South Africa still lacks an action plan after the withdrawal of US aid for HIV and related health services. But when funds do arrive, how will they be managed? In Spotlight, Russell Rensburg suggests the answer may lie in the District Health Programme Grant.
The government’s extended silence on how it plans to solve the funding crisis created by the withdrawal of US aid has thrown much of the health sector in South Africa into severe despair.
It is five months since the withdrawal of the aid amounting to about R7bn per year. It covered the salaries for 15 000 health workers, of whom 8 000 are community health workers, 2 000 are nurses, and 300 are doctors working in 27 of high HIV priority districts. As a result, volumes of high-risk populations have lost access to care, while over-stretched healthcare workers face increased pressure amid ongoing staff shortages.
Recently, the Global HIV Treatment Coalition and a bevy of civil society organisations wrote a strongly worded letter to the government demanding action on a fully-costed emergency plan. They accused the State of not taking concerted action.
They are not wrong: the government has still not made a clear plan available to the public, although there is consensus on the urgent need to strengthen the emergency response.
Plans have been developed internally in the National Department of Health, and a national technical support unit has been established in the office of the Health Department’s director-general to support the integration of services. It is understood several provinces are being supported to develop provincial transition plans that can be translated into concrete action.
But ongoing discussions with National Treasury have made little meaningful progress to close the funding gap. Treasury has indicated that any new funding will either be part of the adjustment budget or as an emergency allocation. At this stage, it is still unclear how much money, if any, will be allocated.
There is another challenge that is yet to be considered. When the funding does arrive, there will need to be consensus on how the money is co-ordinated, incubated and managed.
Here the answer may already be in our back pockets in the form of the District Health Programme Grant. The grant is a mechanism for funding public health efforts, particularly relating to HIV, TB, and other communicable diseases. As an existing instrument, this grant programme could help address issues linked to the funding gap and lay the foundation for the sustainable integration of activities previously funded by the US President’s Emergency Plan for Aids Relief (Pepfar).
Why the District Health Programme Grant could work
The District Health Programme Grant presents an ideal mechanism that can be used to strengthen governance and ensure that the funding, plans and activities down to a district level align with national campaigns and priorities.
But the grant would need to be amended to ensure improved management of the conditionalities so that the funds invested meet their purpose. Conditional grants are allocated to provinces with a primary purpose of ensuring national priorities are implemented consistently countrywide. They facilitate targeted service delivery, equity, accountability and performance monitoring.
The District Health Programme Grant, which has a budget of about R25bn, already has a large HIV component, so additional funding for both the HIV and TB services that are needed could easily be allocated to the grant.
And if the Health department amended the grant mechanism to allow for the contracting in of service providers, like the Pepfar implementing agents which are mostly local NGOs previously funded by the US government, the country would be able to use the capacity built up over time in these organisations to strengthen the delivery of HIV and TB services.
The concern, however, is accountability.
In the grant’s current set up, provinces are able to act more autonomously and the grant conditionalities are poorly managed.
However, for the system to be more effective, there needs to be a greater emphasis on co-operative engagement where two-way reporting between national and provinces can take place.
Amending the grant to include stronger accountability mechanisms would help the Health department to better co-ordinate and manage it.
The clock is ticking
The funding gap comes at a time when the department has launched two ambitious campaigns to tackle HIV and TB. The Close the Gap campaign aims to enrol a record number – an additional 1.1m – of people on antiretroviral medicine this year. Along with teenage girls and young women, the initiative prioritises around 600 000 men who know their status but are not on treatment.
This campaign aligns with the country’s strategy to END TB by 2030. This year, the department also hopes to accelerate TB case finding by scaling up testing to 5m TB tests to reduce the high rate of infections and deaths.
The linkages between the campaigns make sense. TB is the leading co-morbidity for people with HIV. HIV is also the leading contributor to TB mortality, accounting for an estimated 55% of TB deaths, according to the World Health Organisation’s data on TB in South Africa. The campaigns are evidenced informed and well considered.
But the ambition is not matched by budgets that can support and ultimately enable its success. In addition to the R7bn Pepfar funding gap, there is another gap of at least R600m in TB to fund the required 5m tests needed for the campaign. Funding pressures at provincial level are also constraining the scaling up of the capacity required to administer the tests.
A recent analysis from the South African National Aids Council (SANAC) situation room, which every month evaluates the HIV response as part of the Close the Gap campaign, suggests that while there are increases in the number of people being initiated on HIV treatment, the pace is not fast enough to mitigate the losses in retaining patients in care. This has resulted in negative growth in many high prevalence districts.
Similarly, in the first TB provincial managers programme meeting co-ordinated by the National TB programme, reports on the poor performance against the testing targets belied the underlying frustrations many are experiencing.
South Africa has made incredible progress in expanding access to healthcare in the past 30 years. These include significant declines in maternal mortality, decreases in the under-five mortality rates, and significant declines in TB cases. Much of this success, particularly in the past decade, is the result of the mass rollout of lifesaving antiretroviral treatment to about 6m of the estimated 8m people infected with HIV.
But the abrupt withdrawal of US aid has put at least some of this progress under threat.
As we look to the mid-year adjustments budget, we don’t just need new money to plug the gap, we also need a sensible framework for spending it. Channelling the funds through a tweaked District Health Programme Grant is a financial solution that will both provide some quick relief and mitigate the impact of the funding gap on universal health coverage more broadly in the long run.
*Rensburg is director of the Rural Health Advocacy Project and project director for the TB Accountability Consortium.
See more from MedicalBrief archives:
More work vital for HIV campaign’s success, say experts
Nearly 5m South Africans placed on new HIV medicines in four years
Who will plug the US funding gap?
Aids denialism deja vu as government denies funding crisis
HIV testing drops after aid cuts, but Minister denies system collapse