education (DBE) and Social Development (DSD),
USAID and the Global Fund.
7. vii
The consortium sought not only to update available analysis but also to institutionalise capacity within
the government, CEGAA and HE2RO to compile, analyse and interpret available expenditure data and
use the data in relevant forums. Accordingly, the research process included a series of collaborative
training workshops, inclusive consultations with key stakeholders and concurrent development, led by
HE2RO, of an Excel-based automation tool that can search, summarise and code HIV- and TB-related
transactions in the SAG’s public Basic Accounting System (BAS) (Box ES 1).
This review builds on previous analyses of HIV and TB spending, most recently those conducted as
inputs to South Africa’s HIV and TB Investment Case, which covered financial years (FY) 2011/12
through 2013/14. This iteration of analysis answers the following questions:
1. How much was spent on HIV and TB by the three main funders (SAG, USG, and Global Fund)
during FY 2014/15 through 2016/17?
2. How was spending distributed across geographies and interventions?
3. Which cost categories drove spending?
4. How did spending and outcomes compare across provinces for the key HIV programmes?
5. How did government spending change while PEPFAR’s ‘focus for impact’ efforts concentrated
PEPFAR investment in 27 of South Africa’s 52 districts?
6. How does the spending according to interventions compare with the newly costed National
Strategic Plan for HIV, TB and STIs 2017–2022?
7. What financial and epidemiological data challenges limit analysis and interpretation?
Box ES 1.
BASLY - a new tool to catalyse expenditure analysis
In consultation with consortium partners, researchers from HE2
RO developed an Excel-based tool, called
BAS Lightyear (BASLY), that automates several key steps of HIV and TB expenditure analysis. These
include searching Department of Health (DOH) BAS records for every HIV and TB transaction, extracting
these into a common database, crosswalking the interventions and cost categories to the reduced lists of
common codes and running high-level analysis on this dataset. In addition, the tool can analyse any other
expenditure data along with the DOH extract if the data are arranged in the BAS output structure. The
tool will allow government and partners to complete these steps in a few hours*, compared to the weeks,
or even months, previously required. The tool could potentially be adapted to other disease or
programme areas, if the financial transactions have a suitable identifier.
In early 2018, HE2
RO trained officials from the NDOH to use BASLY, which will assist them in their
routine analysis of provinces’ quarterly and annual spending. At the time of writing, the team was exploring
further development of BASLY, such as to add capability for more extensive automated analysis and for
the incorporation of development partners’ expenditure data.
* Depending on the processing power of the laptop on which BASLY is being run.
8. viii
The expenditure review required data from numerous sources, as summarised in Table ES 1. The data
were crosswalked to a common set of spending categories and compiled into a master database for
analysis. In addition to estimating nationwide expenditure in aggregate, by intervention area and by cost
element, where possible the team also disaggregated estimates to the provincial and district levels.
Table ES 1. Summary of data sources and possible levels of disaggregation
Funding source and channel Data source
Disaggregation
National Provincial District
SAG
DOH through voted funds
and conditional grant (CG)
SAG BAS ✓ ✓ ✓
Department of Basic
Education (DBE) through
CG
Estimates of national and
provincial revenue and
expenditure
✓ ✓
Department of Social
Development (DSD)
through voted funds
✓ ✓
USG
PEPFAR
Expenditure Analysis
Tool
✓ ✓
USAID (non-PEFPAR) USAID official ✓
Global Fund
Principal Recipients’
(PRs’) progress updates
and disbursement
requests
✓
Note: Previous analysis also included spending by three additional SAG entities: Department of Correctional Services, the Department of Defence and the
South African Police Service. Together these accounted for less than 0.5% of spending during 2011/12–2013/14 and so were excluded from this study.
Selected Findings
This review includes dozens of spending estimates at the national, provincial and district levels for three
funders of the two multifaceted and interconnected disease responses. A selection of headline findings is
summarised here.
National Level
The SAG continued to lead the scale-up of South Africa’s HIV and TB responses. Combined
spending for HIV and TB across the SAG, USG and Global Fund increased from R22.5 million in FY
2014/15 to R28.8 million in 2016/17, reflecting average annual growth of 13% over the three years and
sustaining steady growth since 2003/04. In 2016/17, the SAG accounted for 76% of total spending—66%
by DOH, 9% by DSD and nearly 1% by DBE—followed by the USG (21%) and Global Fund (3%)
(Figure ES 1). South Africa continues to stand out amongst countries with substantial HIV and TB
burdens for domestically financing most of the disease responses.
9. ix
Figure ES 1. Total HIV and TB spending by source and year (R millions) (left) and funder share
(%) (right)
Conditional grants, especially the DOH’s Comprehensive HIV, AIDS and TB CG, were the
most important financing mechanism for the HIV response. In 2016/17, the DOH CG
channelled 90% of total DOH spending on HIV and 59% of the overall spending on HIV. Only 5% of
DOH HIV spending was financed from provincial DOHs’ voted funds, and only in Mpumalanga, Gauteng
and Western Cape did voted funds accounted for at least 8% of DOH spending on HIV. All the DBE
spending on HIV came from the Department’s HIV and AIDS Life Skills CG. In contrast, DSD spending
on HIV came entirely from voted funds, which accounted for 13% of domestic HIV spending in 2016/17
and included their HIV/AIDS sub-programme (100%), and the community-based care services for
vulnerable children (100%), as well as 20% of: care and services to families, victim empowerment,
substance abuse prevention, child care and protection sub-programmes, and 10% of child and youth care
and youth development programmes – since all these activities are prevention or mitigation priorities in
the new National HIV, TB and STI Strategic Plan. In addition, the DSD provides foster grants and child
support grants for vulnerable children, the spending on which have not been captured here but
nevertheless represent important mitigation efforts.
Donor commitment to combatting HIV and TB in South Africa remained strong despite
long-run expectations of declining support. Support from the USG, mainly through PEPFAR, grew
over the three years, from R4,219 million in 2014/15 to R6,015 million in 2016/171. The USG held
steady as the source of about one fifth of HIV and TB spending, a modest increase in share compared to
the previous three-year period. Meanwhile, after Global Fund spending increased from R865 million in
2014/15 to R1,533 in 2015/16, its contribution dropped to R806 million in 2016/17. This mainly reflects
1 The US dollar value of PEPFAR’s contribution decreased from 2014/15 to 2015/16, but the Rand value increased due to
weakening of the Rand relative to the US dollar during that period.
Global Fund USAID (Non-PEPFAR) PEPFAR DBE DSD DOH
22,472
25,810
28,814 22,472 25,810 28,814
10. x
sluggish spending in the first year of a new three-year grant. Importantly, the new Global Fund grant will
amount to R4.3 billion2 for 2016–2018, compared to roughly R3 billion spent from the 2013–2015 grant.
Within the HIV response, government funded a large share of treatment, whereas donors
drove significant shares of spending in prevention. In 2016/17, South Africa domestically financed
83% of HIV treatment costs and 67% of other care and support activities. In addition, the SAG financed
around half of prevention (including youth interventions, condoms, human papilloma virus vaccination
and workplace interventions,) and investments in enablers, including gender empowerment, substance
abuse prevention, training and some advocacy, communications and social mobilization (ACSM) (Figure
ES 2). Activities for which donors provided more than half of the financing in 2016/17 included HIV
testing services (HTS), prevention of mother-to-child transmission (PMTCT), medical male circumcision
(MMC), post-exposure prophylaxis (PEP) and outreach to key populations. However, the majority of the
PEPFAR funding has been for technical support for these activities rather than for direct service delivery,
while the SAG funding is for the direct service delivery and often a portion of the DOH spending on
these is embedded in the general primary health (PHC) spending, such as salaries of nurses doing HST
or PMTC as well as other PHC services, so these expenditures are not labelled as HST and PMTCT
specifically.
Figure ES 2. Funders' relative contributions to HIV intervention categories (2016/17, %)
Note: Details of which interventions were included in each thematic area can be found in Section 2.7. Column totals may exceed 100% due to rounding.
ART drove most of South Africa’s HIV spending. Spending on ART increased from R9,807 million
in 2014/15 to R12,863 million in 2016/17, reflecting the steady increase of PLHIV on treatment—at the
end of 2016/17, nearly 4 million PLHIV remained in care. Thus in 2016/17, ART accounted for nearly half
of overall HIV spending and ranged from 50% to 80% of the provincial DOH HIV spending. The next
biggest areas of spending were home-based care (9%), HTS (7%), care for orphans and vulnerable
children (7%) and MMC (4%).
2 This amount is equivalent to the US$324 million committed by the Global Fund, based on an exchange rate of R13.25
per US dollar used by the Global Fund in the approved budget for the 2016–2018 grants, provided by the South African
National AIDS Council (SANAC).
R1,931MR2,043MR3,792MR17,962M
83%
54% 54%
67%
15%
41% 34%
33%
2% 6% 12% 0%
Treatment Prevention Programme Enablers Care & Support
SAG USG Global Fund
11. xi
TB spending continued to rise thanks to growing domestic and donor financing for the
disease. Combined TB spending increased from R2,652 million in 2014/15 to R3,147 in 2016/17,
increasing annually by 8% on average, over the three years. The SAG (via DOH) accounted for 79% of
total TB spending, with the USG contributing 20% (nearly 15% through PEFPAR and 6% through
separate USAID funding). The Global Fund contributed R30 million in 2016/17, less than 1% of total TB
spending, in addition to spending on TB/HIV integrated efforts that were included in the HIV spending
total. Whilst modest, this reflects the Global Fund’s increased commitment to combatting TB in South
Africa. In 2016/17, the TB spending was concentrated in the cities of Johannesburg, Cape Town, Durban,
Tshwane and Ekhurleni, which accounted for nearly one third of TB spending.
TB spending was harder to capture than HIV spending. Most domestic spending on TB was
financed from provinces’ voted funds, with some CG funds. The voted funds are less reliably coded in
the BAS than the CG funds. Consequently, the DOH’s decision to increase TB funding via the DOH’s
Comprehensive HIV, AIDS and TB CG should lead to better tracking of the SAG’s TB spending in the
future. Additionally, the actual TB spending was probably higher than captured here because only SAG
expenditure specifically recorded as TB-related in the BAS could be identified. Promisingly, there were
signs of improvement in the coding of TB spending from voted funds. Finally, disaggregated TB spending,
including by geography and programme area, was especially hard to characterise and interpret,
suggesting the need for further improved coding of TB expenditures in the BAS.
Subnational Level
This study broke new ground for district-level analysis and confronted some challenges with respect to
data quality and completeness.
Sub-national analysis of HIV spending is more feasible than ever, although some
constraints persist. This review offers the most detailed analysis available of combined district-level
spending on HIV. Improvements by the SAG and PEPFAR in the geographic disaggregation of
expenditure data were key. Moreover, TB spending was not examined by district in previous reviews.
Nonetheless, certain features of all three funders’ data still limited the sub-national analysis:
• Several provincial DOHs did not comprehensively code their spending to districts, in some cases
leaving substantial portions of expenditure in ‘whole province’ categories;
• PEFPAR’s expenditure data only differentiated between national- and district-level spending, meaning
all support to provincial functions was lumped together with PEPFAR’s national spending, and;
• The Global Fund’s principal recipients (PRs) did not track their expenditure by geography, meaning
that disaggregating the Global Fund spending data would have required intensive dialogue with each
PR merely to generate rough estimates of provincial and district splits. Therefore, in this report
Global Fund’s spending is labelled as “not disaggregated” or “ND.”
With some exceptions, HIV spending was roughly distributed according to district-level
disease burden. KwaZulu-Natal and Gauteng, the highest HIV-burdened provinces, spent the most on
HIV. Eight metropolitan areas account for over a quarter of the spending (26%), reflecting the
concentration of PLHIV in major cities like Johannesburg, Durban (eThekwini), Tshwane and Cape
Town. Combined DOH and PEPFAR spending was spread across districts roughly in accordance with
the estimated numbers of PLHIV, noting enduring challenges with both the disaggregation of spending
and estimation of disease burden at the district level.
12. xii
Figure ES 3. HIV spending by district and funder (left axis) and number of PLHIV (right axis) in 2016/17
Abbreviations: HQ = Headquarter, IP = implementing partner; EC = Eastern Cape; FS = Free State; GP = Gauteng; KZN = KwaZulu-Natal; LP = Limpopo; MP = Mpumalanga; NC = Northern Cape; NW = North West; WC =
Western Cape.
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
-
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
EC:BuffaloCityMetropolitan
EC:ORTambo
EC:NelsonMandelaBay
EC:Amathole
EC:ChrisHani
EC:AlfredNzo
EC:SarahBaartman
EC:JoeGqabi
EC:WHOLEPROVINCE
FS:ThaboMofutsanyana
FS:Lejweleputswa
FS:Mangaung
FS:FelizeDabi
FS:Xhariep
FS:WHOLEPROVINCE
GP:CityofJohannesburg
GP:Ekhurleni
GP:CityofTshwane
GP:Sedibeng
GP:WestRand
GT:WHOLEPROVINCE
KZN:eThekwini
KZN:uMgungundlovu
KZN:uThungulu
KZN:Ugu
KZN:Zululand
KZN:uMkhanyakude
KZN:uThukela
KZN:uMzinyathi
KZN:Ilembe
KZN:HarryGwala
KZN:Amajuba
KZN:WHOLEPROVINCE
LP:Capricorn
LP:Mopani
LP:Sekhukhune
LP:Vhembe
LP:Waterberg
LP:WHOLEPROVINCE
MP:GertSibande
MP:Ehlanzeni
MP:Nkangala
MP:WHOLEPROVINCE
NC:FrancisBaard
NC:JTGaetsewe
NC:PixleykaSeme
NC:ZFMgcawu
NC:Namakawa
NC:WHOLEPROVINCE
NW:BojanalaPlatinum
NW:DrKKaunda
NW:NMMolema
NW:DrRSMompati
NW:WHOLEPROVINCE
WC:CityofCapeTown
WC:CapeWinelands
WC:Eden
WC:WestCoast
WC:Overberg
WC:CentralKaroo
National
AboveNational
Notdisaggregated
EC FS GP KZN LP MP NC NW WC Other
PLHIVpopulation
Rmillions
Global Fund PEPFAR DOH PLHIV Population
DOH bulk spending often
labeled as ‘whole province’
rather than split by district
PEPFAR spending in
Johannesburg may be
overstated due to IPs
assigning cost to HQ
Global Fund PRs still
do not report
spending by district
District-level disease
burden estimates
remain uncertain
13. Implications
Up-to-date data on spending trends are critical for policy, planning and programme management.
Expenditure data help policymakers better match funding allocations to priorities. Detailed
analysis of spending patterns helps the SAG and development partners to compare their plans with their
past and current budgets with spending which, when combined with outcome and population data,
provides a measure of efficiency and equity. The data also equip government officials to make and defend
sometimes controversial decisions to reallocate funds across geographies or interventions.
Consolidated analysis of domestic and donor spending enables better joint planning,
including for an eventual transition away from donor support. The breakdown of SAG, PEPFAR
and Global Fund contributions in this review should focus attention on particularly donor-dependent
interventions that make critical contributions to epidemic control. Like many other countries, South
Africa relies heavily on development partners to finance key outreach, prevention and advocacy
activities, as well as those aimed at addressing social and economic structural drivers of the epidemic.
Transitioning these activities to domestic ownership will require additional domestic resource
mobilisation and new institutional arrangements (e.g., co-financing across sectors), purchasing
mechanisms and monitoring systems to ensure available funds are used efficiently, effectively and
equitably.
Routine expenditure review facilitates programme management and enables real-time
adjustments based on dialogue between national and sub-national actors. This study builds
directly upon existing quarterly and annual CG reviews, during which national, provincial and district
officials interrogate programmatic and expenditure data to understand performance and jointly address
any areas of concern. The study process helped the FIN-CAP team to deepen their analytical skills that
they immediately deployed to help provinces to improve their generation and use of high-quality
expenditure data, leading to significant quality improvements in the HIV CG quarterly financial reports.
Most provincial financial managers also requested FIN-CAP to provide training and technical support to
district managers. Prior to FIN-CAP’s involvement, the NDOH had to expend considerable effort to
cross-check provincial reports with their own analysis of BAS records and work with provinces to
address discrepancies. Insights from FIN-CAP’s engagement with provincial and district officials also
enriched interpretation of the multi-year expenditure trends presented in this study.
Champions of performance-based purchasing in South Africa should draw lessons and
encouragement from the HIV response. This expenditure analysis shows the value of the CGs that
account for the bulk of HIV public spending in terms of the CG ability to be tracked through detailed
and accurate expenditure data directly linked to outputs. The CG Framework and oversight process
constitute an important performance-linked contracting system for government-financed health services.
The model of using funds mobilised and pooled by the national sphere to pay for services delivered by
health providers instead of inputs (e.g. labour and commodities) is, in a sense, a microcosm of the vision
set forth in the recently introduced National Health Insurance Bill. In fact, the SAG is already taking
steps to ensure robust planning and oversight to other facets of primary health care—for example, the
2018 Division of Revenue Act added a component for community outreach services, a key element of
NDOH’s primary health care strategy, to the Comprehensive HIV, AIDS and TB CG. This echoes
previously examined options for extending the grant framework to include more primary care services
as a possible interim step towards integrating HIV financing into the proposed National Health Insurance
Fund.
14. 14
Looking Ahead
This report contributes to the growing body of evidence on the magnitude, composition and trends of
HIV and TB spending in South Africa. Data and analysis assembled during the study have already
informed important management and planning processes, including the NDOH’s routine CG reviews,
the SAG’s annual submission for UNAIDS Global AIDS Monitoring report, negotiations over PEFPAR’s
Country Operational Plan for 2018, and preparation of South Africa’s new funding request to the Global
Fund for 2019–2021.
The report also marks an important capacity milestone. Besides generating the detailed methods and
findings documented here, the consortium organised multiple skills exchanges that bolstered all
partners’ capacity to undertake this work in South Africa and beyond. The process also yielded a tool
for automated data extraction and analysis, which is already being used by the NDOH for its quarterly
review of provincial HIV spending.