A review of the South African Comprehensive HIV and AIDS Grant
Compiled by Michael Strauss, Gavin Surgey and Steve Cohen for the South
African National AIDS Council
Date of Draft: 30 March 2015
Table of Contents
List of tables
List of figures
ii
Error! Bookmark not defined.
1: Introduction
1
1.1 Overview of the magnitude of the HIV and AIDS and TB epidemic in
South Africa
1
HIV
2
TB and HIV co-infection
4
1.2 Role of provinces in the response
5
1.3 Resource needs to respond to the epidemic
6
1.4 Purpose of this review
7
2: An overview of funding for HIV and TB at a provincial level
9
2.1 The budgeting process in South Africa
9
2.2 Procedures and mechanisms for state funding of HIV in provinces
12
2.3 HIV and TB funding from external partners
13
2.4 The Characteristics of Conditional Grants
15
3: An overview of the characteristics of the Comprehensive HIV and
AIDS Grant
3.1 Purpose of the HIV conditional grant
3.2 Administration and Management Arrangements for CG
3.3 Formula and Policy for Dividing Funding by Province
17
17
20
21
4: An analysis of key historical trends in the implementation of the HIV
conditional grant
27
4.1 Annual Growth in Funding for the HIV conditional grant
27
4.2 Recent additions of new sub-programmes and their purpose
28
4.3 Changes in the proportional allocation of funding
29
4.4 Spending performance per annum
33
4.5 Performance against target indicators by programme
39
Antiretroviral Therapy
43
HIV Counselling and Testing
50
High Transmission Areas and Condom Distribution
51
Home and Community Based Care
53
Medical Male Circumcision
55
TB/HIV
57
Prevention of Mother to Child Transmission
58
Post exposure prophylaxis
60
Programme Management
61
Regional training centres
62
5. Conclusion
64
References
67
i
List of tables
Table 1: ART Exposure 2012 ........................................................................... 4
Table 2. HIV and TB Co-infection 2013 ........................................................... 5
Table 3: Timeline for development and setting of national budget ................. 10
Table 4: Timeline for the development and setting of provincial budgets....... 11
Table 5: Distribution of HIV conditional grant between provinces .................. 22
Table 6: Mid-year population estimates 2014 and estimates of HIV .............. 23
Table 7: Percentage of expenditure against DORA allocations 2013/14 ....... 37
Table 8: Allocations and actual expenditure by the end of the third quarter
2014/15 per province .............................................................................. 38
Table 9: Allocations and actual expenditure by the end of the third quarter
2014/15 per programme ......................................................................... 39
Table 10: Performance against indicator targets by the end of the third quarter
2014/15 ................................................................................................... 41
Table 11: New patients initiated on ART performance trends by province..... 47
Table 12: Patients remaining in care performance trends by province .......... 48
Table 13: Patients remaining in care, new people initiated on treatment and
attrition .................................................................................................... 49
Table 14: MMC performance by the end of the third quarter 2014/15............ 56
List of figures
Figure 1. HIV prevalence among antenatal attendees 1990-2012…………….2
Figure 2. HIV Prevalence by Province 2012……………………………………..3
Figure 3: Donor contributions to the South African HIV response .................. 14
Figure 4: Conditional grant allocations to provinces....................................... 21
Figure 5: Conditional grant allocations to provinces and HIV burden............. 24
Figure 6: Conditional grant allocations to provinces and HIV prevalence ...... 25
Figure 7: Conditional grant allocations to provinces and antenatal Prevalence
................................................................................................................ 25
Figure 8: Comprehensive grant for HIV and AIDS growth 2005-2016 ........... 27
ii
Figure 9: Conditional grant allocation to ART trends...................................... 29
Figure 10: Percentage share of conditional grant allocations to programmes
(excluding ART) ...................................................................................... 30
Figure 11: Conditional grant percentage allocation to broad programme areas
................................................................................................................ 32
Figure 12: Conditional grant allocation to broad programme areas ............... 33
Figure 13: Annual percentage of conditional grant funds spent ..................... 34
Figure 14: Actual spending within programmes against conditional grant
transfers.…………………………………………………………………………….36
Figure 15: Actual expenditure against conditional grant allocations 2013/14. 37
Figure 16: HIV burden and percentage allocation of ART funding per province
................................................................................................................ 43
Figure 17: ART spending performance and patients remaining in care ......... 44
Figure 18: ART spending performance and new patients initiated on ART.... 45
Figure 19: HCT spending performance and number of people counselled and
tested for HIV .......................................................................................... 51
Figure 20: Male condoms spending and performance against targets........... 52
Figure 21: Percentage of female condoms distributed against annual targets
................................................................................................................ 53
Figure 22: HCBC spending and performance against targets........................ 54
Figure 23: MMC spending and performance against targets ......................... 55
Figure 24: TB/HIV spending and performance against targets ...................... 57
Figure 25: PMTCT spending and performance against targets ..................... 59
Figure 26: PEP spending and performance against targets........................... 60
Figure 27: Programme management spending trends ................................... 61
Figure 28: RTC spending and performance against targets .......................... 62
iii
1: Introduction
1.1 Overview of the magnitude of the HIV and AIDS and TB
epidemic in South Africa
South Africa currently has the largest HIV and AIDS epidemic in the world
with an estimated 6.4 million people (12.3% of the population) infected and
over 340 000 new cases annually [1]. The tuberculosis (TB) epidemic is also a
serious concern a coordinated response. TB is one of the most common
causes of HIV and AIDS related deaths in South Africa. HIV infection
weakens the immune system and as a result, individuals with HIV are very
susceptible to TB co-infection. Although antiretroviral therapy (ART) reduces
the risk of TB infection, studies have shown that TB incidence is still higher
than in the rest of the population.
The HIV and AIDS and TB response in South Africa has grown steadily,
strengthened by the development of prevention and treatment interventions,
as well as a better understanding of the structural and biomedical drivers of
the disease. However there is still much to be done and a well planned
response is required to ensure the sustainability of the prevention and
treatment agenda, to end the epidemic. The South African National Strategic
Plan on HIV, TB and STIs (NSP) for 2012-2016 identifies HIV and TB as a coepidemic and aims to address both simultaneously. TB is a new inclusion in
the NSP from previous national HIV plans published for 2000-2005 and 20072011 [2].
The HIV and TB response in South Africa is funded primarily by the South
African government, with some assistance from international donors and
development partners – although international assistance is slowly being
decreased. In the public sector, almost 90% of the NSP is funded through the
1
HIV conditional grant with only about 10% allocated from direct national and
provincial discretionary allocations [3].
HIV
For more than 20 years, the HIV and AIDS epidemic has been a major
concern for the health sector in South Africa. The magnitude of the epidemic
grew steadily from the first reported AIDS cases in 1983 with prevalence
among ante-natal attendees reaching its peak in 2005 at 30.2% [4]. Since
then, prevalence has stabilised among ante-natal attendees but the latest
HSRC population level HIV prevalence, incidence and behaviour survey has
show a continued gradual increase in prevalence at a population level [1].
Figure 1. HIV prevalence among antenatal attendees 1990-2012
(Source: The 2012 National Antenatal Sentinel HIV & Herpes Simplex Type-2
Prevalence Survey in South Africa, 2013)
Part of the reason for the persisting high prevalence rates in the country can
be attributed to the success of the HIV treatment programme. South Africa
has the world’s largest Antiretroviral Therapy (ART) programme in the world,
WITH more than 2 million people currently receiving treatment and care –
31.2% of the HIV positive population. This means people are living longer,
and AIDS deaths are declining. The benefits of treatment, not only for the
health of HIV positive people, but also for the prevention of transmission
cannot be underestimated.
2
The most recent HIV population survey has shown a decline in prevalence in
the 15-24 years age group [1]. This shows evidence of an aging epidemic,
where interventions aimed at young people have been relatively successful in
stemming the tide of new infections. The severity of the epidemic varies
substantially between provinces, from 16.9% in KwaZulu-Natal to just 5% in
the Western Cape[1]. This variation can be attributed to a variety of structural
drivers of the epidemic, as well as the effectiveness of the response.
Importantly, it highlights the need for a well-coordinated national response
that recognises the specific challenges that different provinces face.
Figure 2. HIV Prevalence by Province 2012
(Source: HSRC Population survey, 2014)
The ART programme has expanded rapidly since the start of the rollout plan
in the public sector in 2004, with the guidelines for initiation of ART steadily
increasing from 200 cells/mm3 to 350 cells/mm3 in 2010, and since January
2015, to 500 cells/mm3 as per World Health Organisation recommendations.
One of the most successful elements of the treatment programme in the
country is the prevention of mother to child transmissions (PMTCT). The
success of the scale-up of treatment for HIV positive pregnant mothers has
ensured the reduction of mother to child transmission to below 3% [1].
3
Table 1: ART Exposure 2012
(Source: HSRC Population survey, 2014)
TB and HIV co-infection
Although TB is treatable, it remains a primary cause of death in South Africa.
The latest WHO report on the epidemic estimates that prevalence in the
country in 2013 was 380 000, while incidence was estimated at 450 000 – a
staggering rate of 860 per 100 000 people [5]. High-risk populations include
HIV positive individuals, correctional service facility workers, healthcare
workers and mine workers. Drug resistance in South Africa resulting from
inadequate service delivery and treatment defaulters is a serious problem,
especially given the costs of second line treatment.
The link between TB and HIV is well documented and co-infection is a
particular problem in South Africa, where HIV is a key driver of the TB
epidemic. 62% of all TB infected individuals are also HIV positive [5]. The
South African response has been partially integrated with the HIV response,
to address the magnitude of the problem of co-infection. However although
there are specific TB related goals in the NSP, the funds allocated to the TB
epidemic are comparatively small, with some of the general TB response
being funded through provincial equitable share allocations.
4
Table 2. HIV and TB Co-infection 2013
TB patients with known HIV status
HIV positive TB patients
HIV positive TB patients on antiretroviral therapy (ART)
(Source: WHO Global TB Report, 2014)
Number
%
29504
181736
120298
90
62
66
1.2 Role of provinces in the response
The National Department of Health (NDoH) has a limited role in the
implementation of the HIV and TB response, however they are responsible for
planning and policy at a high level as well as monitoring and providing support
to the provinces, which are responsible for rolling out programmes. This role
includes the generation of policy and plans such as the NSP, as well as some
national level interventions like the procurement of condoms, and information,
education and communication activities. The NDoH is also involved from time
to time in procuring antiretroviral drugs when there is a lack of capacity in the
provinces. At a national level, the Department of Social Development and the
Department of Basic Education both play a role in the development of policies
to address the social and structural drivers of the HIV epidemic.
Almost all of the responsibility for the implementation of the HIV and TB
response lies with the provincial and district level health departments. The
various programmes laid out in the NSP are rolled out at the provincial level.
Facilities and infrastructure, human resources, medications and materials for
rolling out the HIV and TB response are all accounted for at the provincial
level. Part of the HIV and TB programme in South Africa is funded through
provincial equitable share allocations and through the equitable share
allocations to national departments. However the overwhelming source of
funding for the response comes from the Conditional Grant for HIV/AIDS and
TB, which is awarded to the NDoH and then distributed to each of the
provinces.
The provincial health departments, with the help of the national department
are responsible for the development of business plans, which set out specific
5
financial allocations and non-financial targets for various health related
expenditures. These business plans are reviewed and refined by the national
department in collaboration with provinces to align with national objectives
and approved business plans are used as a baseline for interdepartmental
transfers and as a baseline for monitoring. There is also a responsibility to
capture expenditures correctly, in the Basic Accounting System (BAS), within
the various provincial programme areas. This should align with provincial
annual performance plans, guidelines set out by the NDoH and allocations in
the approved business plans. Provinces are also required to track
performance using the District Health Information System (DHIS). Facilities at
the district level track the services provided in every healthcare facility in
South Africa. Data collected at a district level is then collated and aggregated
up to the provincial and national levels. The DHIS contains detailed
information about the number of services provided by public healthcare
facilities, by programme, gender of patients, age and facility among other
things. These data are used for annual reporting and planning.
Provincial departments of health, social development, education, and, to a
lesser extent, some of the other provincial departments are responsible for
rolling out HIV and TB related plans and policies developed at a national level.
Interventions are aimed at addressing social and structural drivers of the
epidemic and include support for those indirectly affected by the epidemics,
capacity building and education. The role of all these departments is vital in
the response.
1.3 Resource needs to respond to the epidemic
The resource needs for the HIV and TB response are substantial. A recent
review of the financing of the NSP estimated a total cost of R133.5billion over
the 5-year period set out in the plan, with an estimated R26.84 billion required
in 2014/15 [3]. The money to fund the HIV and TB response in South Africa
comes largely from government (and specifically through the HIV conditional
grant), the private sector and international aid. The vast majority of the
6
resource need in the NSP lies in treatment. It is estimated that around 85% of
the total cost of the response will come from testing and treatment of HIV and
TB.
With the resource needs growing year on year, and commitment from
international partners dwindling, increased political will and a renewed
commitment to prevention and treatment will be vital for the sustainability of
the response. Increasing efficiencies, the development of the South African
Investment Case, and integration of HIV and TB services with existing
healthcare delivery mechanisms will also go a long way to ensuring outcomes
contained within the NSP are realised. Strengthening health systems
including infrastructure and human resources will go a long way to ensuring
the sustainability of the HIV and TB response in South Africa. This will be
supported by the development of the NHI and spending on general healthcare
through this financing mechanism.
1.4 Purpose of this review
The purpose of this review is to build a deeper understanding of the
conditional grant for HIV/AIDS, its investment priorities and its contribution to
the objectives of the NSP 2012-2016.
In order to do this an integrated
programmatic, financial and economic analysis of the HIV/ AIDS Conditional
Grant is conducted.
This review will cover the following areas:
•
Characteristics of the HIV conditional grant.
•
Historical trends of the HIV conditional grant
•
Focused review of the 2013/14 and 2014/15 HIV conditional grant
•
Economic efficiencies of the conditional grants
•
Observations and design recommendations for the HIV conditional
grant programme
7
It will assess how far the conditional grant has gone to achieving the goals of
the NSP. This review will assist contribute to the mid term review of the NSP
which is currently underway.
8
2: An overview of funding for HIV and TB at a
provincial level
2.1 The budgeting process in South Africa
The budgeting process in South Africa is governed by the Public Finance
Management Act (No.1 of 1999 as amended by Act 29 of 1999). The PFMA
applies to both national and provincial public departments and is intended to
promote better financial management, increased accountability and reduce
waste and corruption in the use of public assets. The National Treasury (NT),
established as a result of PFMA legislation, provides financial oversight for all
spheres of government and implements the budget of the national
government. Provincial treasuries also exist to oversee the development of
provincial budgets and enforce uniform treasury norms as prescribed by NT
[6].
There are a number of key players in the national budgeting process in South
Africa. The minister’s committee on the budget is one of the most powerful
bodies and is responsible for policy relating to the budget as well as ultimately
being responsible for approval of the final national budget. The national and
provincial treasuries, the medium term expenditure committee (MTEC) and
formal functional MTECs, which are comprised of members from the various
national and provincial governments and treasuries also meet to review and
scrutinise budget submissions from various departments for the year. These
committees are also mandated to make recommendations to the minister’s
committee on the budget regarding the allocations and spending priorities
among other things and are influential in steering the budgeting process.
The Budget Council is made up of the Minister of Finance and members of
executive councils in charge of finance for provinces. This Council is
responsible for the monitoring and management of provinces and makes
9
recommendations about allocations in provinces. The South African
Parliament also has a role in reviewing and approving the final estimates of
national expenditure and budgets, as well as providing guidance for the
budgeting process in general. This is achieved through the work of a number
of Parliamentary Portfolio Committees responsible for various activities
conducted by the different departments. Parliament also votes on the Division
of Revenue and then the Appropriation Bill, holds consultations with civil
society to get input on legislation from public representatives [6].
The budgeting process starts in June, when the MTEF guidelines have been
finalised and are distributed to relevant institutions. The various activities
conducted by the committees and institutions inform the allocation of finances,
and culminate in the tabling of the finalised budget in parliament and the
delivery of the budget speech by the Minister of Finance to parliament. The
following table, which outlines the key dates and activities in the budgeting
process is extracted from the National Treasury MTEF Technical Guidelines
for 2014/15 [7].
Table 3: Timeline for development and setting of national budget
(Source: National Treasury MTEF Guidelines 2014/15, 2014)
10
The provincial budgeting process follows a similar structure, with timeframes
lagging back by a few weeks for each activity that corresponds with planning
on a national level. Structures and institutions involved in preparing budgets at
a provincial level vary, but are guided primarily by provincial treasuries and
members of the provincial executive councils, and the provincial departments
who also prepare the district level operational plans and annual performance
plans. The following table shows the various activities and timelines in the
provincial budgeting process for 2014/15 [7].
Table 4: Timeline for the development and setting of provincial budgets
11
(Source: National Treasury MTEF Guidelines 2014/15, 2014)
Provincial departments responsible for the spending of conditional grants are
required to submit detailed business plans for the allocation of funds to
various activities, which should align with performance targets. The national
department responsible for the grant approves the business plans and funds
are transferred from national to provincial or local departments for the
implementation of programmes. For the HIV/TB programme, the majority of
funding is allocated through the conditional grants to various governmental
departments, with the bulk of the allocation being administered through the
Comprehensive HIV and AIDS Grant which is managed by the NDoH.
2.2 Procedures and mechanisms for state funding of HIV in
provinces
Almost all the money spent by government comes from the National Revenue
Fund, which is appropriated and managed by National Treasury, and as
discussed above, governed by the PFMA and its legislative framework. From
there, it is distributed to national, provincial and local governments, to
Provincial Treasuries and governmental departments. The broad allocations
from National Treasury to these three spheres of government – namely
national, provincial and local – are set out in the Division of Revenue Act
(DORA). The finer details of the distribution of funds are determined in the
Appropriations Act.
There are two primary funding mechanisms used by National Treasury to
distribute money to departments and Provincial Treasuries. The first is the
equitable share allocation of funds through a series of “votes” for the equitable
allocation of funds between the various governmental departments. These
votes each relate to the budget of a specific department to fund activities set
out in their annual performance plans and business plans. Equitable share
allocations are determined by a number of factors including population size
and need in the various provinces and districts using the Equitable Share
12
Formula. The formula is based on six factors: education (48 percent); health
(27 percent); percentage of the population (16 percent); administration (5
percent); level of poverty (3 percent); and level of economic output (1 percent)
[8].
The second primary mechanism used for the distribution of funds is the
conditional grant. Conditional grants are created in DORA and are allocated to
ensure the rollout of programmes or projects that are of national importance
and require a coordinated response. Conditional grants are allocated to
national government and distributed to provinces, which must then spend the
money according to the conditions set out in the grant. The money allocated
to provinces through this financing mechanism is intended to support and
supplement spending from equitable share spending. There are many
conditional grants allocated to various departments with a total of about R81.8
billion allocated to provinces and R51.1 billion allocated to districts in 2014/15
[9]. This accounts for more than 13 percent of the total government
expenditure planned for the year as set out in the Estimates of National
Expenditure for 2014 in the region of R1.02 trillion [10].
With an allocation of R12.3 billion, the HIV and AIDS conditional grant is the
second largest conditional allocation to provinces, with only the allocation to
human settlements development exceeding it at R17.9 billion in the 2014/15
year [9]. As discussed previously, money distributed to the national, provincial
and district health departments through their Equitable Share allocations can
be used to fund HIV and TB related activities. However, in recent years, the
funding of the HIV programme through equitable shares has decreased
considerably, so that the majority of the programme is funded by the
conditional grant.
2.3 HIV and TB funding from external partners
There are a number of international donors that have committed to funding
the global HIV and TB response over the years. As discussed in Chapter 1,
13
South Africa has made significant progress in increasing it’s own funding, but
there remain a few organisations that still contribute significantly to the
response. The main contributors are the United States government through
USAID and PEPFAR; the Global Fund for HIV, TB and Malaria; the UK
government through the Department for International Development (DIFD);
the German Government and the European Union. The following figure shows
the comparative size of the contributions by various donors in 2014/15 – an
estimated total of R 5.39 billion [3].
Figure 3: Donor contributions to the South African HIV response
2%
1%
1%
2%
United States Government
Global Fund
22%
German Government
European Union
72%
United Kingdom Government
Other
(Source: Cohen & Guthrie, 2013)
PEPFAR began funding HIV and AIDS, and TB in 2003, quickly becoming the
largest bilateral contributor in the global response. In 2012, it was estimated
that PEPFAR contributed 49 percent of all international assistance and 23
percent of total HIV funding across the world. In South Africa, the vast
majority of international assistance for HIV and TB comes from the United
States government, who contributed 72% of the total external funding.
PEPFAR has begun a transition plan to reduce its spending in the country [3].
The cut in funding has primarily been in the area of treatment as funding
priorities have shifted to prevention and technical support, as well as a
decrease in the total funds distributed year by year. The five-year transition
14
plan aims to decrease South African dependency and provide support in the
strengthening of the domestic response to the epidemic. DFID have slowly
decreased their commitment in South Africa as domestic funding and health
systems have strengthened and are not expected to continue their support
into the future.
The decline in support from international donors is a trend across the board in
South Africa, with the exception of the Global Fund, whose contributions have
increased year on year. Global Fund is financed mainly by from the public
sector, with about 95 percent of total funding coming from donor
governments. The Global Fund is directly involved in supporting the Western
Cape HIV programme, specifically assisting with infrastructure and human
resource
development,
ART,
laboratory
costs
and
health
systems
strengthening. The financial commitment from the Global Fund is set to
continue in the province until at least 2016 [11].
2.4 The Characteristics of Conditional Grants
Conditional grants are provided for in many fiscally decentralised countries
and are generally used to influence and support the fiscal decisions of subnational governments, and usually with the intention of achieving some
nationally important objective including constitutional objectives. Transfers
from national departments to provincial or local governments can help to
support the decentralisation of major public services. This is particularly
important in South Africa where services such as health and education are
provided by provinces and local government. The intergovernmental grant
system can be used by the national government to help ensure uniform
access to essential services across the entire country. Conditional grants
provide a way for the national government to monitor progress against
national goals, and support these programmes – especially in provinces
where priorities may be different from those set at a national level. Further,
money allocated through conditional grants can ring-fenced so that progress
15
against targets can be monitored more closely, and so that only initiatives that
align with grant objectives may be funded [9].
There are many grants administered in South Africa through a number of
different national departments. Conditional grants are distributed from national
departments, either to provincial departments or to local governments, and
details of financial allocations are found in DORA. The total allocation in
2014/15 to provinces is approximately R76.6billion through 21 conditional
grants through the following provincial departments: Agriculture, Forestry and
Fisheries (3); Arts and Culture (1); Basic Education (6); Cooperative
Governance and Traditional Affairs (1); Health (5); Higher Education and
Training (1); Human Settlements (1); Public Works (2); Social Development
(1) Sport and Recreation (1); and Transport (2). A further R51.1billion in direct
and indirect grants is allocated to local governments through 22 different
conditional grants [8], [9].
There has been some debate about the use of conditional grants in South
Africa, and the Financial and Fiscal Commission (FCC) have raised concerns
about the increasing number of conditional grants over the past decade,
which makes the allocations through this mechanism increasingly difficult to
manage and can lead to confusion because of the increasing number of
overlapping or competing objectives [12]. They recommend a careful review
of existing grants with more stringent and transparent monitoring of financial
and non-financial performance, as well as the implementation of plans to
make budgeting and target setting more realistic and manageable.
16
3:
An
overview
of
the
characteristics
of
the
Comprehensive HIV and AIDS Grant
3.1 Purpose of the HIV conditional grant
The fight against HIV in South Africa is one that is becoming increasingly
expensive as the magnitude of the epidemic increases. The equitable share
allocations to provinces from the national treasury are spread across a
number of competing departments and programmes and there is insufficient
funding within provincial allocations to ensure the continued commitment and
expansion of the HIV programme across the country. Because the HIV and
AIDS and TB programme is a national priority, the allocation of funds to
provinces through the conditional grant is a way to try to ensure a coordinated
response for the country as a whole [8], [13].
The Comprehensive HIV AIDS Conditional Grant is provided for annually in
the Division of Revenue Bill. The grant provided funding to the health sector
for the following purpose stated in the Act in 2014 [8]:
•
•
•
To enable the health sector to develop an effective response to HIV
and Aids, including universal access to HIV counselling and testing
(HCT)
To support the implementation of the National Operational Plan for
comprehensive HIV and Aids treatment and care
To subsidise in-part funding for the antiretroviral treatment
programme
17
The following expected outputs for 2014/15 are stated in the Division of
Revenues Bill [8]:
• Improved coordination and collaboration in the implementation of
comprehensive HIV and Aids grant between national, provincial and local
government
• Improved quality of HIV and Aids services within the key programme areas
covered by the grant.
• Improved health workers’ capacity at the three levels of care to ensure
quality service delivery to South Africans
• Reduced HIV incidence and prevalence
The programmes covered by the grant in 2014/15 are [8]:
•
HIV Counselling and testing (HCT),
•
Anti-Retroviral Treatment (ART),
•
High Transmission Areas (HTA), including condom distribution,
•
Medical Male Circumcision (MMC)
•
Post Exposure Prophylaxis (PEP),
•
Home and Community based care (HCBC),
•
Prevention of Mother-to-Child Transmission (PMTCT)
•
HIV and TB integration (HIV/TB)
•
Training (through regional training centres, RTCs)
•
Programme management strengthening (PMS)
Step down care (SDC) is currently being phased out of the programmes
covered in the grant and although it does not appear in DORA, the NDoH and
provincial departments have agreed on financial allocations and non-financial
targets in the approved business plans for the year.
Except for the MMC programme and TB/ HIV, which were only introduced in
2011, the programmes described above have been part of the grant for at
18
least the past five years, although some programmes have merged or
expanded from time to time.
There are a number of performance indicators that are measured in relation to
the key programme areas. For 2014/15, these indicators contained in the
approved business plans are listed as:
•
Number of fixed public health facilities offering ART services
•
Number of new patients that started on ART
•
Number of patients on ART remaining in care
•
Number of beneficiaries reached through Adherence Support
•
Number of male and female condoms distributed
•
Number of High Transmission Areas (HTA) intervention sites
•
Number of Antenatal Care (ANC) clients initiated on life-long ART
•
Number of babies Polymerase Chain Reaction (PCR) tested at 6
weeks
•
Number of HIV positive clients screened for TB
•
Number of HIV positive patients that started on IPT
•
Number of active lay counsellors on stipends
•
Number of clients pre-test counselled on HIV testing (including
antenatal)
•
Number of clients tested for HIV (including antenatal)
•
Number of health facilities offering MMC services
•
Number of Medical Male Circumcision performed
•
Number of Sexual assault cases offered ARV prophylaxis
•
Number of Doctors and professional nurses trained on HIV/AIDS, STIs,
TB and chronic diseases
•
No of babies PCR tested at 6 weeks
•
Number of step down care facilities
19
The outputs listed in DORA do not include all of the above, however these
outputs correspond with the provincial business plans approved at the
national level.
In 2014/15 there is not good alignment between the framework for the HIV
conditional grant set out in DORA and that set out by the NDoH. Quarterly
reports on the grant in this financial year have been fairly thin in comparison
to previous years, and the number of indicators reported against has
decreased significantly in comparison to reports in the previous year
2013/14. This is discussed more fully in chapter 4.
3.2 Administration and Management Arrangements for CG
The HIV conditional grant is managed by the National Department of Health
(Vote 16) from the National Treasury. All of the funds are then distributed to
provinces in monthly instalments, depending on performance and adherence
to the conditions of the grant. Provinces are then responsible for the rollout of
programmes and spending of funds to achieve goals and targets set out in the
business plans. The NDoH is responsible for visiting provinces twice annually
to provide support, monitor both implementation of programmes and financial
performance – especially the payment of ARV suppliers – and meet with
National Treasury to review performance of the grant.
Provinces are required to provide performance information regarding financial
and non-financial performance every quarter within 30 days of the reporting
period. These reports need to clearly indicate measurable objectives and
performance targets as agreed upon by the national and provincial
departments in the approved business plans.
There are two conditions set out in DORA pertaining to the HIV and AIDS
conditional grant for 2014/15. Firstly, funding from the grant may only be used
to fund activities within the programmatic areas mentioned above. Secondly,
the provincial departments are required (at the request of the NDOH) to
20
provide information needed to pilot payment reforms to the National Health
Laboratory Services (NHLS) [8].
3.3 Formula and Policy for Dividing Funding by Province
Although the conditional grant for HIV and AIDS is intended to support the
provincial health departments’ response, most provinces have moved the
majority of HIV and AIDS related activities into the conditional grant with
approximately 80% of funds coming from the grant. Part of the total HIV and
TB response is implemented and funded by other departments such as the
department of basic education and the department of social development from
equitable shares, and some funding comes from international donors.
Figure 4: Conditional grant allocations to provinces
3500000
3000000
2500000
2009/2010
2000000
2011/2012
2012/2013
1500000
2013/2014
2014/2015
1000000
500000
0
EC
FS
GP
KZN
LP
MP
NC
NW
WC
(Source: Conditional grant quarterly reports and provincial business plans)
According to the DORA Bill for 2014/15, allocations to provinces from the
conditional grant are based on antenatal HIV prevalence, the estimated share
of AIDS cases and populations post-demarcation. However there is no
specific formula for the allocation and percentage share of the HIV conditional
21
grant outlined in DORA to provinces or programme areas. Rather, allocations
are made based on need given previous expenditure trends and provincial
need based on targets outlined in the provincial business plans.
Funding year on year has increased, largely due to the expansion of the ART
programme, with the number of new people initiated on treatment increasing,
and as the number of people retained in treatment rising year on year.
Allocations for prevention and care, and training, have also increased
annually as the HIV programme has grown to reach more people.
DORA allocations for each province in 2014/15 are shown in the table below.
The allocation for KwaZulu-Natal accounts for more than a quarter of the
grant, with Gauteng receiving a similarly large proportion of the total available
funds. The smallest share of the grant is allocated to the Northern Cape,
receiving less than three percent of the total grant.
Table 5: Distribution of HIV conditional grant between provinces
Province
2014/15 DORA Provincial
share
allocation R'000
of total allocation
EC
1 449 237
11,77%
FS
843 026
6,85%
GP
2 632 578
21,38%
KZN
3 257 992
26,46%
LP
978 132
7,94%
MP
818 836
6,65%
NC
342 789
2,78%
NW
936 938
7,61%
WC
1 051 794
8,54%
Total
12 311 322
100,00%
(Source: Division of Revenue Bill, 2014)
The following table shows population estimates per province from StatsSA
and the HIV burden per province in South Africa – HIV population prevalence
22
from the most recent HSRC population survey and antenatal prevalence per
province. Gauteng and KwaZulu-Natal are the two biggest provinces, and are
also the provinces containing the highest number of people living with HIV.
Table 6: Mid-year population estimates 2014 and estimates of HIV
Mid-year
Province
population
% of the
estimates
total
(Statssa
population
2014)
Population
Prevalence
HIV Estimate
% of
% Share of HIV
people positive people
(HSRC Population living with living in South
Survey 2012 data)
HIV
Africa
Antenatal
HIV
Prevalence
%
(2012
survey)
EC
6 786 900
12,57%
11,60%
787 280
12,67%
29,10%
FS
2 786 800
5,16%
14,00%
390 152
6,28%
32,00%
GP
12 914 800
23,92%
12,40%
1 601 435
25,77%
29,90%
KZN
10 694 400
19,80%
16,90%
1 807 354
29,09%
37,40%
LP
5 630 500
10,43%
9,20%
518 006
8,34%
22,30%
MP
4 229 300
7,83%
14,10%
596 331
9,60%
35,60%
NC
1 166 700
2,16%
7,40%
86 336
1,39%
17,80%
NW
3 676 300
6,81%
3,30%
121 318
1,95%
29,70%
WC
6 116 300
11,33%
5,00%
305 815
4,92%
16,90%
54 002 000
100,00%
TOTAL
6 214 027
100,00%
(Source: Compiled from StatsSA, 2014; HSRC Population Survey, 2014; and
South African National Antenatal HIV and Syphilis Sentinel Survey, 2013)
DORA provincial allocations of the HIV and AIDS conditional grant are fairly
well correlated with the number of people living with HIV in each province,
with a few exceptions. The figure below shows the percentage of the total
DORA allocation per province and the percentage of the total HIV positive
population per province.
23
Figure 5: Conditional grant allocations to provinces and HIV burden
35,00%
30,00%
25,00%
Percentage share of the
HIV positive
population in South
Africa
20,00%
15,00%
Percentage share of the
total allocation in
DORA
10,00%
5,00%
0,00%
EC FS GP KZN LP MP NC NW WC
(Source: Division of Revenue Bill, 2014; HSRC Population survey, 2014;
StatsSA, 2014)
This figure shows how in some provinces, the share of the DORA allocation
exceeds the HIV burden, while in others, provinces are receiving less money
in comparison to their burden. For example, less than two percent of the HIV
positive population in South Africa live in the North West Province, receiving
7.6 percent of the conditional grant. This is also true for the Western Cape
where there is significantly more funding than HIV burden. In Gauteng and
KwaZulu-Natal, there is a slightly smaller share of funding than HIV burden,
but allocations to these provinces are the highest in the country. More of a
concern is in Mpumalanga, where the number of people living with HIV is
almost three times that in the North West, yet they receive less money from
the conditional grant, a continuing trend from previous years.
These variations in the distribution of the grant have to do with a number of
factors other than number of people living with HIV, such as the availability of
infrastructure, the spread of the population across each province and HIV
prevalence. The following figure shows the conditional grant allocations to
provinces and HIV prevalence in the provinces.
24
Figure 6: Conditional grant allocations to provinces and HIV prevalence
30,00%
25,00%
20,00%
Population HIV
prevalence %
15,00%
% Share of DORA
allocation
10,00%
5,00%
0,00%
EC
FS
GP
KZN
LP
MP
NC
NW
WC
(Source: Division of Revenue Bill, 2014; HSRC Population survey, 2014;
StatsSA, 2014)
DORA allocations are also based on antenatal prevalence – another indicator
of HIV burden. HIV positive pregnant women require more intensive care and
treatment regimes, as well as the need for PMTCT, which requires extra
funding. The following figure shows antenatal prevalence and the distribution
of DORA funds.
Figure 7: Conditional grant allocations to provinces and antenatal
Prevalence
40,00%
35,00%
30,00%
25,00%
Antenatal HIV prevalence
percentage
20,00%
Percentage Share of total
DORA allocation
15,00%
10,00%
5,00%
0,00%
EC
FS
GP KZN LP
MP
NC NW WC
(Source: Division of Revenue Bill, 2014; National Antenatal Sentinel HIV &
Herpes Simplex Type-2 Prevalence Survey in South Africa, 2013)
25
Antenatal prevalence does not give a clear picture of the burden of HIV, since
population size, and the number of pregnant women varies per province.
However antenatal prevalence statistics are important in understanding the
severity of the HIV problem among pregnant mothers, and the importance of
allocating sufficient resources to treatment and prevention interventions aimed
specifically at this population group. Investigating the distribution of the
conditional grant among provinces is important for ensuring equal access to
HIV services for all South Africans.
26
4: An analysis of key historical trends in the
implementation of the HIV conditional grant
4.1 Annual Growth in Funding for the HIV conditional grant
Since the 2009/10 allocations, the size of the conditional grant for HIV and
AIDS has more than doubled. Not only has the financial allocation increased
in real terms year on year, but the grant has also received an increasing share
of the total amount of money distributed through conditional grants for health,
and it is estimated that by 2015/16, will account for almost half of the entire
allocation to health through conditional grants.
Figure 8: Comprehensive grant for HIV and AIDS growth 2005-2016
16
Billion Rand
14
12
10
8
6
4
2
0
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
Comprehensive HIV and
AIDS grant allocation
Percentage share of total
health grants
0%
(Source: 2014/15 FCC submission for the division of revenue, 2013)
The growth in the size of the conditional grant is important because almost all
of the HIV response and part of the TB response are funded through this
grant. It seems, however, that the increase in the HIV grant has crowded out
spending from provincial equitable share allocations. While this may not be an
immediate problem, it places emphasis on a national level solution and to
27
some extent, may ignore the province specific variations in the structural
drivers of the epidemic, as well as the specific needs for the response. The
reliance on the grant to fund the HIV epidemic also makes a transition to
funding through equitable share allocations more difficult, and necessitates
the continuation of the conditional grant into the medium and possibly even
long term planning frameworks.
4.2 Recent additions of new sub-programmes and their purpose
The TB/HIV programme is a new addition to the conditional grant, introduced
in DORA for 2011/12. The increase in the severity of the TB epidemic and
increase in HIV and TB co-infection prompted the inclusion of a specific
programme in the new NSP to support the existing TB programme rolled out
by provincial departments of health. Performance targets in this programme
include the number of HIV positive patients screened for TB and the number
of HIV positive patients started on Isoniazid Preventative Therapy (IPT).
Step down care (SDC) is currently being phased out of the list of programmes
supported by the grant. In 2011/12 and earlier, SDC was rolled out as part of
the HIV/TB programme. In 2012/13, it was allocated a separate budget with
its own performance indicators and targets. SDC is not one of the
programmes listed in DORA for 2014/15, although it is one of the programmes
to which money has been allocated and there are targets that have been
agreed upon in the provincial business plans for the financial year.
A new addition to the programmes funded through the conditional grant in
2011/12 was the allocation to medical male circumcision (MMC). The MMC
programme was launched in 2010/11 following recommendations by the
World Health Organisation (WHO) and based on three randomised controlled
trials showing the efficacy of MMC for the reduction in risk of HIV
transmission. The programme aims to reach 80 percent of men aged 15 to 49
years. Targets in this programme relate to the scale-up of facilities offering
MMC and the number of circumcisions conducted per year.
28
4.3 Changes in the proportional allocation of funding
Unsurprisingly, because of the huge number of people on treatment, the cost
of treatment and the number of new people needing treatment year on year,
the majority of the conditional grant is allocated to the ART programme. There
are currently almost 2.9million people on treatment, and over 6.4million
people living with HIV and first line treatment regimens cost almost R1300 per
patient per year, excluding the costs of care and any other related costs. The
amount allocated to the ART programme has increased year on year,
although the proportion of the grant spent on ART has decreased, possibly
due to shifting priorities and an increase in focus on prevention and
programme management. The following figure shows how the allocation of
funds to ART has increased to R7.6 billion in 2014/15, while the percentage
share of the total grant allocated to this programme has decreased to just
over 62 percent, from nearly 69 percent in 2011/12. This may be partly
because the price of drugs has decreased, causing the average price of first
line treatment per person to fall from R2 216 in 2011/12 to R1288 in 2014/15
[14]. Task shifting plans such as the implementation of nurse initiated and
managed ART (NIMART) may have also helped to decrease unit costs within
the ART programme.
Figure 9: Conditional grant allocation to ART trends
9
70,00%
8
68,00%
R Billion
7
66,00%
6
5
64,00%
4
62,00%
3
2
1
0
ART BP alloc
% ART Share of CG
60,00%
2011/2012
2012/2013
2013/2014
2014/2015
58,00%
(Source: Conditional grant quarterly reports and provincial business plans)
29
The size of the conditional grant has increased dramatically over the past few
years, and so almost all programmes have seen increases in the allocation of
funds in DORA. However, the proportion of the grant spent on each
programme has changed, showing a shift in spending priorities. The
proportion of allocations to the TB/HIV programme, home based care and
programme management have all increased significantly year on year, while
the proportional allocation to the HCT programme has decreased. In 2014/15,
the next biggest allocations of the conditional grant after ART were to home
and community based care (8.6 percent), HCT (6.7 percent) and programme
management (5.6 percent). All other programmes received less than 5
percent of the total grant. The following figure shows the percentage share of
allocation of the conditional grant between programmes, with the exception of
ART, shown above.
Figure 10: Percentage share of conditional grant allocations to
programmes (excluding ART)
9,00%
8,00%
7,00%
6,00%
5,00%
4,00%
3,00%
2,00%
2011/2012
2012/2013
2013/2014
2014/2015
1,00%
0,00%
(Source: Conditional grant quarterly reports and provincial business plans)
30
Dividing spending into macro-level programmes is revealing about allocation
trends from the conditional grant. Treatment and care in South Africa is the
main priority of the HIV programme. Prevention is an important part of the
response, but it is often difficult to measure the outcomes in comparison to
providing treatment. The aim of the NSP is to scale up both prevention and
care, while strengthening the healthcare system to be able to support the
increasing number of people requiring treatment.
In the following figure, the DORA allocations are divided up between
treatment and care; prevention; and programme management and training.
Treatment and care includes spending on ART, home based care, step down
care. Testing is also a gateway to treatment, so 50 percent of the HCT
allocation is also included in treatment and care, as well as 50 percent of the
allocation to the HIV/TB programme. Prevention includes MMC, condoms,
PEP, the PMTCT programme, high transmission areas, as well as 50 percent
of the HCT allocation and 50 percent of the HIV/TB programme. The figure
below shows the allocation of funds to these three broad categories over the
past few years.
31
Figure 11: Conditional grant percentage allocation to broad programme
areas
80,00%
70,00%
60,00%
50,00%
40,00%
30,00%
20,00%
10,00%
0,00%
2011/12
2012/13
2013/14
2014/15
Treatment & care
Prevention
79,12%
16,09%
80,24%
79,35%
77,43%
15,80%
15,30%
15,10%
Programme management
& training
3,96%
4,79%
5,35%
7,47%
(Source: Conditional grant quarterly reports and provincial business plans)
The percentage allocation to programme management and training has grown
steadily, almost doubling in the past five years. Although prevention should be
an increasing priority to stem the tide of the epidemic, allocations to
prevention have decreased slightly, and the proportion allocated to treatment
and care has also decreased – largely as a result of the decreased allocation
to the ART programme. Total allocations to these programme areas have
grown year on year because of the increasing size of the conditional grant, as
shown in the following figure.
32
Figure 12: Conditional grant allocation to broad programme areas
12
Billion Rand
10
8
2011/12
6
2012/13
2013/14
4
2014/15
2
0
Treatment & care
Prevention
Programme management
& training
(Source: Conditional grant quarterly reports and provincial business plans)
4.4 Spending performance per annum
Over the past few years, financial performance of the entire HIV grant has
improved, reaching 100 percent expenditure against the budgets in the
approved business plans in 2012/13 and 2013/14. This is positive, as underspending in the past has been attributed to a lack of capacity in provinces to
implement programmes. The variation in spending against DORA allocations
between provinces has decreased year on year, which shows the increased
ability of underperforming provincial health departments to spend their
budgets. The following figure shows the percentage of annual conditional
grant transfers spent across provinces since 2009/10. 1
1
No data was available for 2010/11.
33
Figure 13: Annual percentage of conditional grant funds spent
120%
100%
80%
60%
40%
20%
0%
EC
FS
GP
KZN
2009/2010 86% 100% 100% 92%
2011/2012 100% 85% 100% 100%
2012/2013 104% 99% 100% 101%
2013/2014 102% 94% 100% 100%
LP
MP
100% 80%
91%
91%
NC
97%
99%
NW
98%
WC
98%
Total
95%
93% 100% 97%
83% 111% 92% 100% 100% 100%
100% 100% 100% 100% 100% 100%
(Source: Conditional grant quarterly reports and provincial business plans)
Spending against transfers per programme is not as consistent. Budgets
within many of the programme areas have been consistently underspent,
while the ART programme has overspent its budget by increasing percentage
year on year, making up for the underspend in other programme areas. This
indicates a lack of proper budgeting at a programmatic level. The figure below
shows the percentage spending against conditional grant transfers in each
programme for 2011 to 2014.
34
Figure 14: Actual spending within programmes against conditional grant
transfers
120%
100%
80%
60%
40%
20%
0%
2011/2012
HTA
81%
2012/2013 112%
2013/2014 83%
CONDO
MS
29%
61%
57%
PEP
60%
52%
48%
HCT
96%
111%
92%
PMTCT MMC
114%
93%
83%
70%
40%
87%
ART
SDC
104%
90%
101%
107%
0%
84%
TB/HIV HCBC
71%
83%
88%
100%
97%
88%
(Source: Conditional grant quarterly reports and provincial business plans)
PM
100%
115%
84%
The figure shows how certain programmes such as condoms, PEP and MMC
have consistently underspent against the actual transfer from NDoH, mostly
not using even three quarters of the funds received. The HTA programme,
PMTCT and HCT have seen eratic spending, while spending in some
programmes has exceeded the transfer by as much as 15 percent. The
picture becomes even more complicated when broken down to the
programme level within each province. The following table shows how much
the final expenditure in each programme differs from the targets and budgets
set out in each of the provincial business plans for the 2013/14 financial year.
35
RTC
78%
79%
76%
Table 7: Percentage of expenditure against DORA allocations 2013/14
HTA
83%
40%
207%
53%
64%
85%
36%
42%
72%
Overall
spending
performance
by programme
78%
CONDOMS
8%
91%
41%
52%
34%
63%
21%
28%
70%
46%
PEP
49%
65%
64%
24%
17%
21%
51%
18%
106%
42%
HCT
39%
68%
170%
88%
68%
42%
58%
113%
97%
91%
PMTCT
58%
31%
-47%*
100%
82%
49%
94%
103%
65%
82%
MMC
76%
49%
76%
88%
10%
170%
15%
58%
55%
79%
ART
114%
108%
102%
108%
126%
124%
119%
108%
111%
110%
TB/HIV
114%
68%
62%
88%
384%
8%
121%
116%
83%
93%
SDC
76%
77%
95%
73%
44%
205%
38%
65%
103%
95%
HCBC
84%
59%
68%
90%
87%
38%
121%
74%
105%
83%
PM
102%
62%
40%
95%
47%
24%
123%
139%
103%
80%
RTC
100%
73%
Overall
spending
102%
94%
performance
by province
Spending performance < 25%
77%
7%
53%
48%
29%
125%
92%
73%
100%
100%
100%
100%
100%
100%
100%
100%
Programme
EC
FS
GP
KZN
LP
Spending performance < 50%
MP
NC
NW
WC
Spending performance < 75%
*Negative spending was recorded in the PMTCT programme in Gauteng for 2013/14
(Source: Conditional grant quarterly reports and provincial business plans)
The table shows poor spending performance against business plan targets
and budgets, with almost all provinces significantly over or under spending in
various programme areas. Cells shaded in red show expenditure against
allocations under 25 percent, orange shows actual expenditure against
allocations under 50 percent and yellow cells show expenditure under 75
percent of annual allocations. For example, in Gauteng, spending in the HTA
programme was more than double the initial allocation, while all other
provinces could not spend their allocations. The condom distribution and PEP
programmes performed particularly poorly overall. In Mpumalanga, 100
percent of the conditional grant allocation was spent in the year, but spending
performance within most of the programmes against business plan budgets
was extremely poor. High levels of overspending occurred in the ART (124
percent), MMC (170 percent) and SDC (205 percent) progrmmes, while in the
PEP, HCT, PMTCT, TB/HIV, HCBC, RTC programmes and programme
36
management, spending did not reach even 50 percent of the annual
allocation.
Overspending in all provinces within the ART programme against the biggest
budget by far in all provinces means less funding for other equally important
priorities. The following figure shows the spread of expenditure against
allocations in the provincial business plans for 2013/14.
Figure 15: Actual expenditure against conditional grant allocations
2013/14
12%
4%
Treatment & care
Prevention
84%
Programme management &
training
(Source: Conditional grant quarterly reports and provincial business plans)
Although only 65 percent of the total conditional grant was allocated to ART in
2013/14, nearly 72 percent of the total spending against the actual DORA
transfer was in the ART programme – far higher than the allocation in any of
the previous years. Overspending in the ART programme has been a trend
over the past few years. This is an indication that while funds from the ART
conditional grant are ring-fenced for the HIV programme, funds for provinces
and sub-programmes are fungible, and often not being spent in line with
targets in the business plans. Government have committed to scaling up the
ART programme in the country and have increased thresholds for initiation on
treatment which means costs in this programme will continue to rise in the
near future as more people are initiated treatment and retained in care.
37
Budgets must be more carefully planned from year to year, and provinces
should either allocate additional required funds from equitable share
allocations to make up the shortfall in funds from conditional grants, or
increase their initial budgets for treatment. Alternatively, government must
allocate more funds to the ART programme to support the targets for initiating
people on treatment and retaining them in treatment and care programmes.
Overspending in the ART programme to make up for under-spending in other
programmes to utilise available funds, or indeed underspending in the other
programmes because of over-spending in the ART programme cannot be
called a success. Prevention and systems strengthening must remain a
priority in order to gain control over the epidemic and reduce the number of
new people requiring treatment.
In 2014/15, by the end of the third quarter, only one province had achieved
the spending target against the annual allocation of 75 percent. This means
provinces will need to tail-load their spending in the final quarter in order to
achieve targets set out in the business plans. The following table shows
spending by the third quarter in provinces.
Table 8: Allocations and actual expenditure by the end of the third
quarter 2014/15 per province
Prov
DORA Allocation R’000
Expenditure R'000
% Expenditure/Allocation
EC
1449237
1012430
69,90%
FS
843026
559149
66,30%
GP
2632578
1802011
68,40%
KZN
3257992
2099289
64,40%
LP
978132
618469
63,20%
MP
818836
594300
72,60%
NC
342789
267899
78,20%
NW
936938
674347
72,00%
WC
1051794
745372
70,90%
12311322
8373266
68,00%
Total
(Source: Conditional grant quarterly reports and provincial business plans)
38
Spending performance by the third quarter 2014/15 at a programmatic level
was similarly poor, with only spending in the ART programme reaching the
indicative target of 75 percent. The table below shows spending per
programme for the 2014/15 year by the end of the third quarter.
Table 9: Allocations and actual expenditure by the end of the third
quarter 2014/15 per programme
Business Plan
Budget Allocation
Expenditure
% Expenditure/
Programmes
R'000
R'000
Allocation
HTA
108022
58034
54,90%
CONDOMS
398084
147794
37,10%
PEP
20324
9298
45,70%
HCT
820539
578191
70,50%
PMTCT
24918
171914
69,00%
MMC
384703
111548
29,00%
ART
7636351
5811407
75,70%
TB/HIV
577794
34258
59,50%
SDC
142903
93829
65,70%
HCBC
1054064
625554
63,70%
PM
691821
332256
45,80%
RTC
227537
90861
39,90%
Total
12311322
8373266
68,00%
(Source: Conditional grant quarterly reports and provincial business plans)
Spending within the PEP, MMC, Condoms, RTC programmes, as well as
programme management performed particularly poorly, reaching less than the
targeted spending by the end of the second quarter.
4.5 Performance against target indicators by programme
39
Each of the programme areas supported by the comprehensive HIV and AIDS
grant have performed differently over the past few years, with some
programmes showing huge successes against targets, in spite of poor
spending performance. The following sections highlight some of the key cost
drivers within each programme, where indicators have been reported against
from 2011/12 to the third quarter of 2014/15. The analysis in this section is
drawn from available conditional grant reports and provincial business plans
[15]–[21]. Reporting for the 2011/12 financial year was slightly different from
subsequent years, as the new NSP was only released in 2012. Some of the
key indicators in the new NSP were not reported against in 2011/12, although
most of the data in this year aligns with data from subsequent years.
Reports in 2012/13 and 2013/14 were fairly good at recording spending
performance, as well as performance against key indicator targets within each
of the programmes. For example, of the outputs listed in DORA (and listed in
chapter 3 above), only two of the key indicators were not reported in the
conditional grant review for 2013/14. These two indicators were:
•
Number of babies Polymerase Chain Reaction (PCR) tested at 6
weeks
•
Number of clients pre-test counselled on HIV testing (although the
number of clients tested and counselled for HIV was reported against).
Additionally, the number of step down care facilities was reported against – an
indicator that was included in the 2013 DORA but excluded in 2014 (although
money was still allocated to step down care in most of the provinces in the
2014/15 financial year).
While these performance indicators are reported for 2013/14, the auditor
general’s assessment of the HIV conditional grant, contained in the NDoH
annual report for 2013/14, found non-compliance with the frameworks set out
in DORA for the reporting of financial and non-financial information [22].
40
In the 2014/15 financial year, the conditional grant quarterly reports did not
include performance against a number of different target indicators contained
in the approved business plans. The following indicators are not reported on
in the first three quarterly conditional grant reports[18]–[20]:
•
Number of beneficiaries reached through Adherence Support
•
Number of step down care facilities
•
Number of High Transmission Areas (HTA) intervention sites
•
Number of Antenatal Care (ANC) clients initiated on life-long ART
•
Number of HIV positive clients screened for TB
•
Number of HIV positive patients that started on IPT
•
Number of active lay counsellors on stipends
•
Number of Sexual assault cases offered ARV prophylaxis
•
Number of Doctors and professional nurses trained on HIV/AIDS, STIs,
TB and chronic diseases
This means there are no programmatic performance indicators in the following
programs: HTA, PEP, TB/HIV, HCBC, PM and RTC – more than half the
programme areas receiving funds for the 2014/15 financial year. This lack of
proper reporting against targets makes assessment of the performance of the
grant for 2014/15 difficult, and raises questions about whether quarterly
transfers from the NDoH to provincial departments are being made based on
evidence of progress and proper use of previously administered funds. This
data may be present in provincial reports but were not available for the
analysis contained in this section. The following table shows progress by the
end of the third quarter against targets for each of the indicators reported in
the third quarterly report for 2014/15.
Table 10: Performance against indicator targets by the end of the third
quarter 2014/15
Indicator
2013/14
baseline
2014/15
Annual
% of
Business
progress by annual
plan target
end Q3
target
41
Number of fixed public
health facilities offering
3 651
3 674
3 688
100,4%
659 513
642 080
457 671
71,3%
2 602 032
3 134 232
2 893 474
92,3%
667 210 769
1 000 000 000
495 813 526
49,6%
10 295 276
15 000 000
14 126 488
94,2%
ART services
Number of new patients
initiated on ART
Number of patients on
ART remaining in care
Number
of
male
condoms distributed
Number
of
female
condom distributed
Number
of
1,7% (this
exposed
infants HIV positive at 6
103 664
>2,5%
57015
weeks PCR
Number
is below
the target
of 2,5%)
of
clients
tested for HIV (including
9 713 179
10 000 000
8 009 516
80,1%
539 070
1 000 000
371 802
37,2%
ANC)
Number
of
MMC
conducted
(Source: Conditional grant quarter 3 report 2014/15, 2015)
Although many of the indicators are not reported on, the figures here show
fairly good performance against the targets for the year to date. However in
some of the programmes, more half of the annual target is still to be realised
in the fourth quarter.
The following sections draw on data from annual approved provincial
business plans and various annual and quarterly conditional grant reports
[15]–[21].
42
Antiretroviral Therapy
The ART programme has been the highest spending priority in the HIV
response over the past few years. However money allocated to provinces for
ART does not match the HIV burden in the provinces, with more money being
allocated to some provinces and less to others in comparison to the
percentage share of the HIV positive population. The following figure shows
the HIV burden and percentage allocation of the total funds for ART in each
province.
Figure 16: HIV burden and percentage allocation of ART funding per
province
30%
25%
20%
% Share of HIV
positive people living
in South Africa
15%
% Allocation of the
total conditional
grant ART funds
10%
5%
0%
EC FS GP KZN LP MP NC NW WC
(Source: Compiled from StatsSA, 2014; HSRC Population Survey, 2014; and
conditional grant quarterly reports and provincial business plans)
The figure shows that in North West and Western Cape the percentage
allocation from the total budget for ART is far higher than the burden of people
living with HIV, while provinces such as Limpopo and Mpumalanga are
allocated a smaller proportion of the total budget for ART than the percentage
share of the HIV positive population of South Africa in those provinces. This
can be clearly seen in comparing Western Cape and Mpumalanga. Only 5
percent of the HIV positive population live in Western Cape where they
receive 9 percent of the funds for ART, while 10 percent of the HIV positive
43
population live in Mpumalanga where they receive only 7 percent of the funds
for ART.
One of the primary cost drivers of the programme is the spending on
treatment for patients remaining in care. The following figure shows the
financial allocation and actual spending, as well as the target for patients
remaining in care as well as performance against this target.
8
4
5
2,5
7
6
4
3
2
1
0
3,5
3
2
Million people
Million Rand
Figure 17: ART spending performance and patients remaining in care
1,5
1
0,5
0
Business plan budget
allocation Rmillion
Expenditure Rmillion
Patients remaining in care
Annual targets
Patients remaining in care
Actual performance
(Source: Conditional grant quarterly reports and provincial business plans)
The green bars show the financial allocation from the business plans for each
year, while the purple bars show actual expenditure. The blue line shows the
annual target for patients remaining in care, while the red line shows the
actual number of patients remaining in care. The figure shows that although
there has been overspending against the budget year on year, performance
has been under target for the past four years. Further, the target for patients
remaining in care decreased from 2013/14 to 2014/15, while the allocation
increased. This may be to account for the overspending in the previous year
against the budget. However, antiretroviral drug prices have also decreased
year on year, which raises questions about the overspending and
underperformance.
44
One of the other important cost drivers in the ART programme is the initiation
of new patients on ART. Perfomance in this indicator has been eratic over the
past few years. Spending performance and performance against targets for
the number of new people initiated on treatment is shown in the following
figure.
Figure 18: ART spending performance and new patients initiated on ART
8
7
6
5
4
3
2
1
0
660
640
620
600
580
560
540
520
500
Thousand people
Million Rand
9
Business plan budget
allocation Rmillion
Expenditure Rmillion
New patients initiated on
ART Annual targets
New patients initiated on
ART Actual Performance
(Source: Conditional grant quarterly reports and provincial business plans)
The blue bars show financial allocations in the annual business plans, while
the red bars show actual expenditure. The green line shows the target for the
number of new patients initiated on treatment while the purple line shows the
actual number of people initiated on treatment. Initiation of new patients will
become an increasing priority as CD4 count thresholds for treatment rise, and
treatment as prevention becomes more of a priority. CD4 count thresholds
rose from 200 cells/mm3 in 2006 to 350 cells/mm3 in 2009, and most
recently, increased to 500 cells/mm3 at the beginning of 2015. The move
towards a universal treatment strategy, where patients are initiated on ART
regardless of CD4 count is likely to continue because of the newly discovered
benefits of treatment as prevention. Individuals on treatment can reach full
viral load suppression after a few months on treatment, reducing the chance
of transmitting the virus to almost zero.
45
Retaining patients in care is an important part of the treatment programme. If
patients are not retained in care, they will more than likely need to be
reinitiated on treatment at a later point in time, putting additional strain on
resources and increasing the chance of drug resistance, causing treatment
costs to increase.
The ART programme is one of the key successes of the South African HIV
response in reaching the 90-90-90 targets by 2020: 90 percent of people
know their status; 90 percent of people diagnosed with HIV on treatment; and
90 percent of people on treatment reaching viral suppression. There are
currently more than two and a half million people currently on treatment, and
over half a million new people being initiated on treatment annually. While this
progress is significant and the ART programme is far larger than any other
treatment programme in the world, the number of people in need of treatment
year on year is increasing because of new HIV incidence; increasing CD4
count thresholds for treatment; and attrition from treatment (requiring patients
to be reinitiated on treatment). This means the ART programme will need to
be monitored more closely. Setting appropriate targets, careful budgeting and
close monitoring of both spending and performance against outcome targets
will be vital for the on-going success of the programme. Task shifting
strategies such as the implementation of nurse initiated and managed ART
(NIMART) will help to improve efficiencies in the programme and help to
increase the number of people initiating and remaining on treatment.
By the third quarter of 2014/15, the ART programme had reached its
indicative spending target of 75 percent against the annual budget, but
performance against target indicators was not quite as convincing, with some
provinces meeting or exceeding targets, while others failed to do so. The
following table shows performance trends per province against the indicator
target set for new patients initiated on ART.
46
Table 11: New patients initiated on ART performance trends by province
Annual progress by
Q3 2014/15
% of
% of
% of
Quarter 3 2014/15
2012/13 2012/13 2013/14 2013/14 2014/15
annual
Province Actual
target
Actual
target
Actual
target
68 674
92 80 548
106
EC
52 803
70
40 666
110 35 292
93
FS
22 764
62
98 288
60 110 969
88
GP
97 536
72
173 595
102 184 866
108
KZN
134 603
75
49 843
108 61 819
128
LP
44 062
84
47
975
112
55
770
124
MP
43 665
59
7 598
95 9 465
120
NC
6 682
76
39 746
88 44 480
118
NW
28 520
65
32 509
99 35 873
108
WC
27 036
77
559 195
92 619 082
107
ZA
457 671
71
(Source: Conditional grant quarterly reports and provincial business plans)
KwaZulu-Natal, Limpopo, Northern Cape and Western Cape had all reached
their indicative target in 2014/15 of 75 percent by the end of the third quarter,
building on strong performance in respect to this indicator in previous years.
Performance in Gauteng is was below the target by the third quarter in
2014/15, a continuing trend of underperformance from previous years.
Although Gauteng has the second largest target of almost 100 000 people, a
huge undertaking, KwaZulu-Natal, reaching the largest number of people has
managed to reach targets consistently in the recent past. Performance in
North West has been sporadic, with the province exceeding its target in
2013/14, but underperforming significantly in 2014/15 against a much lower
target.
Initiating new patients on treatment is important, but retention of patients on
treatment and in care is vital to prevent drug resistance and maintain the
health of people living with HIV. The benefits of treatment as prevention
further highlight the need for low rates of attrition from treatment to reduce
transmission rates and risk, especially in communities where prevalence is
high. The following table shows provinces’ performance against the indicative
targets for patients remaining in care.
47
Table 12: Patients remaining in care performance trends by province
Annual progress by Q3
2014/15
% of
% of
% of
2014/15
2012/13 2012/13 2013/14 2013/14 Quarter 3
annual
Prov Actual
target
Actual
target
2014/15 Actual target
EC
237636
80 288449
105
309153
105
FS
150602
106 110619
61
158258
95
GP
516105
65 591848
63
651426
100
KZN
705024
93 792991
94
904278
87
LP
197719
105 187991
79
204802
86
MP
198617
105 226670
97
261395
85
NC
31286
109
38553
98
40578
90
NW
191467
82 187053
68
190069
84
WC
137642
102 157130
100
173515
105
ZA
2362124
85 2582301
81
2893474
92
(Source: Conditional grant quarterly reports and provincial business plans)
The table shows an improvement in 2014/15 from previous years, with
performance already reaching 92 percent of the annual target and three
provinces having reached their full target for the year (although this is not
against an indicative target of 75 percent since the number of people
remaining in care at the end of 2013/14 was just over 89 percent of the annual
target for 2014/15). The annual target for 2014/15 had also decreased slightly
from 2013/14 from 3 194 757 to 3 134 232 (a 1.89 percent decrease).
Provinces performing worse than the national average in 2014/15 include
KwaZulu-Natal, Limpopo, Mpumalanga and North West. Gauteng have
significantly improved their performance against targets set in previous years,
but their annual target for patients remaining in care decreased from 944 000
in 2013/14 to 650 000 in 2014/15. North West has performed consistently
poorly over the past few years and although performance against targets for
2014/15 seems to have improved, the annual target decreased from 276 737
to 226 735.
As discussed above, a concern for the ART programme is attrition. The
following table shows the number of new people initiated on treatment by the
third quarter in 2014/15, the number of people lost from the programme by the
48
end of the third quarter in 2014/15 and the percentage of people lost in
comparison to new initiations. 2
Table 13: Patients remaining in care, new people initiated on treatment
and attrition
Prov
EC
FS
GP
KZN
LP
MP
NC
NW
WC
ZA
2014/15
Baseline
Patients
remaining
number of
people
in care
actual
remaining
2013/14
in care
288 449
266 460
110 619
145 307
591 848
587 572
792 991
792 991
187 991
189 002
226 670
239 537
38 553
39 158
187 053
185 302
157 130
156 703
2 582 301 2 602 032
(Source: Authors own
Quarter 3
2014/15
number of
new
people
initiated on
ART
52 803
22 764
97 536
134 603
44 062
43 665
6 682
28 520
27 036
457 671
calculations
Rate at
Quarter 3
which
2014/15
people are
Number of
number of people lost
lost from the
people
ART
from the
remaining
treatment
programme Attrition
in care
programme %
rate %
309 153
10 110
19,1
3,3
158 258
9 813
43,1
6,2
651 426
33 682
34,5
5,2
904 278
23 316
17,3
2,6
204 802
28 262
64,1
13,8
261 395
21 807
49,9
8,3
40 578
5 262
78,7
13,0
190 069
23 753
83,3
12,5
173 515
10 224
37,8
5,9
2 893 474
166 229
36,3
5,7
based on conditional grant quarterly
reports and provincial business plans)
Baseline estimates for the number of people remaining in care in 2014/15
differ significantly from the reported figures at the end of 2013/14 in the final
quarterly report for the year. This may have been as a result of unaudited
figures being reported in 2013/14, and audited figures or new estimates being
2
This rate is calculated as the number of people lost from the programme as
a percentage of the number of new patients initiated on treatment. Attrition
may be the result of death (not necessarily HIV and AIDS related), migration
or patients exiting the treatment programme for any other reason. The attrition
rate is calculated as the number of people lost from the programme as a
percentage of the number of people remaining in care by the end of the third
quarter 2014/15.
49
reported in provincial business plans. Both are reported in the table above for
comparison, but baseline figures for 2014/15 are used for calculations
The figure above shows that although 457 671 people were initiated on
treatment by the third quarter in 2014/15, 166 229 people were lost from the
treatment programme (36 percent against annual progress to date). This is a
particular problem for provinces like North West, where 28 520 new people
were initiated on treatment, but 23 753 (83 percent) were lost from the
treatment programme by the third quarter of 2014/15. In Northern Cape and
Limpopo, these rates are also alarmingly high at 79 percent and 64 percent
respectively. Although these levels of attrition are a small percentage of the
patients in the entire treatment programme in comparison (13 percent in North
West and Northern Cape, 14 percent in Limpopo, and a national average of 6
percent), these figures show the need for programmes that are more efficient
at retaining patients on treatment and in care.
HIV Counselling and Testing
The second largest allocation of conditional grant funds is to the HIV
counselling and testing (HCT) programme. HCT is a pillar of the HIV response
because it is a gateway to treatment. Early detection of HIV can help to
reduce transmission, and has been proven as a cost effective prevention
intervention. HCT is vital for educating the population about HIV and is also
key to monitoring progress in the fight against the epidemic. However, the
proportion of the HIV conditional grant has decreased every year, and
performance against key indicators has been consistently poor. The following
figure shows spending performance and performance against indicator targets
within the programme.
50
Figure 19: HCT spending performance and number of people counselled
900
18
700
14
800
16
600
12
500
10
400
8
300
6
200
100
0
Million people
Thousand Rand
and tested for HIV
4
2011/12 2012/13 2013/14 2014/15
2
0
Business plan budget
allocation
Expenditure R'000
Number of people tested
for HIV target
Number of people tested
for HIV achieved
(Source: Conditional grant quarterly reports and provincial business plans)
The figure shows how allocations and spending have increased steadily year
after year, while targets have not been met over the last three years. As
discussed above, performance by the third quarter of the 2014/15 financial
year is on track to achieve the target of 10million people set for the year.
However, this target is substantially lower than previous years, and only
slightly higher than the achievement in 2011/12. The success of the national
HCT campaign launched in 2010 and aiming to test 15 million people and
reaching about 13 million has dwindled and although spending in this
programme has increased, the number of people reached by the testing
initiatives has been relatively stable over the past few years.
High Transmission Areas and Condom Distribution
The high transmission areas (HTA) programme aims to provide extra support
and care in terms of treatment and prevention in high transmission areas and
among high-risk populations. Allocations from the conditional grant to this
programme support HTA intervention sites. Allocations to this programme are
fairly small in comparison to other programmes, however by the end of the
2013/14 financial year, over 1072 HTA sites had been set up across the
country and exceeding the fourth quarter target of 757 sites.
51
The distribution of condoms is a key part of prevention within the HIV
programme. The efficacy of condoms for the prevention of HIV transmission is
higher than any other prevention method. Female condoms are targeted at
empowering women and the role out of both male and female condoms has
been one of the key targets for the HIV programme in recent years. Systems
for distributing condoms vary across the provinces and success against
targets has been mixed. The following figure shows financial and non-financial
performance trends for the distribution of male condoms.
Figure 20: Male condoms spending and performance against targets
Million Rand
400
350
300
250
200
150
100
50
0
1200
1000
800
600
400
200
0
Million condoms
450
Business plan budget
allocation
Expenditure
Male condoms Annual
Target
Male condoms Annual
Performance
(Source: Conditional grant quarterly reports and provincial business plans)
The figure shows the poor performance in spending against budgets as well
as distribution of condoms. However, in 2013/14, KwaZulu-Natal and the
Western Cape were both able to exceed their targets for the distribution of
condoms. This shows that it is possible to achieve targets, but not without
proper distribution mechanisms and increased effort within this programme.
As with HCT, the distribution of condoms is key to the prevention programme
and although the financial allocation is only a small proportion of the grant,
increasing the acceptability of condoms and the number of condoms
disbursed can help to significantly decrease incidence and reduce the number
of new patients needing treatment.
52
The distribution of female condoms has had relatively higher success than the
male condom distribution programme. This could be attributed to the
significantly smaller number of condoms and the better-established channels
through which women can access these condoms – such as the maternal,
women’s and children’s health (MWCH) programme. The following figure
shows the percentage of female condoms distributed against annual targets.
Figure 21: Percentage of female condoms distributed against annual
targets
400
Percentage
350
300
250
2011/2012
200
2012/13
150
2013/14
100
50
0
EC
FS
GP
KZN
LP
MP
NC
NW
WC
ZA
(Source: Conditional grant quarterly reports and provincial business plans)
In 2011/12, the North West province were able to meet 770 percent of their
annual target for female condom distribution, although they have never
reached these levels before, with the province failing to even meet their target
in 2013/14. The reasons for this erratic performance should be investigated in
order to understand why performance varies so drastically. The effectiveness
of the systems used for the disbursement of condoms needs to be
investigated to ensure there is a consistent supply of condoms to clients.
Home and Community Based Care
The home and community based care (HCBC) programme is intended to
support the ART programme by providing stipends to community workers to
53
help care for HIV positive people and help to increase retention on treatment
rates. The programme is also intended to increase access to HCT and other
HIV prevention services. The proportion of the conditional grant allocated to
HCBC has grown year on year, but spending against this increased allocation
has not performed quite as well. The following figure shows financial and nonfinancial performance trends for the number of carers receiving stipends – the
primary cost driver in the programme.
Figure 22: HCBC spending and performance against targets
1
0,8
0,6
0,4
0,2
0
50
45
40
35
30
25
20
15
10
5
0
Thousand carers
Million Rand
1,2
Business plan budget
allocation
Expenditure
Carers receiving stipend
Annual targets
Carers receiving stipend
Actual Performance
(Source: Conditional grant quarterly reports and provincial business plans)
Reporting against the number of people reached by home-based carers in the
programme should be key to understanding the success of the programme.
However performance is both difficult to track and define since the type of
care and support provided to different people in the community varies
dramatically depending on the needs of clients. Performance in terms of the
number of people reached through the programme and the impact this
programme has on the South African HIV response is not captured in the
conditional grant quarterly reports. While financial performance in HCBC is
better than in most other programmes, it is difficult to judge the success of the
interventions without an independent study that assesses not only the impact,
but also the cost effectiveness of the interventions within the programme.
54
Medical Male Circumcision
Medical Male Circumcision (MMC) is one of the key interventions targeted in
the South African investment case. MMC provides approximately a 60 percent
protective effect against sexual transmission of HIV for men. When the MMC
programme was launched in 2010/11, the target was to circumcise 80 percent
of men between the age of 15 and 49 by the end of 2015/16. The following
figure shows trends of financial and non-financial performance against
targets.
Figure 23: MMC spending and performance against targets
Million Rand
400
350
300
250
200
150
100
50
0
1200
1000
800
600
400
200
0
Thousand circumcisions
450
Business plan budget
allocation
Expenditure
Number of circumcisions
performed target
Number of circumcisions
performed actual
(Source: Conditional grant quarterly reports and provincial business plans)
Spending performance against allocations has been consistently poor and
although the total number of circumcisions performed has increased year on
year, this has fallen short of targets since the start of the programme. In the
2014/15 year, the target number of circumcisions increased from 600 000 to 1
million (a 67 percent increase), while the budget allocation in the business
plans only increased by 10 percent. Task shifting measures can decrease the
unit costs per circumcision, but increasing targets so drastically while not
supporting this with an increase in funding will put strain on the health system
and will likely mean continued underperformance within the programme.
55
Models have shown the cost effectiveness and effectiveness of MMC as a
prevention mechanism showing significant cost savings in the long run as a
result of decreased incidence and low unit cost of the intervention.
Provinces had shown vastly different performance in the 2014/15 year by the
end of the third quarter. The following table shows performance against
targets per province for 2014/15.
Table 14: MMC performance by the end of the third quarter 2014/15
2014/15 Business Total by
% of annual target
Prov
plan target
end Q3
reached by end Q3
EC
55171
41441
75,1
FS
67268
26059
38,7
GP
235573
112333
47,7
KZN
291377
63159
21,7
LP
100000
41141
41,1
MP
83439
38409
46,0
NC
32615
8394
25,7
NW
84557
39618
46,9
WC
50000
13889
27,8
ZA
1000000
384443
38,4
(Source: Conditional grant quarter 3 report 2014/15)
Only Eastern Cape had reached its indicative target of 75 percent by the end
of the third quarter of 2014/15 with none of the other provinces reaching even
their target for the end of the second quarter yet. Traditional circumcision is
widely practiced in the Eastern Cape, and initiatives to integrate medical
circumcision with traditional practices are currently being scaled up. The wide
acceptability of MMC in the province may be one of the reasons for the
success of the programme. KwaZulu-Natal, a province where traditional
circumcision is not widely practiced, performed the most poorly, achieving
only 22 percent of the annual target by the end of the third quarter. MMC
programmes that do not aim to increase demand for MMC and change the
acceptability of the procedure in targeted communities will continue to fail to
reach targets. The target of 80% of the male population aged 15 to 49 is very
high, requiring innovative demand creation strategies to achieve these
56
targets, especially as the number of circumcisions performed increases.
Targeting men who want to undergo MMC will be relatively easy compared to
targeting men who are opposed to the procedure.
TB/HIV
The TB/HIV programme in South Africa aims to address the magnitude of the
co-epidemic by ensuring HIV positive patients are tested for TB and initiating
HIV positive patients on Isoniazid Preventative Therapy (IPT), which reduces
the risk of TB infection. The following figure shows spending trends and
performance against targets in the TB/HIV programme.
Figure 24: TB/HIV spending and performance against targets
Million Rand
600
500
400
300
200
100
0
1600
1400
1200
1000
800
600
400
200
0
Thousand people
700
Business plan budget
allocation
Expenditure
HIV positive screened for
TB annual targets
HIV positive screened for
TB actual performance
HIV positive patients
started on IPT target
Actual HIV positive
patients started on IPT
(Source: Conditional grant quarterly reports and provincial business plans)
The TB/HIV programme is a relatively new inclusion in the South African HIV
response, and progress against both spending and performance targets has
had mixed success over the past few years. In the 2013/14 financial year,
expenditure only reached 88 percent of the total amount transferred to
provinces through the conditional grant, and performance against indicators
did not reach 100 percent, both in testing HIV positive people for TB and
rolling out IPT for HIV positive patients. In 2014/15 the conditional grant
57
allocation to the programme increased from R357million to R577million (61
percent), while targets for TB screening of HIV positive patients, and initiating
patients on IPT decreased by 32 percent and 19 percent respectively.
The TB epidemic is a particular problem in specific areas and more prevalent
among certain population groups. The TB/HIV programme must focus on
these key populations as well as expanding services to the general
population. Careful monitoring of spending and realistic target setting will be
key to the success of the programme going forward.
Prevention of Mother to Child Transmission
The PMTCT programme is one of the biggest successes of the HIV response
in South Africa. Transmission rates from mothers to their children have
dropped to almost zero among mothers attending antenatal clinics and
adhering to treatment. The PMTCT programme is implemented within the
MWCH programme, which has received increased commitment and finances
in recent years, both from the public sector and donors. The success of the
programme has increased women’s access to sexual health and family
planning services, greatly increasing the health of women and their children.
The following figure shows spending and performance trends within the
PMTCT programme.
58
Figure 25: PMTCT spending and performance against targets
Million Rand
250
200
150
100
50
0
250
200
150
100
50
0
Thousand people
300
Business plan budget
allocation
Expenditure
Pregnant women started
on ART target
Actual pregnant women
started on ART
(Source: Conditional grant quarterly reports and provincial business plans)
Targets and performance have drastically increased over the past few years,
with the number of pregnant women initiated on treatment in 2013/14 far
exceeding the annual target, even though the entire budget was not spent.
This is likely to be as a result of increases in cost-effectiveness because of
the success of the MWCH programme, as well as task shifting initiatives such
as NIMART in the rollout of treatment for HIV positive mothers. As a result of
the success of the programme in 2013/14, the target for the number of new
initiations increased in 2014/15 almost one and a half times.
The PMTCT programme includes HCT among antenatal clinic (ANC) clients.
The annual National Antenatal Sentinel HIV & Herpes Simplex Type-2
Prevalence Survey in South Africa is one of the richest sources of data used
to model HIV incidence and prevalence at a national level. The continued
success of the PMTCT programme is vital for prevention, treatment and care,
as well as for monitoring the progress of the HIV response in the country.
59
Post exposure prophylaxis
The PEP programme is aimed at patients who need counselling, treatment
and care following sexual assault. Performance in this programme is
predicated on patients presenting at health facilities shortly after an incident
has occurred. This programme is allocated the smallest portion of the total
conditional grant budget, with only 0.17 percent allocated in 2014/15, down
from 0.21 percent in 2013/14. As the price of treatment decreases and
number of sexual assault cases decreases, increasingly less money will need
to be allocated to this programme. The following figure shows spending and
performance trends in the PEP programme.
Figure 26: PEP spending and performance against targets
Million Rand
20
15
10
5
0
40
35
30
25
20
15
10
5
0
Thousand people
25
Business plan budget
allocation
Expenditure
Number of sexual assault
cases offered ART
prophylaxis target
Actual number of sexual
assault cases offered ART
prophylaxis
(Source: Conditional grant quarterly reports and provincial business plans)
Performance against the target for the number of sexual assault cases offered
ART prophylaxis in this programme has been fairly good in comparison to
spending performance. In 2013/14, the performance target was exceeded,
while actual expenditure was less than 50 percent of the annual allocation.
This is an indication that budgeting and target setting in this programme is
poor, with the average cost per patient being lower than expected.
60
Programme Management
The allocation of funds to programme management increased significantly
from 2013/14 to 2014/15. Systems strengthening is an important part of the
delivery of health services in South Africa, especially in the HIV and AIDS
programme where patients need to be carefully managed for the rest of their
lives and prevention interventions are aimed at large proportions of the
population. The following figure shows allocation and spending trends in the
PM programme.
Figure 27: Programme management spending trends
Million Rand
800
700
600
500
400
300
200
100
Business plan budget
allocation
Expenditure
0
(Source: Conditional grant quarterly reports and provincial business plans)
By the end of the first, second and third quarters in 2014/15, spending on
programme management had only reached 13 percent, 27.5 percent and 45.8
percent respectively of the annual allocation. Tail-loading of expenditure on
programme management in the fourth quarter will not be helpful in ensuring
targets are met and that systems improve in 2014/15 and the benefits of
increased spending on programme management are only likely to be realised
in following years. Poor spending performance on programme management in
spite of the increased financial allocation is an indication that programme
management is not a priority in the HIV programme. The NDoH can provide
support to provinces in finding staff and monitoring performance of
programme managers at the provincial and district levels, and increase the
61
monitoring and evaluation of programmes as well as financial and nonfinancial reporting systems.
Regional training centres
Building human capacity for the HIV response is increasingly important as the
programme expands to reach more people year by year. The success of the
HIV programme is dependent not only on increasing the number of people
trained, but also on task shifting measures to increase both financial and nonfinancial efficiencies. The following figure shows spending and performance
trends within the RTC programme.
Figure 28: RTC spending and performance against targets
250
35
25
150
20
15
100
10
50
5
2011/2012 2012/2013 2013/2014 2014/2015
0
Thousand people
Million Rand
200
0
Business plan budget
allocation
30
Expenditure
Number of doctors trained on
HIV/AIDS, TB and other
chronic diseases target
Actual number of doctors
trained on HIV/AIDS, TB and
other chronic diseases
Number of nurses trained on
HIV/AIDS, TB and other
chronic diseases target
(Source: Conditional grant quarterly reports and provincial business plans)
The figure shows good performance against targets for both the number of
nurses and doctors trained in the programme, in spite of actual spending in
the programme consistently falling short of budgets allocated in the business
plans. The targets for the number of health professionals trained have
decreased over the past two years. This will be an issue for the HIV
62
programme, which is already understaffed, unless human resource capacity is
being built using other initiatives (for example through other grants).
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5. Conclusion
The size of the South African Comprehensive HIV and AIDS Grant has grown
quickly in the last ten years, supporting the largest national HIV programme in
the world. In 2014/15, R12.3 billion was allocated to the HIV and AIDS
response through this conditional grant, and providing about 80 percent of the
public funding for HIV. There are currently 2.9 million people on treatment,
more than 600 000 people being initiated on ART and over 9 million people
counselled and tested for HIV every year. Expenditure against the annual
grant allocation has improved over the past few years, with provinces
spending 100 percent of the total conditional grant in 2014/15.
The success of the national HIV programme cannot be overlooked, but the
management of the grant including the budgeting process, target setting and
implementation of programmes funded through the grant must be improved in
order to increase efficiency and cost-effectiveness as the HIV response
expands to reach more people every year. Spending performance across
programmes is erratic with consistent overspending against ART allocations
and under-spending in all other programmes year after year. The
management of funds and performance against programmatic targets varies
across provinces, with very poor budgeting particularly in Mpumalanga,
Limpopo and the Northern Cape.
Reporting against targets outlined in the business plans has been poor up to
the end of the third quarter in 2014/15 and performance indicators for more
than half the programme areas funded by the conditional grant have not been
reported. Careful monitoring and evaluation of programmes at the provincial
and district level is vital to ensure the success of the HIV response, reduce
waste and increase efficiency in an effort to provide equitable access for all
South Africans. At the end of the 2013/14 financial year, the auditor general’s
report of the NDoH was critical of reporting of the conditional grant financial
and non-financial performance, raising questions about the transparency of
the reporting procedures and quality of data. The Financial and Fiscal
64
Commission have recommend a careful review of existing grants with more
stringent
and
transparent
monitoring
of
financial
and
non-financial
performance, as well as the implementation of plans to make budgeting and
target setting more realistic and manageable. This report supports these
views, calling for a more careful evaluation of the conditional grant for HIV and
the success with which funding is being allocated to achieve national
objectives.
The allocation of the grant has been heavily focused on the ART programme
in recent years, both because of the number of people needing treatment, and
the average cost of treatment per patient. The percentage allocation to
programme management and training has grown steadily, almost doubling in
the past five years. Although prevention should be an increasing priority to
stem the tide of the epidemic, allocations to prevention have decreased
slightly, and the proportion allocated to treatment and care has also
decreased slightly – largely as a result of the decreased allocation to the ART
programme because of the decrease in the price of ARV drugs. Although total
allocations to all programme areas has grown year on year because of the
increasing size of the conditional grant, actual spending trends show that
prevention has been further sidelined, with only 12 percent of expenditure
going to prevention interventions.
Building capacity, both infrastructural and human resource, must be a key part
of the HIV programme. Systems strengthening will be vital as South Africa
increases the coverage of all interventions as it aims toward the 90-90-90
targets set for 2020. The data contained in the approved provincial business
plans show that the target for patients remaining on ART and in care
decreased from 2013/14 to 2014/15, while the financial allocation increased.
This trend cannot continue as the threshold for initiation on treatment
decreases and more people are considered to be in need of ART. Task
shifting strategies, especially NIMART will become increasingly important in
increasing the number of people initiated on treatment and retained in care,
as well as improving cost effectiveness in the HIV programme.
65
Overall, although the Comprehensive HIV and AIDS Grant as been
instrumental in increasing the success of the HIV response in South Africa by
funding the NSP, there is a need for renewed commitment to strengthen the
channels through which the grant is administered. While programmes have
shown successes the increasing funds required for the HIV response coupled
with decreasing commitment from international partners necessitates an
increase in the efficiency and cost effectiveness of programmes as they are
scaled up across the nation, as well as a careful evaluation of the systems
and procedures through which funds are administered and plans are
implemented.
66
References
[1]
O. Shisana, T. Rehle, L. Simbayi, K. Zuma, S. Jooste, N. Zungu, D.
Labadarios, D. Onoya, and et al., South African national HIV
prevalence, incidence and behaviour survey, 2012, no. June 2013.
Cape Town: HSRC Press, 2014.
[2]
South African National AIDS Council, “National Strategic Plan on HIV,
STIs and TB 2012 - 2016,” Pretoria, 2012.
[3]
S. Cohen and T. Guthrie, “Financing the South African National
Strategic Plan for HIV, STIs and TB 2012 -2016: An analysis of funding,
funding gaps and financing considerations.” 2013.
[4]
National Department of Health, The 2012 National Antenatal Sentinel
HIV & Herpes Simplex Type-2 Prevalence Survey in South Africa.
Pretoria: Department of Health, 2013.
[5]
WHO, “Global Tuberculosis Report 2014,” 2015. [Online]. Available:
www.who.int/tb/data. [Accessed: 12-Jan-2015].
[6]
T. Guthrie and A. Hickey Tshangana, “Overview of the public finance
system in South Africa: The budgeting and expenditure procedures.”
CEEGA & R4D, 2012.
[7]
National Treasury, “MTEF Technical Guidelines,” Pretoria, 2014.
[8]
Republic of South Africa, Division of Revenue Bill, no. 37337. 2014.
[9]
Financial and Fiscal Commission, 2014/15 Submission for the Division
of Revenue. Johannesburg: FCC, 2013.
[10] National Treasury, “Estimates of National Expenditure 2014,” 2014.
[Online]. Available: http://www.treasury.gov.za/documents/national
budget/2012/ene/FullENE.pdf. [Accessed: 15-Jan-2013].
[11] The Global Fund to Fight AIDS Tuberculosis and Malaria, “The Global
Fund,” 2015.
[12] Financial and Fiscal Commission, “Are Conditional Grants Spiralling Out
of Control?,” Johannesburg, 2013.
[13] Republic of South Africa, Republic of South Africa Division of Revenue
Amendment Bill, no. 38059. Pretoria, 2014.
67
[14] G. Meyer-Rath, “National ART Cost Model, South Africa.” Health
Economics and Epidemiology Research Office, Boston University/
University of the Witwatersrand, Johannesburg, 2015.
[15] National Department of Health, Consolidated Fourth Quarter Report for
Health Conditional Grants 2011/12. Pretoria: Department of Health,
2012.
[16] National Department of Health, Consolidated Conditional Grants Report
Fourth Quarter 2012/13. Pretoria: Department of Health, 2013.
[17] National Department of Health, Fourth quarter performance report for
health conditional grants 2013/14 financial year. Pretoria: Department of
Health, 2014.
[18] National Department of Health, Health Sector Conditional Grants Third
Quarter Report 2014/15. Pretoria: Department of Health, 2015.
[19] National Department of Health, Health Sector Conditional Grants First
Quarter Report 2014/15. Pretoria: Department of Health, 2014.
[20] National Department of Health, Health Sector Conditional Grants
Second Quarter Report 2014/15. Pretoria: Department of Health, 2014.
[21] National Department of Health, Annual Performance Evaluation Report
for the Comprehensive HIV and AIDS Conditional Grant for Financial
Year 2011/12. Pretoria: Department of Health, 2012.
[22] National Department of Health, National Department of Health: South
Africa - Annual Report 2012/2013. Pretoria: Department of Health,
2013.
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