MAXIMIZING POSITIVE SYNERGIES - World Health Organization

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South Africa: The effects of Global Health Initiative funding for HIV/AIDS on the health system Abstract Thomas Bisika, 24 Eric Buch, 24 Thubelihle Mathole, 25 Annie Parsons, 25 David Sanders 25 The study seeks to understand how GHIs operate in South Africa and their effects on the health system. GHI funding mostly focuses on HIV/AIDS; since apartheid, the South African health system has aimed to ensure equal access to health services. Preliminary results presented in this paper rely on interviews conducted as part of qualitative data collection at national level. Secondary data sources were used where available. Data analysis was framed by the WHO building block thematic areas. External financing centres on HIV/AIDS and is considered additional to state spending. The government is concerned about sustainability as such funding is not part of its long-term budget plans. GHIs have positively contributed towards HIV service scale-up by providing trainings and staff. However, health workers in the public sector are generally struggling with increased workloads. Historically, donors and government have failed to coordinate activities, with donors competing for attribution of outcomes. This is improving, however, with common indicators being developed to minimize parallel reporting systems. HIV/AIDS is a challenge to South Africa, but well-meant interventions should not undermine government efforts. Effectively utilized, GHIs can increase health care coverage and improve access to health care in South Africa. Background The Republic of South Africa is bordered to the north by the Republics of Namibia, Botswana, and Zimbabwe; to the east by the Republic of Mozambique and the Kingdom of Swaziland; while the Kingdom of Lesotho is surrounded by South African territory. South Africa is home to 47.6 million people and averaged a 1.0% population growth rate from 2001 to 2007 [1]. South Africa ranked 125 th out of 179 countries on the UN Human Development Index in 2006 [2]. The country has experienced substantial economic growth in 15 years of democracy following the end of apartheid 24 University of Pretoria 25 University of Western Cape 168
(4.8% real GDP growth in 2007), and is seen as a major emerging economy [3]. However, high rates of unemployment (38.8% in 2005) and income inequality pose major social and economic challenges [4,5]. First identified in South Africa in 1982, HIV/AIDS has had a major impact, and has helped fuel the spread of TB, including multi-drug resistant TB (MDR-TB). Recent years have seen a growing incidence of extremely-drug resistant TB (XDR-TB) [6,7]. Forty percent of total health care expenditure in South Africa flows through the public health sector, which in turn serves around 80% of the population [8]. The current South African health system features free health care for vulnerable groups (particularly pregnant women, children aged less than six years, the disabled and the elderly), waivers for the poor, and free primary health care for all [9]. In 2006, 66% of South African doctors worked in private practice, with the remaining third working in the public sector [10]. In 2007, 26% of the government’s HIV/AIDS budget was externally financed though total donor aid was less than 1% of South Africa’s overall health budget [11]. Official development assistance to South Africa was US$ 717.8 million in 2006 [12]. The country’s total external debt was US$ 35.5 billion or 13.9% of GDP [12]. Table 1 Basic Socioeconomic, Demographic and Health Indicators (*) (*) Full data sources for all indicators are provided in Annex 1. Indicator Value Year Source Population (thousands) 47,588 2007 World Bank Geographic Size (sq. km) 1,214,470 2007 World Bank GDP per capita, PPP (constant 2005 international $) 9,191.38 2007 World Bank Gini index 57.78 (†) 2000 World Bank Government expenditure on health (% of total government expenditure) 9.1 2006 WHO NHA Per capita government expenditure on health at average exchange rate (in US$) 176 2007 WHO NHA Physician Density (per 10,000) 8 2004 WHO SIS Nursing and midwifery density (per 10,000) 41 2004 WHO SIS Maternal mortality ratio (per 100,000 live births) 400 2005 WHO SIS DPT3 coverage (%) 97 2007 WHO SIS Estimated adult HIV (15-49) prevalence (%) 18.1 (15.4-20.9) 2007 UNAIDS Estimated antiretroviral therapy coverage (%) 28 (22-36) 2007 WHO/UNAIDS/UNICEF Tuberculosis prevalence (per 100,000) 998 2006 WHO GTD Estimated malaria deaths, all ages 146 2006 WHO WMR † 2000 Gini data provided to facilitate cross-country comparison. South Africa’s Gini figures have increased since 2000. South Africa’s Gini coefficient stood at 0.73 in 2005 (Source: Statistics South Africa. Income and expenditure of households 2005/2006: Analysis of results. Pretoria, Statistics South Africa, 2008). 169
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Table of Contents Key Acronyms Intr
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Policy analysis of the impact of Gl
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OIs Opportunistic infections OVC Or
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core section of the document then p
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Figure 1: Analytic framework for MP
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studies. MPS researchers have linke
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Burundi: Building a health system t
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at between US$ 14.5 and US$ 18.5 pe
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collaborations with European school
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epresent only US$ 1.75 per month pe
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Service Delivery The decentralizati
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Long term HSS will require governme
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Cameroon: Evaluation of the Nationa
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Table 1 Basic Socioeconomic, Demogr
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of treatment interruptions (>two da
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side effects) were associated with
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Prevention behaviours Nearly half (
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References [1] The World Bank Group
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Out-of-pocket payments account for
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as well as the number of community
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Table 1: Characteristics of facilit
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Table 4: Estimated changes in human
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Central African Republic: Impact of
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Objectives and Methodology In this
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Financing There was a general appre
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NGOs and Civil Society The overall
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Discussion Interviews with key info
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China: The Impact of the Global Fun
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Table 2 Global Health Initiative In
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In Yunnan and Henan, the epidemic i
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funded only from the MOH Pilot Prog
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References [1] China at a glance. W
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1994, private spending and emergenc
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understanding of their roles and re
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References [1] Human Development Re
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In 2003, the government launched th
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Objectives and Methodology The data
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Health Workforce Ghana is challenge
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Discussion GHIs are critical for ra
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Haiti: Maximizing Positive Synergie
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Table 1 Basic Socioeconomic, Demogr
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with need. With GHI funding, distri
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I know that within [the organizatio
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Much of the initial enthusiasm abou
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services, or for measures of qualit
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funds and more funding focused on i
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INDIA: Exploring how disease-specif
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PEPFAR* Year Amount Disbursed (in U
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Primary data collection - facility
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The Global Fund has strengthened th
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Background The Republic of Kenya li
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Results Leadership and Governance D
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Informants noted that a general lac
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time periods. Informants believed t
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A comprehensive, long-term reform o
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The effects of GHIs on the capacity
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their budget was comprised of Globa
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Quality of services The majority of
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References [1] Kyrgyzstan at a glan
Page 124 and 125: Commission (NAC) in 2001 as a multi
Page 126 and 127: Objectives and methodology The main
Page 128 and 129: Discussion The findings of the Mala
Page 130 and 131: Pakistan: The impact of the Global
Page 132 and 133: international standards. The Under
Page 134 and 135: the US Centers for Disease Control
Page 136 and 137: Some negative effects are also attr
Page 138 and 139: to country health systems by way of
Page 140 and 141: Peru: Effects of the Implementation
Page 142 and 143: Table 2 Global Health Initiative In
Page 144 and 145: HIV/AIDS, mainly around the Compreh
Page 146 and 147: without substantial emphasis on pre
Page 148 and 149: References [1] The World Bank Group
Page 150 and 151: Rwanda: The Impact of Global Health
Page 152 and 153: Rwanda was US$ 584.9 million in 200
Page 154 and 155: International Health Partnership, t
Page 156 and 157: PEPFAR’s funding practices were l
Page 158 and 159: medical staff to higher-paying admi
Page 160 and 161: system (CPDS), in which many stakeh
Page 162 and 163: needing medical transport. Both GHI
Page 164 and 165: Some informants felt that local NGO
Page 166 and 167: Senegal: The effects of Global Heal
Page 168 and 169: Table 1: Basic Health System and Ep
Page 170 and 171: case study. Data analysis was condu
Page 172 and 173: of respondents aware of treated net
Page 176 and 177: Table 2 Global Health Initiative In
Page 178 and 179: of South Africa (GHI2, ND6). 26 Don
Page 180 and 181: NDOH to disburse external funds in
Page 182 and 183: The lack of effective monitoring an
Page 184 and 185: Despite these problems, GHI funding
Page 186 and 187: [19] The Global Fund for Aids Tuber
Page 188 and 189: Official Development Assistance (OD
Page 190 and 191: The study employed both purposive s
Page 192 and 193: Figure 1: Number of Clinicians at S
Page 194 and 195: There were very significant increas
Page 196 and 197: GHIs created an opportunity to cond
Page 198 and 199: Ukraine: Effects of the Global Fund
Page 200 and 201: GAVI (in US$) Disease Priority Amou
Page 202 and 203: government and nongovernmental prov
Page 204 and 205: • The introduction of new service
Page 206 and 207: References [1] Data are from the Mi
Page 208 and 209: The health system struggles with a
Page 210 and 211: Objectives and Methodology This stu
Page 212 and 213: Nonetheless, efforts to recruit and
Page 214 and 215: References [1] The World Bank Group
Page 216 and 217: average annual population growth of
Page 218 and 219: 2006 149,022,153 2007 216,012,780 2
Page 220 and 221: isks duplication of services but al
Page 222 and 223: centres have only one qualified hea
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Policy analysis of the impact of Gl
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countries” [6]. The TRP apply sev
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PEPFAR I & II The newest PEPFAR leg
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Types of fundable HRH interventions
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Global Fund In two country applicat
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TABLE 3: Selected Countries: MPS Ca
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HRH Intervention Categories GAVI: C
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HRH Intervention Categories GLOBAL
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HRH Intervention Categories PEPFAR
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Conclusion: Directions for future r
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GHIs and health systems. Civil soci
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Annex 01: Data sources for tables i
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Annex 02: Contributing Institutions
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