NHLANHLA NDLOVU CEGAA Presentation to the 2014 International AIDS Conference MELBOURN 23 JULY 2014

1. NHLANHLA NDLOVU CEGAA Presentation to the 2014 International AIDS Conference MELBOURN 23 JULY 2014 Monitoring and evaluation of the national health (NHI) insurance for effective health care financing and implementation in South Africa

2. Government, Health and HIV spending trends

3. Consolidated (national & provincial) government, national health, health HIV and AIDS spending, and percent shares of health and HIV /AIDS expenditures in the consolidated allocations (2009/10 -2016/17) Source: National Treasury (2010/11 – 2014/15 documents): Estimates of Provincial Expenditure; Estimates of National Expenditure; Budget Reviews. Author’s calculations.

4. Historical record of increasing health HIV and AIDS funding in South Africa, nominal figures, R’million. 2003/4 to 2012/13 budget outcomes and 2013/14 – 2016/17 budget estimates. Sources: National Treasury (2004/5 – 2014/15 documents): Estimates of Provincial Expenditure; Estimates of National Expenditure; Medium Term Budget Policy Statements; Budget Reviews; Division of Revenue Bills/Acts.

5. National Health Insurance (NHI) goals  Effective functioning and integration of the new primary care delivery models.  Planning, monitoring and evaluation of school health teams, family health teams, district specialist teams and the HIV and AIDS, sexually transmitted infections and TB outreach model.  Improved pharmaceutical supplies management systems and processes to support efficient and effective provision of health services in the districts.  Improved supply chain management in relation to the sector non-negotiables.  Enhanced district capacity in the areas of district health services planning and monitoring and evaluation including research/impact assessment reports of selected interventions.  A rational referral system based on a re-engineered primary health care platform with a particular focus on rural and previously disadvantaged areas.

6. The NHI Pilot at district level • Pilot started in 2012/13 • Some serious challenges and delays in spending of the initial NHI grant of $14 million • Reduced conditional grant allocations for the NHI pilot from 2013/14, with more money allocated to national health department to support the NHI pilot • Issues around contracting with private GPs mainly consultation fees • However some progress in NHI piloting districts regarding: • Building of doctors’ consulting rooms • Upgrading nursing colleges, rehabilitation of clinics, and purchase of some essential equipment. • Due to slower than anticipated spending, the NHI grant allocations have been reduced over the medium term.

7. Reduced direct NHI spending by provinces, supplemented by increased national health spending on the pilot

8. Issues from service delivery level • Communities are empowered to monitor and demand health care service delivery, and to engage with government decision-makers • Community monitoring and multi-stakeholder processes show some visible results of the NHI pilots in some places: • Increased health personnel, refurbished facilities, smoother transport system to deliver drugs and test results, enhanced communication between health facilities and district health officers • Serious issues identified in many facilities, especially in O.R. Tambo District, Eastern Cape Province: • Shortage of health personnel; Poor working conditions for health workers • Extremely poor emergency health services, especially unavailability of ambulances in deep rural areas; Drug stock-outs still prevalent due to poor road conditions and transport logistics • Most facilities provide good HIV/AIDS services, but outcry for interventions for non-communicable illnesses • E.g. insufficient supply of medical supplies for diabetes, skin and heart conditions, child immunisation; Referrals to hospitals very costly, some patients cannot afford transport costs, and ambulance systems not functioning well • Except for a few cases, clinic committees are dysfunctional, and thus clinic governance issues are not attended to

9. So what? • Problems will not be solved by the NHI grant – which is very small, but the bulk of health funding should assist in dealing with the challenges. • NHI grant provides excellent opportunity for provinces to prioritise systems and processes that will make the health system work. • Monitoring of the total health budget is key to ensuring sufficient resources to address the problems. • Governance issues need to be addressed. Clinic committees and management teams need to be trained and provided with adequate resources to perform their work. • This should be supported by the district level counterparts: the District Health Authorities and District Health Management Teams. • Ongoing monitoring is required to ensure that the NHI goals are achieved, since this will mean better systems and processes of health care provision, and improved access to health care by all South Africans. • The increasing HIV/AIDS funds from the public purse are commendable, but these need to be watched closed as South Africa has entered the transition to country ownership, with donors like PEPFAR and Global Fund expected to reduce funding and to eventually exit

10. Thank You!!Nhlanhla NdlovuDirectorCEGAAnhlanhla@cegaa.orgwww.cegaa.org