DEPARTMENT OF HEALTH Republic of South Africa

1. Presentation to SANAC Technical Task Team: Treatment, Care & Support Health Sector Impacts of HIV/AIDS: Key Issues for PlanningMartin HensherDirectorate: Health Financing & Economics DEPARTMENT OF HEALTH Republic of South Africa

2. Presentation Objectives • To summarise key results of the recent Abt Associates Health Sector Impact Study • To discuss strengths and limitations of the study • To identify key resource issues of relevance to the workshop discussion DEPARTMENT OF HEALTH Republic of South Africa

3. Impact Study - Background • Abt Associates commissioned by DoH with World Bank funding • Project overseen by DoH Steering Committee • Report “The Impact of the HIV Epidemic on the Health Sector in South Africa” delivered in November 2000 DEPARTMENT OF HEALTH Republic of South Africa

4. Status of Report • Presented at various DoH fora • Considerable internal discussion • Not yet a public document • Presentation contents should not be regarded as reflecting official DoH policy DEPARTMENT OF HEALTH Republic of South Africa

5. Study Methods - Overview • Synthesises multiple data sources to develop several models • Core provided by Doyle model of epidemic • No primary data collection, all estimates generated from existing sources DEPARTMENT OF HEALTH Republic of South Africa

6. Main Limitations • Heavy reliance on a few data points, especially for costs of care – some of which are open to question • Heavy use of (strong) assumptions • Projection forwards of “current practice” is not sustainable or realistic – but gives an outer limit to cost projections DEPARTMENT OF HEALTH Republic of South Africa

7. Main Strengths • Successfully assembled more relevant data in one place in a workable form than anyone else to date • Based on a generally respected epidemiological model • The only show in town until we have much stronger primary research DEPARTMENT OF HEALTH Republic of South Africa

8. Objectives • Project the likely course of the epidemic, and its impact on the South African population, divided into populations depending on public and private health care services. • Estimate the likely increase in health service utilisation, and the costs associated with this. • Estimate total expenditure requirements until 2010 • Estimate the impact that the epidemic will have on employees in the public health sector.

9. Epidemic Projection Assumptions • Most up to date Doyle simulation model • Model has been extensively used for other impact assessments in South Africa • Base populations for public and private sectors taken from 1995 October Household Survey and projected until 2010 • Assumes that there will be little cross-over between public and private sector membership and mid case scenario • The Doyle model produces conservative estimates of the course of the epidemic

10. HIV PREVALENCE: ADULTS 20-64

11. ADULT HIV PREVALENCE BY MEDICAL AID STATUS(Mid Case)

12. AIDS CASES 1995-2010(Best and Worst Scenarios)

13. AIDS AND NON-AIDS DEATHS IN ADULTS

14. CUMULATIVE AIDS DEATHS IN ADULTS

15. Public Sector Utilisation data • Chris Hani Baragwanath Hospital and three mine hospitals (average taken) • Extracted by approximate WHO clinical stage of disease • Removed chronic TB care, and all occupationally compensatable TB care • Utilisation measured in terms of acute inpatient days, ambulatory visits, and full courses of TB therapy • Calculated separately for children and adults

16. Private Sector Utilisation Data • No data on HIV-related utilisation in the private sector • Used Johannesburg Hospital data (1989-1996) as best available proxy • Same units of utilisation used as for public sector data

17. Expected number of HIV-related admissions by year and age category

18. HIV related acute bed-days, ambulatory attendances and days of DOTS required in the public sector by year.

19. Public Sector HIV Expenditure

20. Total Public Expenditure

21. Total Private Expenditure

22. Impact of substitutes for in and outpatient hospital care on HIV-related expenditure requirements.

23. Price Reductions for HAART * Base case is without HAART

24. Costs of Generic HAART – Current Offer

25. Predicted annual costs of MTCT prevention, INH and cotrimoxazole prophylaxis.

26. Conclusions (1) • Largest impact will be on acute public hospital inpatient facilities under current mode of care • Projected impacts on the private sector are significant, but no reason to predict the demise of the industry. If anything they support the Government view that this sector can and should bear its share of the weight of the epidemic. • Tuberculosis is the largest cause of admission, and uses a disproportionate number of acute bed days • Rationalising and improving the effectiveness of TB care will be critical to reducing the impact of HIV

27. Conclusions (2) • Regarding antiretrovirals: • Vertical transmission prevention strategies warrant introduction because they are cost effective, not because they would have massive impact reduction potential • HAART may be cost-effective in certain contexts, but affordability problems are likely to prevent it being introduced to the public sector. Affordability would not seem to be a significant problem in the private sector assuming they have access to discounts.

28. Conclusions (3) • Equity implications • The already strained public sector (and its users) will bear most of the health sector impact of HIV/AIDS. This is likely to increase • Private/public sector differential spending on health care will increase from 4 to 6 fold • Battle is to maintain status quo, let alone righting the balance • Equity between provinces may be affected

29. Conclusions (4) • Rationing of care to HIV infected individuals is inevitable • Critical to direct rationing imperatives towards more cost-effective and appropriate forms of care • This will require an extensive capital investment programme in terms of facilities and training of health care workers willing to undertake this task

30. Projected HIV infection levels in the Health Sector

31. Projected HIV infection levels in the Health Sector by Job Category (middle scenario)

32. CUMULATIVE AIDS DEATHS AMONG HEALTH SECTOR EMPLOYEES (mid case)

33. STAFF IMPACT Conclusions (1) • The HIV epidemic will be the biggest challenge facing HR management in the health sector over the next decade. • The DPSA is planning around general labour issues, including benefits, BUT: • The Department needs to plan programmes at a provincial, district and institutional level. • All managers will need to become proficient in HR issues

34. STAFF IMPACT Conclusions (2) • Aggregated data may hide devastating impacts at a local level. • Vulnerable institutions and work processes should be identified for special attention. • The Department needs to make staff aware of their risk outside the wards, as well as inside. • An environment needs to be created where PLWHA (patients AND staff) are treated with respect and care.

35. Treasury Projected Real Public Health Spending vs. Abt Model Projections