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NSP Review Engaging with South Africa’s National Strategic Plan for HIV, STIs and TB

Edition 2 April 2012 – June 2012

Better budgets

for better health Budget basics: A simple guide Local production: Not a silver bullet PEPFAR problems: Patients to pay the price

Things to watch

A publication of the Treatment Action Campaign and SECTION27


Contents

This NSP Review is jointly published by the Treatment Action Campaign and SECTION27.

NSP Review, April – June 2012

Editorial by Daygan Eagar.............................................................................................................................1 Costing the NSP: Making the most of our money ...................................................................2 Budget basics ...........................................................................................................................................................7 Budget buzzwords............................................................................................................................................... 8

The Treatment Action Campaign (TAC) advocates for increased access to treatment, care and support services for people living with HIV and campaigns to reduce new HIV infections. Learn more about TAC’s work at www.tac.org.za.

Show us the money – Can government deliver on its health promises?........ 10 The NSP needs a good M&E system – will it get one?.................................................... 14 Local production: Not a silver bullet ...............................................................................................18 PEPFAR problems: Patients to pay the price .......................................................................... 20 Global Fund at a crossroads: Keep fighting for the fund .............................................. 24 The production and distribution of this magazine was paid for by the South Africa Development Fund.

SECTION27 catalysts for social justice

SECTION27 is a public interest law centre that seeks to influence, develop and use the law to protect, promote and advance human rights, particularly the right to health. Learn more about SECTION27’s work at www.section27.org.za. This is the second issue of NSP Review. As with our debut last December, we aim to keep providing quality analysis and monitoring of the implementation of South Africa’s new National Strategic Plan (NSP). It is our hope that this publication will increase awareness of, and critical engagement with the NSP. We will strive to keep it relevant using evidence from new research and feedback from the district offices of the Treatment Action Campaign as well as from organisations with which we work closely. Our vision is a vibrant, evidence-based publication that helps all stake holders drive a more successful response to HIV, STIs and TB. We encourage you to get in touch with us should you want to contribute to future editions of NSP Review. You can e-mail the editor at nsp@tac.org.za.

Things to watch

NSP Review is now online at www.nspreview.org Editor: Marcus Low Assistant editor: Thania Gopal Contributors: Daygan Eagar, Nathan Geffen, Catherine Tomlinson, Donela Besada, Mara Kardas-Nelson Cover photo: Matthew Willman, courtesy of Photoshare. Design: Design for development (www.d4d.co.za) Printing: Tandym Print


Editorial Now, with the NSP 2012 - 2016 we have a new plan containing all the ingredients to not only ensure rapid progress towards universal treatment access but also to turn the tide on high HIV and TB incidence. Of equal importance is how the new plan allows us to establish systems for dealing more effectively with human rights abuses and discrimination based on HIV status. Despite the progress we have already made, the success and sustainability of our response depends heavily on how well it is financed and how well those finances are managed. Few health activists fully grasp the inextricable link between effective financing for health and the realisation of the right to health. This edition of NSP Review aims to help activists, policy makers and the public to understand this link. The magazine provides a critical review of some of the most important aspects of the allocation and management of financial resources for dealing with HIV/AIDS and TB. It also offers useful insights into how we can hold key players to account. Our first article looks specifically at the NSP. We examine how the plan was costed and why full costings of all provincial and departmental implementation plans are key to developing accurate and sustainable budgets. The next article builds on this by taking a more practical approach to the financing of the plan. It identifies steps to monitor in the budgeting process, showing what we can do to influence the development and implementation of budgets. The review then draws our attention to more nuanced debates on the best use of available resources. On page 18, Catherine Tomlinson and Marcus Low of the Treatment Action Campaign (TAC) look at the value of proposals for a state-owned pharmaceutical company that would locally manufacture Active Pharmaceutical

Ingredients (APIs) for ARVs. The authors take a critical look at the scheme, questioning whether local production of APIs really would create many jobs or contribute to cheaper high-quality drugs. Then, Nathan Geffen, also of TAC, argues for the value of a well-formulated and fully-resourced Monitoring and Evaluation (M&E) strategy. He explores how M&E can measure the use of resources and evaluate the success of programmes. Geffen takes us through the problems with M&E systems in the previous NSP and the importance of getting it right this time. Contributions from Mara Kardas-Nelson and Donela Besada, both based at Médecins Sans Frontières (MSF) broaden the discussion by considering the global nature of health care finance. The authors assess the impact that the crises in international funding mechanisms such as the Global Fund and PEPFAR will have on South Africa’s response to HIV/AIDS and TB. This issue of NSP Review is a valuable resource in any effort to secure the full financing of health interventions and the appropriate use of resources. However, it is only a tool. Everyone who is interested in the realisation of the right to health, as set out in Section 27 of our Constitution, must take action to ensure that government no longer uses scarcity of resources as a de facto excuse for failing to meet its obligations. Daygan Eagar is a researcher with SECTION27 and a member of the SANAC Costing Task Team.

Things to watch

The launch of the National Strategic Plan (NSP) 20072011 marked the end of state-sanctioned AIDS denialism in South Africa. Since then, we have taken significant strides in response to HIV/AIDS and TB. Most notable has been the dramatic expansion in our ARV treatment programme; by the middle of 2011 more than 1.79 million people were on treatment, more than seven times the number recorded at the beginning of 2007. Reports indicate that in the last year alone over 600,000 new patients enrolled on treatment.

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COSTING THE NSP: COSTING THE NSP

Making the most of our money

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In order to control HIV, we need to be sure we have enough money and that we spend that money effectively. Daygan Eagar of Section27 shows us how to work out the cost of implementing South Africa’s new National Strategic Plan for HIV, TB and STIs.

Costing and budgeting may seem like boring and difficult topics, but they are a key part of our struggle against HIV and TB. If we don’t budget and spend money effectively, our clinics will run out of medicines. The laboratories that carry out HIV and TB tests will be unable to function. If we dismiss budgeting and costing as dull, what we are really saying is that it is too dull to ensure that our health system works well.


What is costing? Costing is the process of placing a monetary value on the activities of an organisation. This information is then used to develop budgets and to monitor use of the organisation’s resources.

In terms of our response to HIV, TB and STIs, costing is critical to identifying which resources we need. If the South African government does not know what health interventions will cost it becomes very difficult to budget properly for their implementation. The best way to determine these costs and our resource needs is to carry out a proper costing of the National Strategic Plan (NSP) itself. In other words, even before we put the plan into action, we have to calculate all of its costs and make sure that we have sufficient funds available to meet the goals of the new NSP (2012-2016).

Calling government to account For civil society, getting to grips with costing and what the numbers really mean is essential if we want to hold government and other agencies to account for their allocation and use of scarce resources. If we simply remove some of the technical language that surrounds the costing process, it is not too hard to understand. Even though we can use various models and tools to price activities and health interventions a few key elements are common to most costing methods.

The following steps outline how the South African National AIDS Council (SANAC) Costing Task Team costed the 2012-2016 NSP:

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3 2 1

WHAT are we costing?

All the interventions for every subobjective contained within each of the four main strategic objectives.

WHOSE health are we costing?

What is the total population in need of each intervention? We gathered this information from epidemiological and demographic data from various sources such as Statistics South Africa and government departments’ own M&E data.

What are the TARGETS?

Once we knew the total population in need we determined the targets for each intervention. These were often given as the percentage of the total population in need that each intervention would cover. This information was drawn from the NSP itself.

What are the UNIT COSTS?

Next, we calculated the unit cost of interventions by finding the price of all the ingredients of each intervention (for example, ARVS, staff and equipment) and adding these figures together. In this way we arrived at a total cost for each unit and type of intervention.

What is the TOTAL COST?

Once we had a unit cost for each intervention we could then multiply that figure by the number of people targeted for that intervention—or the number of times the intervention would be needed. We then added up the costs of all interventions for each year of the NSP, to arrive at the approximate annual cost of the plan.

COSTING THE NSP

Many people think that unless you actually work in government planning and budgeting it is not worth the time and effort that it takes to understand these processes. However, in recent years we have seen enough evidence that leaving these tasks to other people is no guarantee of success. At its worst, poor budgeting and costing led to a deadly ARV moratorium in the Free State in 2008. And in late 2011 and early 2012 similar failures lay behind the near collapse of the National Health Laboratory Service. Costing and budgeting are where you often find the real bottlenecks. Activists—or indeed anyone who wants to see South Africa bring HIV and TB under control—are not doing the best they can unless they engage with costing and budgeting.

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Costing complications In reality the NSP costing was somewhat more complex than we have described above. It required the use of several statistical and epidemiological tools and models. These allowed us to determine unit costs for many of the biomedical interventions such as antiretroviral treatment (ART) and TB treatment.

implementation of the NSP, by the time the 2012-2016 plan had been finalised it was still unclear what M&E structures would look like or how its processes would work. We could not use costs from the previous NSP because the lack of effective M&E was one of the major shortcomings of that plan.

In some instances, particularly for interventions related to human rights, there were no readily available ingredient costs. Therefore we had to do some research to find these and where necessary to adapt data for our purposes.

In some cases, for parts of the new NSP that resisted costing we had to leave out these costs. In others we added onto the total cost of the plan a percentage that could adequately cover these interventions. We based the percentages on international best practice and on some educated estimates. This should not have a significant impact on the estimated total cost of the plan, however, as the predicted cost of these interventions was small. The cost of M&E, for example, was estimated to be only 0.12% of the total cost of implementing the NSP.

For a few activities and interventions that feature in the plan there is simply no way to accurately establish the ingredients of an intervention. For example, where the plan mentions ‘research’ as part of any intervention there is insufficient information to know what this research would involve. It is not possible to foresee how wide-ranging the research would be or how long it would take. For the costing team, this meant there was no way to determine the unit costs of research. Nor could we accurately estimate the total annual cost of research. Monitoring and Evaluation (M&E) posed similar difficulties. Even though M&E is essential for the successful

In the end despite such challenges this was the most comprehensive NSP costing to date. The team managed to generate detailed figures for all of the high-cost elements of the plan. We also priced several interventions that could not be included in the costing of the 2007-2011 NSP.

Where the money will go

COSTING THE NSP

The results of this costing give a good indication of resource needs for the NSP. They also highlight the importance that the NSP gives to various strategic objectives and types of interventions such as treatment, prevention and the protection of human rights.

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The annual total cost of implementing the NSP was found to be R18.73 billion for 2012-13. This total is expected to pass the R32 billion mark by 2016-17. As the graph on page 5 shows, by far the largest cost of putting the plan into action will be the provision of antiretroviral treatment. Estimates suggest that the price of ART provision will rise from R11.68 billion for 2012-13 to almost R20 billion by 2016-17. Therefore ART will account for roughly 62% of the total annual cost of the NSP. If we add to this the 9% for HIV screening as well as the 12% for TB screening and treatment we see that biomedical interventions make up around 83% of the total annual cost of the plan. By contrast, interventions aimed at prevention, such as the provision of condoms, medical male circumcision (MMC) and youth HIV prevention, account for only about 5% of the total annual cost of the plan. However it is worth remembering that recent research shows that treatment is also a highly effective form of prevention.

Other key areas essential to the success of the NSP—such as administration, M&E, research, the protection of human rights and access to justice—also form only a small proportion of the total annual cost of the plan. For example, the cost of Strategic Objective Four (SO4), ‘Ensuring the Protection of Human Rights and Improving Access to Justice’, makes up only around 1% of the total annual cost of the NSP. Unfortunately the costing does not tell us why certain interventions appear to take priority over others. There may be very good reasons for these decisions and in many cases, such as ART, we know that there are. ART has been shown to be highly effective—and cost effective—not only as treatment but also as prevention. What the costing does, however, is to give us a tool to begin questioning how we allocate our country’s resources for HIV and where this may need improvement.

By far the largest cost of putting the plan into action will be the provision of antiretroviral treatment


A medical intern checks medications at a hospital in South Africa. Photo by Marilyn Keegan, courtesy of Photoshare.

Annual costs summarised by key cost driver 35,000

30,000

ZAR Millions

25,000

20,000

15,000 Antiretroviral treatment

10,000

Antiretroviral treatment

Antiretroviral treatment

Antiretroviral treatment

Antiretroviral treatment

5,000

HIV screening

HIV screening

HIV screening

2012/13

2013/14

2014/15

2015/16

2016/17

Remainder

870

960

967

1061

1070

Youth HIV prevention

323

451

529

689

756

MMC

244

293

293

488

781

Condoms

329

355

399

442

469

OVC support

1227

1400

1575

1750

1930

Antiretroviral treatment

11681

14783

16827

18352

19737

TB treatment

1329

1337

1356

1253

869

TB screening

985

1243

1175

1291

1418

HIV screening

1739

2609

3478

4348

5217

0

COSTING THE NSP

HIV screening

HIV screening

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The costing continues Translating the NSP into figures is not the end of the costing process. Nor is it necessarily the most important aspect of the task team’s briefing. The NSP costing is carried out at policy-level and therefore only includes costs by strategic objective and intervention. It does not, and cannot, provide enough detail to cost the actual activities needed to implement each intervention. Therefore, while the costing gives us a good estimate of the resources we need, it does not provide sufficient detail to ensure that South Africa mobilises the right resources through its implementation budgets. This is due to the fact that the NSP is a broad policy document. It considers interventions and targets at a national level. Government cannot simply divide these targets between provinces based on the size of their populations or even on their burden of disease.

Getting down to details

COSTING THE NSP

Instead, putting the NSP into action will require implementation plans for each province, department and implementing agency (for example, an NGO). These plans will detail how to carry out each intervention and what activities must be completed each year to do so. The plans will be developed with specific provincial and local settings in mind. Each will vary depending on local priorities, the burden of disease, and even on whether a province is mainly rural or mainly urban. While all these plans should clearly align with the NSP they will need individual costing.

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These detailed documents will also address important activities that the NSP does not cover. Strategic Objective 4 (SO4) is a good example here. It contains a number of sub-objectives that are vital for removing barriers to treatment access. These also aim to If we do prevent or deal with acts not actively take of violence and discrimination against part in all aspects of the HIV-positive people. National Strategic Plan and Yet many of the interventions listed its implementation—even the within SO4 only seek to remove barseemingly complex areas riers to the protecsuch as costing—we can tion of human rights in legislation and never hope to truly take strategic planning or to ownership of it. enable the monitoring of human rights abuses.

Interventions that aim to ensure access to justice and the protection of human rights will require development in the plans of departments and implementing agencies. Here bodies such as the Department of Justice and the Department of Corrections will need to draw up and cost detailed implementation plans.

Local knowledge This is where the value of a costing task team made up mostly of locally-based experts really comes into play. The primary goal of the team is not a once-off costing exercise. Instead, the group aims for long-term collaboration with provinces and departments throughout the life of the NSP. This collaboration must allow the team to provide ongoing technical assistance with implementation planning, costing and budgeting. In addition to helping provinces and departments to cost their own strategic plans, the task team is also developing costing models and tools. These will allow provinces and departments to integrate their costed plans with the development of their business plans and budgets.

Reaping the benefits This kind of long-term technical assistance has a number of benefits. For example, it harmonises priorities, targets, and costings across national, provincial and local levels of implementation. It also ensures that budgets are based on detailed, realistic implementation plans. Finally, it allows for greater monitoring and evaluation of the plan’s financing and expenditure. We will only see the benefits of this exercise if departments develop implementation plans that are truly practical. Over the long term the exercise will also require those carrying out the plan to commit to working with the Costing Task Team. Activists and civil society alike have an important role to play here. We must first understand these processes and what we can do to influence them at national, provincial or district level. It is our responsibility to ensure that the implementation plans developed in our own provinces accurately reflect the true principles and goals of the NSP. We must then hold those implementing the plan to account for how they use South Africa’s resources. Daygan Eagar is a researcher with SECTION27 and a member of the SANAC Costing Task Team.


Budget basics How health is structured Our public health care system is divided into several different levels. Each level has particular responsibilities to ensure that people have access to health care services. These levels are the National Department of Health (NDoH), the Provincial Departments of Health (PDoH), and district or municipal health departments. National Department of Health

Limpopo

Gauteng

Provincial Departments of Health

National Department of Health (NDoH) The NDoH is responsible for developing the government’s health policy. It does not provide health care to people directly. Instead, the NDoH tries to regulate how health care services are provided to the public. It does this by formulating legislation and issuing regulations and guidelines that determine the levels of care a person is entitled to receive when he or she goes to a hospital or clinic. The NDoH must also monitor the programmes that provinces put in place, to check that they provide quality services.

Provincial Departments of Health (PDoH)

KwaZulu Natal

District/ Municipal Health Departments

The PDoHs are primarily responsible for providing health care services to people. They structure the health care system for the province and determine the placement of hospitals and clinics. PDoHs spend most of South Africa’s health budget. For example, KwaZulu-Natal alone spends more money on health than the NDoH. This is because the PDoHs have to maintain hospitals, pay doctors, nurses and other health workers, and buy all supplies, such as medications, that people use when attending public hospitals or clinics.

Clinic

Clinic

Clinic

The job of providing health care services is sometimes also the responsibility of a local district or municipal health department. This is becoming less common though because provincial governments often do not believe that local government will be able to manage the facilities better than they could. However, this often makes it difficult for members of a community to raise their concerns or to demand action from the PDoH, because the PDoH may be located far from that community. Fortunately, greater control at the local level is one of the priorities of the National Health Insurance Proposals. This would give communities better access to officials to make complaints or to demand action.

BUDGET BASICS

District or Municipal Health Departments

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Budget Basics

What does DORA do? DORA first divides the NRF into three large pots: the National Government Revenue; the Equitable Share for Provinces; and the Equitable Share for Local Governments. These three pots of money are used to fund the three different spheres of government.

Almost all money spent by government comes from the National Revenue Fund (NRF). The NRF is like a bank account into which all the money collected by national government is deposited before it can be spent. At the beginning of each financial year, all of the money in the NRF is allocated for spending in two acts passed by Parliament: the Division of Revenue Act (DORA) and the Appropriation Act.

Of the money allocated via DORA in the 2010/11 financial year, the national government got R359 billion (44%), followed by the provinces with R323 billion (39%), then R71 billion for the state debt, R59 billion for local government and R1 billion for contingencies. Local governments are expected to raise most of their own money in the form of fees and taxes on the services they provide, which is why they get little from the national government.

What is the Equitable Share? For provinces, something called the Equitable Share Formula is used to determine how much money each province will receive from the Equitable Share. This money is not simply divided according to the size of the population in each province because the circumstances of each province vary. Therefore the Equitable Share is divided based on six factors:

Level of Poverty (3%) Administration (5%) Percentage of Population (14%) Health (26%)

Conditional Grants DORA also creates conditional grants. Conditional grants are allocated by national government to the provinces, but the provinces must spend them according to conditions set down by national government. There are many conditional grants.

Budget Buzzwords

BUDGET BASICS

Conditional grants are designed around a single programme that national government recognises requires a significant amount of money and is of national importance. Importantly, conditional grants are only meant to supplement provincial funding for a programme. They are not the total amount that a province spends on that programme.

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Level of Economic Output (1%)

Education (51%)

Importantly, despite the Equitable Share Formula dividing the money up according to these factors, there is no obligation on the provinces to spend according to this formula. Money given out through the equitable shares to provinces and local governments is called an “unconditional allocation�. This is because the money can be used in any way that provinces or local government determine is best.

One example of a conditional grant is the Comprehensive HIV and AIDS Grant. It is intended to help pay for each province’s HIV/AIDS programme. When a conditional grant is allocated to a provincial department, that department must submit a business plan showing how it will spend the money. In the case of health-related conditional grants this means the provincial departments of health submit their business plans to the NDoH which must approve the plans as being strategically and financially reasonable. If the NDoH does not agree with a plan, it can reject it and force the provincial department to develop a new plan that is more reasonable according to NDoH criteria.

Appropriation Act: Act that allocates money to different departments for spending. The Appropriation Act is essentially the national budget. Parliament and every provincial legislature passes an appropriation act.

Conditional Grants: Money given to provinces by the national government that comes with conditions on how it must be spent. It is monitored by national departments.

Adjustment Appropriation Act: An Act generally passed in November that adjusts the allocations from the Appropriation Act to take into account new information about the amount of money available.

Division of Revenue Act (DORA): Act that divides money between national, provincial and local governments and provides conditional grants.


While DORA makes major decisions about how to divide money between national, provincial and local governments, the Appropriation Act makes detailed decisions about how each sphere of government will spend money across different departments through a series of “Votes”. Each of these Votes sets out a budget for a single department. So, for example, there will be one Vote for the National Department of Health, one Vote for the National Department of Social Development, one Vote for the National Department of

The MTEF and long-term planning Part of the budgeting process also includes planning for more than one financial year through the Medium Term Expenditure Framework (MTEF). The MTEF guides spending over three years so that departments can have a longer-term view of how much money they will get each year. The budgets include targets so that government can both estimate how much it will cost to achieve those targets and also hold departments accountable if they do not meet them. As an example, a target in every provincial health budget is the number of patients who will be on ARV treatment by the end of the financial year. Usually the MTEF, with the exception of new programmes, is incremental. This means that targets and budgets are increased every year to account for inflation and achievement of the previous year’s targets. They are not estimated using a thorough review of the targets themselves. Ideally every health facility should develop a budget based on government policy and on the needs of the community that it serves. These clinic budgets should then be consolidated into district budgets. District budgets should be used to construct provincial health budgets. National government should then try to ensure that there is enough money in conditional grants and the equitable share to cover these budgets. At every stage budgets should be negotiated, discussed and verified. If there is not enough money to cover the budgets, the most important areas of need should be determined through a consultation process. Unfortunately South Africa is a long way from implementing this kind of system.

Equitable Share (ES): The ES is a constitutionally required distribution of money from national government to the provinces, district and municipal governments. This money is allocated according to the Equitable Share Formula. Equitable Share Formula: The Equitable Share Formula determines how much money from the ES each province and district or municipal government should get.

Home Affairs, etc. Parliament passes an appropriation act for national departments and each provincial legislature passes an appropriation act for its province’s own departments.

Timeframes for the budgeting process The South African government’s financial year runs from 1 April to 31 March. Budgets for all departments are negotiated between the National Treasury and provincial treasuries, national departments and local governments. These negotiations start almost as soon as the previous year’s budget begins. This means, to get involved and have an influence on budget decisions, as civil society, we need to act early and be proactive. (See page 30 for more on the budget cycle.)

Demand district health and human resource plans Every health district in the country is required by law to develop annual district health and district human resource plans that explain how they intend to provide health services to the people in that district. These plans are extremely important as districts and municipal governments are directly responsible for providing services to people. Without these plans, it is not possible to develop accurate budgets. These plans should be developed with community involvement and be open to scrutiny by community members. As far as we can tell, very few—if any—districts actually do this.

Sit on clinic committees and district health councils Every district is required to have a District Health Council and all clinics are required to have a Clinic Committee in terms of the National Health Act. Many of these councils and committees do not yet exist, but community members should demand that they be established! Clinic committees are required to have representatives from the community. District health councils can have community representation, but are not obligated to do so at the moment. Nevertheless, communities should demand representation on district health councils.

Financial Year: The year for which the budget is set. It runs from 1 April to 31 March every year. Medium Term Expenditure Framework (MTEF): The MTEF is a preliminary budget plan that covers three financial years. It is usually presented in October or November. National Revenue Fund (NRF): The NRF is the main fund in which almost all money collected by national government must be placed before being spent according to a budget.

BUDGET BASICS

What is done in the Appropriation Act?

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Members of the organisation Grandmothers Against Poverty and AIDS (GAPA), which provides food and day care for children with HIV/AIDS in South Africa. Photo by Omar Eid, courtesy of Photoshare.

If you want to know a government’s real priorities, you’ll find them in the budget.

Show us the money Can government deliver on its health promises? UNDERSTANDING THE BUDGET

By Daygan Eagar

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Some would argue that a government’s most important policy document is its budget. A budget not only makes promises, it outlines what resources are available to fulfill those promises. If there is no budget, or if the budget is insufficient for a particular health priority then that priority is nothing more than an empty promise. This is why budgets can provide some of the most valuable information for anyone who wants to hold public institutions to account for HIV service delivery. In South Africa we are lucky that our government, at both national and provincial levels, generally publishes

a great deal of high-quality budget information. In fact, on the 2010 Open Budget Index (OBI), which compares countries in terms of budget transparency and accountability, South Africa gets top ranking out of 94 nations. But all this information is only as useful as we make it. If we do not understand the budget and how we can engage with it, we miss important opportunities. Budget information can help us pressure the government to deliver on its commitments and to respect the promises made in our Constitution and Bill of Rights.


What do we spend on HIV? The 2010 mid-term review of the previous NSP (20072011) was particularly critical about this problem. The review argued that a major failing in the implementation of the NSP was the ’scattergun‘ approach to financing. Countless government, private and donor sources all funded interventions but without sufficient coordination. As a result there was no way to properly monitor and evaluate what was spent, where and how. In the last two years, however, there have been attempts to improve monitoring and evaluation. The recently completed National AIDS Spending Assessment (NASA) for South Africa, prepared by the Centre for Economic Governance and AIDS in Africa (CEGAA) on behalf of UNAIDS, tried to pinpoint actual HIV expenditure by the South African government, the private sector, NGOs and development partners. Unfortunately, the final results of the NASA country report are not yet publically available. But what we do know about the NASA suggests that although the review of government expenditure was thorough, private sector and development partners were often unwilling to participate fully in the project. As a result data from these sources is limited. The lack of complete data is frustrating. Over the last decade South Africa has relied heavily on donor funding to supplement money from the public purse. The exact amount provided by donors is unknown, but Treasury

estimates place it somewhere between R5 billion and R6 billion annually. We know even less about private sector spending on HIV. This expenditure is highly fragmented and diverse. It comes from sources such as private medical aid schemes, workplace insurance programmes and outof-pocket payments by individuals funding their own treatment. However, government is by far the largest service provider, spending a lot more on its HIV programmes than the private sector.

Bridging the funding gap Indeed, the South African government is becoming more important to our response to HIV as donors like PEPFAR and the Global Fund start to cut back on their funding. Fortunately it does appear that government is stepping up to bridge the funding gap with domestic contributions. Since 2006 South Africa has dramatically increased funding for HIV services. Estimates suggest that total HIV-specific allocations from the public sector rose from approximately R2.5 billion in 2005-06 to more than R11 billion in 2010-11. This amounts to an increase of more than 400%. HIV spending has become perhaps the biggest budget item of all.

HIV spending has become perhaps the biggest budget item of all

UNDERSTANDING THE BUDGET

Even though our government comes out on top in the OBI, it has been surprisingly difficult to find out exactly what South Africa spends on its response to HIV.

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Government’s commitment to expanding HIV services is also clearly visible in its most recent budget. Even though expenditure was cut in other important areas due to the slow recovery of the global economy, altogether government allocations for HIV programmes have once again risen substantially. For the 2012-13 financial year government has earmarked more than R8.76 billion through the HIV and AIDS Conditional Grant alone. This translates to an increase of around R1 billion or 13% on last year’s allocation. The trend looks set to continue over the next two years with allocations from the Grant increasing by 20% (R1.77 billion) in 2013-14 and by a further 16% (R1.68 billion) in 2014-15.

AIDS Council to begin investigating such options. So far, however there is no indication that any particular mechanism will be introduced in the near future.

Many of these gains are due to the efforts of civil society organisations. These include groups such as the Treatment Action Campaign, Médecins Sans Frontières (MSF), CEGAA and SECTION27.

A number of civil society organisations already monitor the assignment of resources. They also help to track expenditure and to push for greater government accountability in the use of resources for managing HIV.

Expanding domestic funding

SECTION27, for example, currently scrutinises the allocation of resources for HIV at the policy level. The organisation analyses these allocations using the national and provincial health budgets.

UNDERSTANDING THE BUDGET

But our fight for sustainable resources is by no means over. Government needs to secure additional domestic funding to further grow its HIV programmes. Yet South Africa is approaching the limit of what can be found through sources such as tax revenue. Therefore in the medium-term civil society will need to push for government to consider new financing mechanisms. These could include additional ‘sin taxes’ or an AIDS levy such as the one used in Zimbabwe. There are moves within government and the South African National

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It is not enough for us to fight for more money, though. An equally important challenge is to ensure that the money we have is used properly. Endemic corruption and poor financial management are now perhaps the greatest threats to our HIV programmes. Each year millions of rands are wasted through improper tender procedures and through government’s failure to guarantee that the money it earmarks for specific interventions is used only for its intended purpose.

CEGAA is involved in similar work. It not only examines the allocation of resources through the budget but has also carried out a NASA report on South Africa (see above). The NASA project tracked the flow of resources from their source right down to actual spending at the point of service delivery.


It is not enough for us to fight for more money, though. An equally important challenge is to ensure that the money we have is used properly.

Two young boys who have lost parents stand next to a community worker in South Africa. Like many other vulnerable children in this community, their living conditions are poor and there is little opportunity to go to school. Photo by Melissa May, courtesy of Photoshare.

It is important to remember that budget monitoring and expenditure tracking are not only for organisations with specialised technical expertise. The Treatment Action Campaign (TAC), in partnership with CEGAA, is currently conducting a Budget Monitoring and Expenditure Tracking (BMET) project in several of its model districts throughout South Africa. This BMET uses various tools including citizen report cards and direct monitoring of expenditure on the ground. In this way TAC aims to hold government to account for what actually happens with our money. In addition to this regular work, organisations such as TAC, CEGAA and SECTION27 are part of a civil society coalition known as the Budget and Expenditure Monitoring Forum (BEMF). The purpose of BEMF is to bring diverse organisations together to share information about health financing.

Pooling expertise The coalition also aims to strengthen joint advocacy by pooling the diverse expertise of these groups. Some such as CEGAA have strong technical know-how while others like TAC are adept at monitoring what happens on the

ground and are able to mobilise those people who are worst affected by poor financial management. To date BEMF has successfully united civil society organisations to advocate on a number of important issues including: • The release of the Integrated Support Team Reports into provincial health financing; • The negotiation of significant cost reductions in the 2010 ARV tender; • The full costing of the NSP (2012-2016); • The cancellation of the Global Fund’s Round 11 funding; and • The Gauteng Budget crisis We must build on this success to achieve even more in future. With regard to the NSP, South Africans have a chance to ensure that departments and provinces develop realistic implementation plans that are properly costed and budgeted. Once these plans are in place and the resources have been allocated we will have the difficult task of making sure that the money is spent appropriately.

UNDERSTANDING THE BUDGET

The BMET project

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The NSP needs a good M&E system

will it get one? By Nathan Geffen

m&e and the NSP

The new National Strategic Plan on HIV, STIs and TB, 2012-2016 (NSP), like its predecessor, contains a large section on monitoring and evaluation (M&E). But despite ambitious targets in this field, poor M&E followed the last NSP. At the time, the Department of Health lacked the will and the staff to make a success of M&E.

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World AIDS Day (2010) in Driefontein in the North West Province. With well over 5,000 people in attendance, community members were able to apply for identity documents, birth certificates, social grants and get tested for HIV. Photo by Simonia Mashangoane, courtesy of Treatment Action Campaign Archive.

Hopefully the new NSP will fare better. M&E in the new plan is better conceived than in the old one. The latest M&E section uses a more manageable set of indicators, a few of which contain plausible baseline data and describe feasible methods for measuring success both during and at the end of the NSP period.


The indicators are: (numbers rounded to avoid false accuracy)

9% 4%

no baseline data

1%

50%

0.5%

40%

20%

NSP targets (by 2016)

Baseline data (2012)

HIV prevalence in 15-to24-year-olds, estimated at baseline to be 9% (HSRC Household Survey). The NSP targets a reduction to 4% in 2016.

HIV prevalence in key populations. The NSP contains no baseline data for this, even though it proposes a 50% reduction.

1%

50 per 100,000

HIV incidence, estimated to be 1% in 2012 (ASSA). The goal is to reduce this by half by 2016.

HIV mortality, estimated at over 40% of deaths at baseline (Stats SA). The aim is to reduce this percentage by half by 2016.

Some of these statistics should be treated with caution. The drafters of the NSP recognise this and have tasked the South African National AIDS Council (SANAC) secretariat with leading a process to calculate better baseline data. For example, one indicator not mentioned above is called a stigma index. This is poorly defined and the NSP describes no way of measuring it. Nevertheless, most indicators in the plan are reasonable and can be used as the basis for a good M&E programme. The NSP also commits to annual programme reviews, a mid-term evaluation in 2014 and a final evaluation in 2016 that will also provide baseline values

0.5%

TB incidence, estimated to be almost 1% in 2010 (WHO). South Africa aims to reduce it by half by 2016.

25 per 100,000

TB mortality in HIVnegative people, estimated to be 50 per 100,000 in 2010 (WHO). The NSP targets a reduction to 25 per 100,000 in 2016.

4% 2%

94% Year 1

88% Year 2

Rate of transmission to infants, estimated to be just under 4% at six weeks after birth in a study published last year by the MRC. South Africa aims to reduce this to less than 2% at six weeks and less than 5% at 18 months in 2016.

82% Year 3

76% Year 4

70% Year 5

Patients alive and on ART. No data is currently available for this indicator, but by 2016 the target is to have 94% retention in care by one year after commencing ART, 88% by two years, 82% by three years, 76% by four years and 70% by five years.

for the next NSP. This is ambitious. If it is to happen, there must be clear leadership and enough people to do this work. Overall responsibility for M&E falls to the M&E Unit in the SANAC secretariat. The plan also notes that M&E units in provincial AIDS councils and sectors should co-ordinate M&E provincially. Exactly how this will all work, and who will lead the process, is unclear, as is the role of the Health Department. But wherever the M&E programme is located, it must have a substantial budget and quality human resources. The Director General of Health must take ultimate responsibility for ensuring the implementation of M&E.

m&e and the NSP

Total

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Getting it right for treatment How many people began antiretroviral treatment in public clinics and hospitals in South Africa? How many are still in treatment? How many have died? What regimens are people taking? How many have moved to second-line regimens? At what CD4 count does the average person start treatment? How many have suppressed viral load at one year? What is the average time that people have been on treatment? A well-monitored antiretroviral rollout should be able to answer these questions. There should be reports every six months containing all these data and more. Unfortunately the monitoring of South Africa’s antiretroviral rollout does not yet provide this information consistently and accurately, although data collection and processing appear to be improving. Occasionally the Department of Health releases a spreadsheet showing the numbers of people on treatment. The latest figures are for June 2011. According to the Department of Health, over 1.5 million people were on treatment in the South African public health system by the end of June. E: FS: GP: KZN: LP: MP: NW: NC: WC: Total:

151,878 79,204 375,798 481,809 109,121 121,516 130,901 17,407 101,812 1,569,446

There are problems with these data:

m&e and the NSP

• The methodology used to collect

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them is unpublished. Therefore it is difficult to have confidence that robust systems to collect this information are in place. Most facilities get little support on how to track numbers and there is no standardised auditing system. Do health workers consistently record patient visits, viral loads and deaths? Probably not.

• Some provinces report the number of people who started treatment and others report the number of people on treatment.

• Even if these data were accurate and consistent, they would help answer only one of the above questions. One of the best sources of information on South Africa’s rollout is the International epidemiologic Databases to Evaluate AIDS Southern Africa (IeDEA). This is a pooled database from multiple sites across southern Africa, including ten projects in South Africa. The group regularly publishes useful information about the rollout. It can reliably report number of patients, loss-to-follow-up and mortality. But although it covers a large number of patients, it is still only a fraction of the total population of patients on antiretroviral treatment in the country.

The Western Cape approach The Western Cape, assisted by UCT’s Centre for Infectious Disease Epidemiology (CIDER), had the best provincial data collection system. The system allowed the provincial health department to produce a regular detailed report that helped answer many of the above questions. Although the system began in paper format it is slowly being converted to a digital system that emulates its paper-based predecessor. However two factors have made the Western Cape system unwieldy in recent years. The province has been trying to integrate the HIV treatment system into its wider data systems—a complex task—but it has not invested in enough dedicated staff to maintain the system properly. If the number of people on ART were stable neither of these factors would be likely to present a problem. But coupled with the swift scale-up these factors have set back the province’s treatment data collection system.

In addition to the Western Cape, several donor-funded projects operating in the public health system have their own systems to monitor their subsets of the antiretroviral rollout. An audit showed there were at least 40 such systems, about 15 of which were properly functional. Most of these projects are funded by PEPFAR, which requires detailed treatment statistics so that it can report to the US government.

One consolidated system The National Department of Health recognises that there are too many systems and that what is needed is one properly working consolidated system. It is encouraging all the various projects to merge their data collection into one national system. For this it has largely adopted the Western Cape system. This national system recognises that there are three tiers of data collection that need to work together:

• Paper-based systems at small clinics. • Standalone electronic data capturing systems at medium-sized clinics.

• Networked Electronic Medical Record systems at large facilities. Clinton Health Foundation officials have been contracted to assist with the rollout of the system. The government’s move towards a unified, rationally designed treatment monitoring system looks promising after many years of rudderless monitoring and evaluation. There is progress in some provinces, but getting M&E right will require herculean efforts by government and cooperation from donor-funded projects. The response from donor-funded projects is mixed. Some deserve praise for the way they are trying to merge their systems into the national one. However, others could do a lot better.


Technological improvements that will help Several technological improvements and better management of technology will improve M&E systems. The issues discussed here are not exhaustive.

Networked computing is too expensive

Free cell phone access to download viral load, CD4 and other results

Many health workers have cell phones with internet access. It should not be too technically challenging to build a system that allows them to download their patients’ blood results from the NHLS—obviously, with suitable security. It should also not be difficult to make this downloading free for nurses, i.e. if the cell phone companies redirected bandwidth charges for certain sites to a health department instead of to the health worker’s account.

Integration of information

South Africa has some very useful health data systems. Home Affairs tracks deaths. The NHLS has a database

TAC members march of viral load and CD4 results. Many pharmacies have implemented sophisticated dispensing systems. It would during the International AIDS Society meeting be ideal if these systems synchronised relevant data in Cape Town to demand more funding with the antiretroviral Electronic Medical Record system. for HIV and TB So for example if a patient died and Home Affairs treatment. Photo by Liz processed a death certificate, the medical system would Highleyman, courtesy of Treatment Action be automatically updated; a loss-to-follow-up could be Campaign Archive. correctly recorded then as a death. Viral loads and CD4 counts could be automatically saved onto patient records. The patient record It system could automatically send is vital that the prescription requests (or vice National Department of versa) to pharmacy systems. Health continue its effort to This would be a complex undertaking but if our get the monitoring and evaluation treatment monitoring systems for the ART programme up and system could get to this running properly. To do this, donor-funded level of sophistication programmes and provincial governments it would greatly improve the quality of must cooperate and work together, information on the ART with the aim of creating one national rollout.

Protection of equipment

integrated system that records all useful implementation data and reports it regularly.

A key challenge is maintaining computers in peripheral clinics that lack IT departments. Thefts and breakdowns can take weeks or months to rectify. Nathan Geffen is treasurer of the Treatment Action Campaign. Special thanks to Andrew Boulle for assistance with this article.

m&e and the NSP

Moving from paper to digital format is an important step forward. Computerised algorithms are far more accurate and faster at calculating the number of patients lost to follow-up than humans sifting through mounds of paper. When clinics computerise their records they usually find that they have underestimated loss-to-follow-up. One of the barriers to moving to networked computers is the State Information Technology Agency (SITA), from which network access must be purchased. SITA charges in the region of R20,000 per month for a Diginet line. Few clinics can afford, or need, such a sophisticated solution. Moreover it typically takes months to install such lines. Yet a simple wireless internet connection can be set up within days costing approximately R500 per month. While it is understandable that a central state agency should be responsible for this kind of infrastructure in order to prevent abuse, SITA’s exorbitantly priced solution is impractical and wasteful.

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Local production:

Not a Silver bullet

By Catherine Tomlinson and Marcus Low

The South African government recently announced plans to manufacture active pharmaceutical ingredients (APIs) in partnership with the Swissbased chemicals and biotechnology company Lonza Ltd. APIs are the active ingredients that are used to produce medicines. Medicines also contain inactive ingredients called excipients, which usually function as carriers for APIs.

LOCAL PRODUCTION

Will local production of active pharmaceutical ingredients offer the health and economic benefits promised by government?

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TAC members demonstrate outside the Supreme Court of Appeal in Bloemfontein. Photo by Patrick Mdletshe.

South Africa has a relatively large and competitive generic pharmaceutical industry consisting of a number of private companies. These companies sell finished products which are manufactured from raw materials or semi-finished products. However, the vast majority of APIs for these locally-produced medicines are imported. The joint venture between government and Lonza Ltd will set up a local API manufacturer called Ketlaphela. Generic manufacturing companies will be able to purchase APIs from this firm. Initially, Ketlaphela will focus on developing

APIs for drugs to treat HIV, malaria and TB and later expand its production to include APIs for treating other diseases. Government has promoted Ketlaphela as a means to reduce the cost of medicines through local, cost-effective production of APIs. In addition to touting these savings which would help to address health needs, government has also highlighted the potential development and economic benefits of the venture - such as job creation and a reduction in South Africa’s trade deficit.

On May 15 2012 the Supreme Court of Appeal heard a patent dispute between Aventis Pharma SA and Cipla Life Sciences. The case, involving the cancer drug Docetaxel, was going to be decided on the technicalities of patent law. However, TAC approached the court and argued that the judge should also take into account public health considerations. If the judge agrees with TAC, it will set an important precedent that courts should consider public health implications when adjudicating patent disputes.


In the long run, Ketlaphela could provide the impetus for a competitive API manufacturing industry in South Africa. This could extend access to medicines by increasing competition and reducing the vulnerability of API supply. Competition has played a vital role in lowering the cost of medicines, as shown by the significant drop in the price of antiretroviral therapy that coincided with the entry of generic competition (see below). Also, a number of drugs that are off-patent, including some for MDR-TB, remain extremely pricey due to the inadequate supply of APIs. If South Africa is able to establish a home-grown industry for API manufacture, it could reduce this supply vulnerability for a number of medicines. While local API production offers great potential, establishing such an industry will not be easy. Both India and China, countries with low manufacturing costs and highly skilled workforces, have emerged as the major global suppliers of APIs. Ketlaphela will need to match the efficiency of these competitors in order to sell its products. Given the South African government’s poor track record in managing parastatals, there is understandable concern that Ketlaphela may not be competitive.

Fair and open competition It is vital that Ketlaphela competes fairly and transparently with other manufacturers. Every two years government conducts a large antiretroviral (ARV) tender to purchase ARVs for the public sector. Should Ketlaphela be unable to match the best prices available on the international market, government may be tempted to engineer its drug tenders so as to favour generic companies supplied by Ketlaphela. This could ultimately lead to higher prices and reduced access to medicines.

There are also concerns that Ketlaphela is unlikely to stimulate the kind of job growth that South Africa needs. Pharmaceutical and API manufacturing is not a labourintensive industry. It requires significant numbers of highly skilled workers such as pharmacists and chemists. South Africa already faces a critical shortage of these workers, with more than 60% of pharmacist posts in the public sector remaining vacant. It is therefore likely that following the construction phase, the venture will for the most part encourage job creation in a field already noted for its high demand and shortage of skills.

Reducing the trade deficit The Department of Trade and Industry has plugged Ketlaphela as a tool to reduce South Africa’s trade deficit. Business Day recently reported that pharmaceutical imports—costing R21.3bn in the first 11 months of last year—were the fifth largest contributor to the country’s deficit. Minister of Health, Aaron Motsoaledi said that South Africa’s pharmaceutical market was worth R25 billion, according to the newspaper. An analysis of the pharmaceutical industry in 2008 (published by Deloitte in 2010) found that pharmaceutical imports at R12.97 billion far outnumbered pharmaceutical exports at R1.38 billion. The top five countries from which South Africa imports medicines are, in descending order: Germany, the US, France, India and the UK. Tellingly, this list does not include China and India is ranked only fourth. While these figures deserve further analysis by a health economist, they strongly suggest that the importation of branded medicines under patent contributes far more to the trade deficit than the importation of APIs for the production of generics. Additionally, granting fewer patents could begin to reverse the deficit, as occurred in India. India removed product patents on pharmaceuticals in 1970 in an effort to boost local industry and improve access to drugs. This led to rapid growth in the pharmaceutical industry. As a result, by the 1990s India had progressed from net importer to net exporter of medicines.

For many drugs it is not the lack of APIs but rather the lack of licences for generic manufacture and sale that drives up medicine prices—although there are exceptions such as drugs for MDR-TB. Today the Department of Health is able to purchase low cost first- and second-line treatment through generic manufacturers that are mainly based in South Africa. A first-line ARV regimen for the treatment of HIV costs only R115 per person per month. In the early 2000s the cost of an inferior regimen was over R5,000 per month. Today’s low prices have been achieved through generic competition and increasingly open drug tenders that aim for a fairer balance between the interests of producers and the health needs of South Africa.

Patent barriers However, many newer, more effective ARVs are not available in the public sector due to their high cost. In fact, the public sector currently provides no third-line ARV treatment. Many third-line drugs remain prohibitively expensive due to the lack of competition in the market. Without legislative reform of South Africa’s Patent Act, it is likely that Ketlaphela’s costsaving potential will be undermined by strict patent barriers. If the joint venture is restricted to producing off-patent APIs or finished medicines, Ketlaphela may find itself roped into a part of the market that has already seen massive price reductions due to generic competition. Only through progressive reform of South Africa’s patent laws will Ketlaphela be empowered to make significant inroads into the high prices of many life-saving drugs that remain under patent. (See www.fixthepatentlaws.org for more on potential legal reform.) Catherine Tomlinson and Marcus Low are researchers with the Treatment Action Campaign.

LOCAL PRODUCTION

These promises have been uncritically repeated in the media. Yet they deserve closer inspection and discussion as government moves ahead with its investment in API manufacturing.

Sources: http://www.businessday.co.za/articles/ Content.aspx?id=164729; Deloitte, ‘Insights into the high level financial contribution of the Pharmaceutical Industry in South Africa’ (February 2010); Pharma Focus Asia, ‘Generic to innovation: Transition of Indian Pharmaceutical Companies’, http://www. pharmafocusasia.com/strategy/indian_pharma_ transition.htm

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Photo by Alon Skuy, courtesy of Treatment Action Campaign Archive.

PEPFAR problems: Patients to pay the price

By Donela Besada

Nine years of PEPFAR

FUNDING ISSUES

The United States President’s Emergency Plan for AIDS Relief (PEPFAR) was initially launched in 2003 as a fiveyear commitment of $15 billion for 2003–2008. At that time the programme pledged to provide antiretroviral treatment (ART) for two million HIV-positive people, to prevent seven million new infections, and to support care for ten million people (the ‘2–7–10 goals’) by 2010. PEPFAR soon grew to be the largest bilateral health contributor worldwide. The programme’s major achievements include:

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• nearly four million people placed on ART; • 200,000 infant HIV infections prevented thanks to greater investment in prevention of mother-to-child transmission (PMTCT) programmes; • 13 million people supported on care, including four million orphans and vulnerable children;

• cost of treatment per patient decreased from $1,100 to $335 through the use of generic drugs and cheaper shipping; • task-shifting to nurses and community health workers; and • HIV/AIDS services linked to other programmes such as those for maternal and child health. The savings shown above allowed PEPFAR to more than double the number of people it directly supported on treatment during the first five years of the programme. In many African countries PEPFAR has been fundamental to increasing treatment coverage. Botswana, for example, has seen its coverage rise from nearly zero to almost 80%. Other nations such as Zambia and Ethiopia have increased their coverage to at least 50%.


Budget cuts bring down targets 2011 brought exciting breakthroughs in HIV research showing that it is possible to curb the epidemic. The HPTN052 trial demonstrated that putting people on ART earlier in the progression of the disease could reduce the risk of HIV transmission by 96%. Drawing on this outcome, US Secretary of State Hillary Clinton announced a major shift in the US global AIDS response. She noted, “Creating an AIDS-free generation has never been a policy priority for the United States Government until today, because this goal would have been unimaginable just a few years ago.” Clinton highlighted certain interventions as key to reaching this goal, including the scale-up of ARV treatment to prevent new infections. Further commitments followed, this time from President Obama. He announced PEPFAR’s pledge to reach an additional two million people with ART and 1.5 million HIVpositive pregnant women with PMTCT by the end of 2013. However, it is unclear how the US can achieve these goals in the face of proposed budget cuts to PEPFAR and other bilateral AIDS programmes. The newly-released 2013 US national budget proposes a dramatic cut of $542.9 million for worldwide PEPFAR programmes. This would put PEPFAR in the position of having to treat 40% more people in 2013 than in 2012, but with 13% less funding. The US Congress could impose even more severe cuts. According to the State Department budget proposal for the

As the United States cuts back on aid, patients will pay the price.

2013 fiscal year—to which most PEPFAR funding in the national budget request is directed—many PEPFAR-funded countries face hefty cuts. These could range from 10% in South Africa to as high as 50% and 80% in Kenya and Ethiopia respectively. Furthermore, total US funding for HIV/AIDS could be slashed by almost 11%, while TB funding is expected to fall by 7%. These potential reductions could spell disaster for country-level programmes. What is more, PEPFAR cutbacks would do little to solve the US budget crisis. Global health represents just one quarter of one percent of the federal budget.

A shift in focus The reduced funding coincides with a shift in focus at PEPFAR, away from direct service provision and towards technical assistance. A recent study of PEPFAR operational plans highlights a significant fall in HIV treatment funding since 2008. This can be seen both as a proportion of total budgets and in absolute amounts. According to PEPFAR Operational Plans up to 2010, the percentage of total funding that goes toward the supply of ARVs, both adult and paediatric, has decreased from 35% to 28%. Declines varied by country. Some saw their grants flatlined, while others – including Namibia, Mozambique, Kenya, and Tanzania – had lost between 10% and 30% of their total treatment budgets by 2010.

A dangerous transition in SA • place 680,000 pregnant women on PMTCT services; and • avert 40,000 infant infections.

• support 920,000 people on treatment;

Furthermore, in 2009 PEPFAR contributed $120 million to the bulk purchase of ARVs for South Africa. This one-time funding would help meet the increased demand generated by the HIV Counselling and Testing (HCT) campaign which kicked off in April 2010. The investment supported South Africa’s shift towards greater use of generic drugs, and helped to double the country’s ARV supply. It also facilitated the later adoption of WHO treatment guidelines requiring earlier ART initiation.

• give 2.2 million people care and support for HIV and TB;

However, long-term budget requirements for South Africa’s AIDS response are likely to dwarf

FUNDING ISSUES

South Africa is experiencing first-hand the effects of PEPFAR’s shift from direct supporter of ART to provider of technical assistance. PEPFARsupported clinics have begun closing down and redirecting patients to often-overburdened public health facilities. The shift poses an enormous challenge for South Africa as the largest recipient of PEPFAR grants. Between 2004 and 2011 South Africa received $3.1 billion from PEPFAR that allowed a significant scale-up of HIV treatment and care. By 2010 PEPFAR is estimated to have helped South Africa

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these sums, reaching a staggering R35-R45 billion (approximately $4.5-$5.9 billion) per year by 2020. Collective spending on the disease by public and development partners was estimated at R17 billion for 2010, up from R9 billion in 2008. Yet PEPFAR’s contributions to South Africa—$548 million in 2011— are expected to halve by 2016/2017. It is clear that government faces a considerable challenge to bridge the funding gap.

Building a framework PEPFAR’s renewed mandate in 2008 directed the US government to develop framework agreements with partner countries to increase country ownership of the HIV/AIDS response. These partnerships are intended to build the capacity of national governments to manage health programmes. Ultimately, the framework agreements aim to migrate PEPFAR-funded programmes to the control of government-coordinated systems. PEPFAR’s five-year Partnership Framework between the US and South African governments, signed in December 2010, is one such agreement. The Framework highlights the South African government’s future leadership role in decision-making and planning for PEPFAR activities in the country. It looks at the alignment of PEPFAR operations to national plans, and anticipates the shift of PEPFAR-supported staff and programmes to the South African government. Furthermore, the Framework acknowledges the likely decline in funding for South Africa and the need for larger domestic contributions.

Shifting PEPFARfunded programmes to the control of the South African government is a huge endeavour, involving all nine provinces

FUNDING ISSUES

A detailed plan of how this transition will work is only expected in June 2012 with the late completion of the PEPFAR Partnership Framework

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Implementation plan. This plan will make it possible to assess the feasibility of the transition. It will also be useful for monitoring how the transition is implemented, to avoid any interruptions to essential services or to the employment of health staff. Shifting PEPFAR-funded programmes to the control of the South African government is a huge endeavour, involving all nine provinces. The transition will affect over 30,000 health professionals who are currently PEPFAR-funded, over 1.79 million people now receiving treatment, and close to 400,000 orphans and vulnerable children. Despite assurances from the US and South African governments that efforts will be made to avoid disruptions to HIV services during the transition, uncertainties exist. The scale of HIV services in South Africa and the complexity of the transition process are such that Médecins Sans Frontières (MSF) and other organisations—including the Treatment Action Campaign (TAC) and SECTION27—remain concerned. These organisations plan to monitor how the implementation affects people on the ground. As PEPFAR begins a new phase in South Africa, we need the US government to provide a clear and comprehensive view of the funding flow. To date there has been a lack of transparency in the way that PEPFAR’s investment in South Africa is spent. It is now vital to identify clearly which NGOs receive PEPFAR funding and to pinpoint the operational costs of PEPFAR programmes. The transition process will involve costing the absorption of thousands of PEPFAR-funded staff into the public sector. Many of these workers are paid much higher wages than those offered in the public sector. As a result salary structures may need adjustment in order to retain health workers. Ultimately, PEPFAR must be accountable for ensuring transparency in how it spends its country-specific financial commitments.

Sources: UNAIDS., “World AIDS Day Report.” (2011), http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_ WorldAIDSday_report_2011_en.pdf; Speech by Michel Sidibé, Executive Director of UNAIDS, UN General Assembly High Level Meeting on AIDS, New York (8 June 2011); PEPFAR, “Using Science to Save Lives: Latest PEPFAR Results”, PEPFAR Press Room Electronic Press Kit (November 2011), 1-2, http://www. pepfar.gov/documents/organization/178217.pdf; World Health Organization, “Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector”, Progress Report (2010), http://www.who.int/hiv/pub/2010progressreport/en/; US Department of State, Remarks on “Creating an AIDS’-Free Generation (November 2011), http://www.state.gov/secretary/rm/2011/11/176810.htm; U.S. Department of State, “State and USAID-FY 2013 Budget.” (February 2012), http:// www.state.gov/r/pa/prs/ps/2012/02/183808.htm; Henry J. Kaiser Family Foundation, “U.S. Funding for the Global Health Initiative (GHI): The President’s FY 2013 Budget Request” (February 2012), http://www.kff.org/globalhealth/upload/8160-02.pdf; Kavanagh, M. Thorp, M., “PEPFAR’s declining investment in HIV/AIDS Treatment.” Health Affairs Blog, http://healthaffairs.org/blog/2011/11/29/pepfars-declining-investment-in-hivaids-treatment/; PEPFAR Operational Plans, http:// www.pepfar.gov/about/c19388.htm; PEPFAR, “Partnership to fight HIV/AIDS in South Africa.”, http://www.pepfar.gov/countries/southafrica/index.htm; PEPFAR, “Partnership Framework in Support of South Africa’s National HIV & AIDS and TB Response 2012/13 - 2016/17 between the Government of the Republic of South Africa and the Government of the United States of America” (December 2010), http://www.pepfar.gov/frameworks/southafrica/161215.htm; Tanser F., “Effect of ART Coverage on Rate of New HIV Infections in a Hyper-endemic, Rural Population: South Africa.”, Conference on Retroviruses and Opportunistic Infections 2012, Seattle (8 March 2012).


Thirty years after the discovery of HIV, it now seems possible that we can break the back of the epidemic. The number of new cases is declining in 22 sub-Saharan countries, including Ethiopia, Nigeria and Zimbabwe, as more people are put on antiretrovirals. New science has shown that treatment not only saves lives but reduces new infections. Yet just as we are making headway, the world is seeing a decline in HIV funding that could devastate this progress. Our hope of controlling HIV can only become a reality with renewed political commitment and sufficient funding. And we will need these soon, if we are to save lives and prevent costs from spiralling out of control. Photo courtesy of Treatment Action Campaign Archive.

Will the opportunity be squandered?

Treatment as prevention In line with the new scientific evidence of ‘treatment as prevention’, MSF has opened a pilot project in KwaZulu-Natal. The project aims to reduce infections in the community through testing and accelerated treatment, along with conventional prevention. And a new study released in March 2012 by the AfricaCentre’s project in Umkhanyakude district in northern KwaZulu-Natal shows that in areas where ART coverage reached 30-40% of need, HIV incidence was significantly lower than in areas with ART coverage below 10%. People in high ART coverage areas were nearly 40% less likely to become infected with HIV than those in low-coverage areas. Furthermore, researchers found that for every 1% increase in ART coverage there was an associated 1.7% decrease in HIV incidence.

For the first time ever there is hope that a combination of prevention methods—including increased treatment coverage—can bring the HIV and TB epidemics under control. The major barrier to this is the retreat of donors from their promises to help pay for 15 million people on ART by 2015. The donor default is leaving poor countries with insufficient resources to expand their treatment efforts. Inevitably, this will cause increased suffering and lead to the deaths of many people with HIV who cannot access treatment. The world could also miss an incredible opportunity to decrease HIV transmission, which would otherwise reduce our future need for ART. The principle of national ownership of the HIV and TB response is a worthy one. But coupled with diminished donor support it risks punishing the success of the last decade. It could also waste our chance to treat as many people as possible as quickly as possible. In the coming years, the pace of the global response and of South Africa’s own HIV programmes will be critical to breaking the back of these epidemics. Donela Besada is the Advocacy Manager at Médecins Sans Frontières South Africa and Lesotho.

FUNDING ISSUES

PEPFAR’s budget cuts and policy changes coincide with a period of immense opportunity. South Africa and neighbouring countries are making headway against the epidemic. They are helped by greater political and financial ownership of the HIV response, and by policies and programmes that support accelerated treatment.

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Global fund at a crossroads:

Keep fighting for the fund By Mara Kardas-Nelson

Last year, on November 22, just days before the commemoration of World AIDS Day, the global HIV community was shocked by an announcement from the Board of Directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). With far less funding available than originally forecast for 2011-2013, the board decided that there was simply not enough to support funding Round 11. While the Global Fund did eventually announce in May that $1.6 billion would be made immediately available, questions remain as to how this money will be spent and what the organisation’s funding model will look like in future.

FUNDING ISSUES

The cancellation of Round 11 of the Global Fund: Why it happened; what impact it will have; and what we need to do about it.

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Given that the Global Fund is the largest multilateral funder of HIV treatment, the cancellation of Round 11 threatened programmes that support millions of people who are at risk of contracting, or infected with, HIV, TB or malaria. Now that some money has been made available for immediate release, many programmes in danger of losing their lifeline will hopefully be able to stay

afloat. New money may also be made available to scale up programmes so that more people can be reached. But the Global Fund’s November announcement must function as a wake-up call for activists around the world to maintain the pressure for continued financial support of the Fund. Activists must also watch closely as the Global Fund undergoes restructuring, to ensure that grants continue to be disseminated through a demand-driven model. This would allow countries to apply for adequate funding to comprehensively scale up their responses. The new $1.6 billion will be disbursed from 2012-2014; if there are delays in these payments, especially for programmes now facing cuts, life-saving services could be threatened again. Activists must continue to report on the needs that countries have for Global Fund and other monies. It is also vital to ensure such money is distributed in a timely way and used to achieve the maximum possible impact.

An HIV-positive person stands near an audience of children at the HIV/ AIDS candle memorial in Kibera, Africa’s largest slum in Nairobi, Kenya. The ceremony was part of the International AIDS Candlelight Memorial Campaign. Photo by Felix Masi, courtesy of Photoshare.

FUNDING ISSUES

In over a decade the Global Fund has financed antiretroviral treatment (ART) for 3.3 million people and saved an estimated 7.7 million lives. The organisation is expected to play a central role in placing around half of the nearly nine million people in need of ART on treatment. This could make it possible to reach the United Nations member states’ target of 15 million people on ART by 2015. UN Member states have also committed to reducing the number of new HIV infections by 50% by 2015.

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States have a duty to provide quality healthcare services to their citizens. Providing health care services is not a favour, but an obligation. Over the last decade, the humanitarian organisation Médecins Sans Frontières (MSF) has witnessed the impact of the Global Fund and other bilateral and multilateral funding groups on HIV, TB and malaria. MSF has worked in many high-burden countries for over a decade, often as the first provider of HIV treatment. In that time MSF has seen the Global Fund and other grant bodies enable countries to increase their number of new HIV treatment slots. ART has not only transformed HIV from a death sentence into a manageable disease for millions of people, it has also shown itself to be a powerful tool for preventing new infections. A key study released in 2011 demonstrated that early HIV treatment reduces the risk of sexual transmission by 96%. In one area with high HIV prevalence a 1% increase in ART coverage was linked to a 1.7% decrease in HIV incidence.

FUNDING ISSUES

The Global Fund’s May announcement is just one step among many that are needed to adequately address the HIV, TB and malaria epidemics. The scientific community supports the premise that scaling up HIV treatment and proven prevention can break the back of the epidemic. But this will only become reality if we rapidly expand our response to HIV. We must ensure that more people receive ART, and receive it early in the progression of the disease. Time is of the essence if we are to save lives and prevent costs from ballooning out of control. As Michael Sidibé, Executive Director of UNAIDS has noted, “…either we pay now, or we pay forever”.

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And yet donors are pulling back. While the Global Fund was originally envisioned as a $10 billion-a-year fund, over the past several years it has increasingly faced financial shortfalls. Despite a 2007 commitment by the Fund’s board to making $6 to $8 billion available annually—up from the $2 to $3 billion available at the time—at the Global Fund’s October 2010 replenishment conference, donors pledged only $11.7 billion for 20112013. The Fund had asked for a minimum of $13 billion, the amount considered essential to maintain existing programmes and to provide limited funds for their expansion. Reneging on these already weak commitments led to the cancellation of Round 11. While the Global Fund has a new lifeline, donors must step up to further strengthen

their commitments to the Fund and to the expansion of its activities. The cancellation of Round 11 mirrored a global trend of reduced HIV funding. Worldwide in 2010 funds stood 10% lower than in 2009. Yet as we see donors retreat, politicians are ramping up their rhetoric: just weeks before the Global Fund announced the cancellation of Round 11, US Secretary of State Hillary Clinton said that the world could see an “AIDS-free generation” if it expanded its HIV response. Dr. Anthony Fauci, Director of the US National Institute of Allergy and Infectious Diseases, also speaking on the eve of the Board’s announcement, noted, “The fact that treatment of HIV-infected adults is also prevention gives us the wherewithal, even in the absence of an effective vaccine, to begin to control and ultimately end the AIDS pandemic.” We have also seen measurable progress in the HIV/AIDS response, as 2011 brought the first drop in fatalities. But our progress feels seriously threatened, and those words and commitments feel hollow, as donors continue to scale-back. The crisis could not have come at a worse time. When Round 11 was due for launch, countries began to see other donors reduce their support. They therefore looked to the Global Fund to fill the gap. For example, the World Bank is ending its funding for antiretrovirals (ARVs) in countries such as the Democratic Republic of Congo (DRC) and Mozambique. The President’s Emergency Plan for AIDS Relief (PEPFAR) also faces potential budget cuts, with Kenya alone confronting a possible 44% slash in funding. Without external support, how will the country achieve goals outlined in the PEPFAR Strategic Framework? One such goal is to place one million people on ARVs by 2015, up from 500,000 today. How will it be possible to do this, or for Kenya to implement lifelong treatment for all HIV-positive pregnant women, another of the Framework goals? In Zimbabwe, the Expanded Support Programme—a funding mechanism supported by bilateral donors and the European Commission—has also stopped its financial support for ARVs. The government has had to take on 80,000 people who were receiving treatment through the ESP. Many African countries are doing their bit to increase their own response to HIV. Between 2009 and 2010 alone, the number of people in sub-Saharan Africa receiving antiretroviral therapy rose by 30%. Since 1997 the rate of new infections has dropped by 26% in the region. This is partly due to improved treatment access. Given the


But countries such as Malawi and Zimbabwe, committed to implementing the latest World Health Organization (WHO) guidelines on HIV treatment simply do not have the funds available to put these policies into practice. The WHO guidelines call for the use of tenofovir in all first-line regimens and for ART initiation at CD4 counts of 350. The implementation of new policies is not the only progress on the line. In the DRC an estimated one million people are HIV-positive and 300,000 need ART. 15,000 patients are currently waitlisted for HIV treatment because funding shortfalls have led to a cap on the number of new treatment slots. In 2011 only 2,000 people were initiated onto treatment. The DRC is not alone in this predicament. In Guinea, there will be only enough money to place 110 people on ART each month. This amounts to half of the current rate. Uganda had hoped to reach its target of 100,000 people on treatment this year, but the funding squeeze means that the target must be reduced to 50,000-65,000. While funding mechanisms like the Global Fund and PEPFAR must support the implementation of these policies, African countries also need to spend more of their own money on health. Despite African nations having promised to spend at least 15% of their national budgets on health, few have made this a reality. While some countries have tried to fill the gap with domestic financing, they still need help. Zimbabwe, for example, plans to increase the proportion of its AIDS levy—a 3% tax on income—that it spends on ARVS. Currently the levy supports 26% of patients who receive treatment. While the Zimbabwean government hopes that the levy can double its support for ARVs by the end of the year, without further funding, large gaps will remain. In fact, by 2014 the country’s treatment gap could balloon to 120,000 people.

Living up to commitments Now that new money will be made available, we must ensure that it goes to support the programmes most in need. The funds must not only serve as a stop-gap, but also to scale up programmes so that the scientific promise and the rhetoric of the past year can become a reality. While $1.6 billion is a step in the right direction, it is still not enough: activists demanded that $2 billion be made available for the support and scaling up of programmes. And this is based on a low estimate, given that donors only pledged $11.7 billion at the last

Many African countries are heavily dependent on donor funds to supply antiretroviral treatment. The global funding crisis could spell disaster for these countries and will hinder any progress made in stemming the tide of this epidemic.

People eligible for ART and receiving it (%) Kenya

Uganda DRC

44%

12 %

52%

Malawi

67%

Zambia

35%

68% Zimbabwe

63 %

Mozambique

78 %

49 % South Africa

Swaziland

66 % Lesotho

replenishment conference. Now is the time to boost funding commitments and available funds, not to skimp on essential services. High-burden countries most affected by Global Fund cuts did not speak out about what the funding crunch could mean for their HIV, TB and malaria programmes. Now that money will be made available, it is important that Global Fund recipient countries make their voices heard as discussions take place on how to distribute Global Fund monies. Money must be made immediately available to programmes facing cuts, and the Global Fund must encourage countries to submit new, ambitious proposals to enable the release of fresh funds.

FUNDING ISSUES

large increase in the number of South Africans now on treatment, UNAIDS expects to see “substantially fewer new infections” in future.

Art in Africa

27


South Africa has been far too blasé about the crisis affecting the Global Fund and about the wider contraction in donor funding. According to news reports, South Africa’s Health Minister, Dr. Aaron Motsoaledi, said he was “not alarmed” by donors diluting their support because the country has continually expanded its domestic response to the epidemic. But while South Africa has made an impressive job of raising domestic finance to manage HIV/AIDS, poorer countries in the region are unable to match this effort. South Africa only relies on foreign donors to support 10% of its ARV programmes. For other countries in the region this figure is closer to 90%. Although South Africa may be more self-sufficient now, historically the country has relied in part on the Global Fund and other sources such as PEPFAR to develop its response to HIV. As a leader in the HIV response, and a political leader both regionally and internationally, the country must lead the call for demand-driven distribution of Global Fund money. It

A united regional strategy In March 2012 SECTION27 hosted a regional consultation on the right to health, with a specific focus on its implications for health care financing. The meeting was attended by members of civil society from all over Southern Africa as well as the United Nations Special Rapporteur on the Right to Health, Senior Advocate Anand Grover. The purpose of the meeting was to ensure that financing for health is understood as a key enabler in the progressive realisation of the right to health. Understanding this link is essential because of the continued retreat of foreign sources of funding; instability of vital funding mechanisms (such as the Global Fund) and the failure of governments in the region to prioritise the funding of their health systems, all threaten the lives of millions of people. The meeting provided an opportunity for civil society to identify prospects for a united regional advocacy stratergy that will help ensure that health care financing can assist in transforming the rhetoric of the right to health into reality. Three key principles were identified which are necessary to achieve this:

FUNDING ISSUES

1. The right to health mandates that states take primary responsibility in ensuring equitable health care.

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2. The state is under a responsibility to identify and eliminate barriers including corruption and lack of accountability, which hinder the realisation of the right to health. 3. Under international law, the responsibility to protect implies that the right to health must be coupled with the obligation of other states to supplement existing resources Read more about the meeting at www.SECTION27.org.za.

must also push the international community to expand its financial commitment to dealing with HIV, TB and malaria. At the same time, Motsoaledi and Zuma need to continue their support for domestic leadership in the fight against HIV. For decades we have seen HIV devastate countries in southern Africa. Yet we have the tools to reverse the epidemic. What we need now are the funds that will turn our vision of an HIV-free generation into a reality. We cannot afford to wait. Mara Kardas-Nelson is the Access and Innovation Officer for Médecins Sans Frontières South Africa Sources: Global Fund Observer, “Board Cancels Round 11 and Introduces Tough New Rules for Grant Renewals.” Issue 167 (23 November 2011), http://www.aidspan.org/index. php?issue=167&article=1; Mazzotta, Meredith. “Global Fund explains ‘Transitional Funding Mechanism’ — No funding for HIV treatment scale up.”, Science Speaks (14 December 2011), http://sciencespeaksblog.org/2011/12/14/global-fund-explains%E2%80%9Ctransitional-funding-mechanism-no-funding-for-hivtreatment-scale-up/; The Global Fund to Fight AIDS, TB and Malaria, “About Us: Fighting AIDS, Tuberculosis and Malaria.” http://www. theglobalfund.org/en/about/diseases/; The Global Fund to Fight AIDS, TB and Malaria, “Our Strategy: The Global Fund Strategy 20122016: Investing for Impact.” http://www.theglobalfund.org/en/about/ strategy/; Cohen, MS et al. “Prevention of HIV-1 Infection with Early Antiretroviral Therapy.” New England Journal of Medicine, (2011), 365:493-505, http://www.nejm.org/doi/full/10.1056/NEJMoa1105243; Tanser F. “Effect of ART Coverage on Rate of New HIV Infections in a Hyper-endemic, Rural Population: South Africa.”, Conference on Retroviruses and Opportunistic Infections 2012, Seattle (8 March 2012); Speech by Michel Sidibé, Executive Director of UNAIDS. UN General Assembly High Level Meeting on AIDS, New York (8 June 2011); The Global Fund to Fight AIDS, TB and Malaria, “Pledges and contributions.”, http://www.theglobalfund.org/en/; The Global Fund to Fight AIDS, TB and Malaria, “Replenishment meetings: Third Replenishment 2011-2013.”, http://www.theglobalfund.org/en/donors/ replenishments/; Kates, J. et al. “Financing the Response to AIDS in Low- and Middle- Income Countries: International Assistance from Donor Governments in 2010.” UNAIDS and the Kaiser Family Foundation (August 2011), http://www.unaids.org/en/media/unaids/ contentassets/documents/document/2011/08/20110816_Report_ Financing_the_Response_to_AIDS.pdf; Clinton, Hilary. “Remarks on ‘Creating an AIDS-Free Generation.’” National Institutes of Health’s Masur Auditorium, Bethesda (8 November 2011), http:// www.state.gov/secretary/rm/2011/11/176810.htm; Fauci, Anthony S. “AIDS: Let Science Inform Policy.” Science, Volume 333 (1 July 2011), http://www.niaid.nih.gov/about/directors/articles/Documents/ FauciJuly1.pdf; “Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access.” World Health Organization, UNAIDS, UNICEF (November 2011), http:// www.unaids.org/en/media/unaids/contentassets/documents/ unaidspublication/2011/20111130_UA_Report_en.pdf; World Health Organization, UNAIDS, UNICEF, “Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access.” (November 2011), http://www.unaids.org/en/media/unaids/ contentassets/documents/unaidspublication/2011/20111130_UA_ Report_en.pdf; Médecins sans Frontières, “Losing Ground: How funding shortfalls and the cancellation of the Global Fund’s Round 11 are jeopardising the fight against HIV & TB.” (27 March 2012), http:// www.msfaccess.org/sites/default/files/MSF_assets/HIV_AIDS/Docs/ AIDS_briefing_LosingGround_ENG_2012; Bodibe, Khopotso. “AIDS funding cuts had been coming ‘long ago’ – Motsoaledi.” Health-E News Service, (9 December 2011), http://www.health-e.org.za/news/ easy_print.php?uid=20033374;


MONEY MATTERS

How the Global Fund’s top donors spend their top $ This is what the top five donors to the Global Fund pledged versus what they actually paid over the last ten years. Below, is what they spent in a single year on military expenditure.

What SA needs: a drop in the ocean

USA 9.5 France 3.8

5.1

2.4

$698 billion

UK 2.2 1.4

Billions Pledged to the Global Fund

Military spend in 2010:

France

59.3 billion

Japan 2.1 1.3

$5.9 billion

Germany 2 1.3

Billions Paid to the Global Fund

USA

UK

698 billion

59.6 billion

Japan

Germany

54.5 billion

45.2 billion

Long-term budget requirements for the AIDS response in South Africa are estimated at R35 – R45 billion (approximately $4.5 – 5.9 billion) per annum by 2020. In 2010, the US spent $698 billion on defence. It is the world’s largest military spender. All of the world’s countries combined couldn’t find $ 20 billion to fully fund the Global Fund for HIV, TB and Malaria for five years.

Source: The Global Fund 2010 Annual Report, SIPRI (Stockholm International Peace Research Institute) Yearbook 2011

Investment in HIV

paying off

2001

2010

In South Africa AIDS-related mortality has decreased by 21% between 2001 and 2010.

In South Africa, the rate of new HIV infections decreased by 22% between 2001 and 2009.

2001

2009

500,000 Stagnating levels of investment in HIV services would result in a stabilisation of new infections at around 500,000 per year. However, if South Africa continued to increase its AIDS investments with domestic and international support, the annual number of new HIV infections could be reduced to less than 250,000.

250,000

57%

95%

South Africa now provides an estimated 95% of eligible women with ARVs to prevent new HIV infections among children, up from 57 % coverage in 2007.

R11 billion

The South African government has increased spending on HIV/AIDS from approximately R2,5 billion in 2005/6 to R11 billion in 2010/2011 – an increase of more than 400%.

Source: UNAIDS. “World AIDS Day Report.” 2011. Available http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_ WorldAIDSday_report_2011_en.pdf] PEPFAR, MSF

Things to watch INFOGRAPHIC

R2,5 billion

29


2. the Legislative Stage,

timeline 3 year cycle

to

r

tation s

t ag e

Budgets become Debating the budgets: Between the time when law: budgets are tabled and 1 April – the beginning of the financial year – when they become law and Budgets are are implemented, cabinet and provincial now finalised legislatures have time to review and debate and signed into their contents. The law does allow for law. changes to budgets at this stage – although this seldom happens.

st ag e

be

lem en

Budget negotiations: Departments, both national and provincial, negotiate with the relevant treasury for a share September of the available revenue based on what – December they have outlined in their draft budgets. The Minister of Finance and Finance MECs then draw up a combined draft budget that is submitted to Cabinet and provincial executive councils for approval. Tabling of the budgets: The budgets are presented to Parliament in late February and to provincial cabinets two weeks later. Departmental allocations are outlined in these budgets and are called ‘Votes’.

iv e

Oc

During this stage these bodies are responsible for monitoring expenditure and taking action to solve any problems that arise.

– rch Ma ugust A

– y ar ch nu ar Ja M

responsible for service delivery receive their budget funding. They use this money to pay staff, develop infrastructure, and buy equipment and supplies that are necessary to provide services.

April

1A 31 pril – Ma rch

Adjusting the budget: In October of the year of implementation Treasury tables an Adjustments Budget. This budget gives Treasury the opportunity to assign extra funds for priority 1 April-31 March of interventions that are working well or to the following calendar address unforeseen expenses within year: Departments and departments. other government agencies

3. I mp

y

Budget

We can influence this phase by pushing the Treasury, Department of Finance and departments delivering services to draw up budgets that reflect South Africa’s most pressing needs. We can do this directly by engaging with key officials during meetings or indirectly by using the media and other tools for advocacy.

Draft budgets: Each national and provincial department develops a draft budget.

uar

Januar y

The drafting stage begins one year before a budget is implemented.

Setting the overall budget: The Finance Department estimates how much revenue will be available. It makes recommendations on how to divide this money between the different levels of government and between departments.

Feb r

4. Re vi e

4. the Review Stage.

Auditing and review of expenditure: During the first six months of the financial year that follow a budget’s implementation, the Auditor General audits spending and departments review their performance. These reviews and audits are compiled into reports and published. The reports influence future planning and budgeting and help to identify any issues in need of urgent attention. Parliamentary oversight groups also use these reports to hold departments and officials to account for how they have used public funds.

Things to watch

age

1. the Drafting Stage, 3. the Implementation Stage and

This is arguably the most important stage for us. In this phase we should monitor spending by analysing expenditure reports or monitoring outlays at the point of service delivery. To do this we can use social audits and citizen report cards. If money is not spent as it should be we must campaign for immediate action to correct the problem.

aftin g st

The budget process has 4 important stages:

w

ge ta

1. Dr

S A e pte pril mb – er

s

We can use the information generated during this stage or analyses we have carried out in earlier stages to lobby oversight committees and departments to correct any problems that have become evident.

L 2.

at sl i eg

At this stage we can analyse the tabled budgets and comment on them. We can also campaign for Parliament and/or provincial legislatures to make changes if any budget does not give enough priority to the most critical issues.

NSP Review Issue 2  

Engaging with South Africa's National Strategic Plan for HIV, STIs and TB

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