Dr. Yogan Pillay National Department of Health South Africa

1. Optimization, Effectiveness and Efficiency of Service Delivery – Integration of HIV and Health Services Dr. Yogan Pillay National Department of Health South Africa

2. Proudly African “Dramatic progress made in access to HIV treatment in Africa during the past decade has transformed the lives of numerous families, strengthening the social fabric and increasing economic productivity. We can state that we have renewed hope, but there is no room for complacency. “I am working closely with all African leaders to develop a roadmap for shared responsibility with concrete milestones for funding, for access to medicines that must imperatively be produced locally in Africa, for enhanced regulatory harmonization and for improved governance.” Yayi Boni, President of Benin and Chairperson of the African Union (GAR, 2012)

3. Proudly South African "It seems now as if the health department is, once again, dragging its feet when it comes to implementing a comprehensive and efficient strategy to combat the disease. “Yet the reality on the ground is that HIV/AIDS is killing mothers, fathers, and children. HIV and AIDS will not go away if we ignore it. It is getting worse. Anglican Archbishop Njongonkulu Ndungane (2004)

4. 19 July 2012 “For many years UNAIDS talked about the vital importance of political leadership in the HIV epidemic as one of the key components to an effective response. This was something civil society also fought for in South Africa. “Today there is now no question that in Dr Aaron Motsoaledi, the Minister of Health, we have great political leadership. “It is this leadership that is mobilising society and now beginning to show the dramatic reduction in vertical transmission (of HIV) that is being announced today.” Mark Heywood, Director of SECTION 27, 19 July 2012

5. Overview • Optimizing spending – alongside increasing funding commitments – will help us identify the resources we need to end AIDS • Country ownership of the HIV response means country ownership of the funding envelope • Targeting HIV spending towards interventions that will most effectively drive reductions in mortality and incidence • Pursuing improvements in technical efficiency of services, to find savings and/or drive value for money by improving outcomes • Attention will need to focus on structural costs • Driving change will require: • Political will and strong government ownership • Transparency across donors • Partnerships with civil society, with affected communities and other stakeholders like the HIV professionals

6. Optimizing E2 of HIV spending can create opportunities to be more ambitious in our response The Strategic Use of Antiretrovirals to Help End the HIV Epidemic. WHO, July 2012.

7. Efficiencies can be examined within three broad categories: allocative, technical, and structural This saved amount can be reallocated and spent on scaling up other high impact treatment and prevention interventions ILLUSTRATIVE

8. Overview • Optimizing spending – alongside increasing funding commitments – will help us identify the resources we need to end AIDS • Country ownership of the HIV response means country ownership of the funding envelope • Targeting HIV spending towards interventions that will most effectively drive reductions in mortality and incidence • Pursuing improvements in technical efficiency of services, to find savings and/or drive value for money by improving outcomes • Attention will need to focus on structural costs • Driving change will require: • Political will and strong government ownership • Transparency across donors • Partnerships with civil society with affected communities and other stakeholders like the HIV professionals

9. Distribution of HIV/AIDS Spending: KwaZulu-Natal, SA (Osewe, 2012)

10. Evidence that people are nearly 40% less likely to acquire HIV in areas of high ART uptake • Researchers from the Africa Centre for Health and Population Studies completed a seven-year study in the rural area of KwaZulu-Natal, SA • Key Findings: • In areas where ART uptake is high (>30%), people who do not have HIV are 38% less likely to acquire the virus than in areas of low uptake (<10%) • Every percentage increase in ART coverage lowers transmission rate by 1.7% • The decrease in transmission rate is expected to be even more dramatic if ARV treatment is initiated at CD4 <350 instead of <200 “The results give clear evidence that HIV incidence is reduced as a result of high coverage of antiretroviral therapy. It is the first time that we have been able to show such results in a population setting –– an important finding which will help guide the AIDS response.” Frank Tanser from the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa.

11. In MATCH study facility-level ART averaged $200 per patient-year in LICs/LMICs; $682 in South Africa Cost of treatment per ART patient-year by country US Dollars In SA – and likely other UMICS – significant cost savings are possible Costs are so low in LIC/LMICs that savings opportunities are limited *Lab category includes consumables only in all countries except SA ** Simple average numbers are not representative of the countries. Weighted average numbers are currently being calculated which will be a better representation of the countries

12. Ongoing drug optimization will be needed to offset cost of switching from d4T to TDF ARV costs are driven by regimen choice* Percent However, the increase will be minimized due declining prices for TDF-based regimens CHAI Ceiling Prices for TDF/3TC+EFV, 2007-2012 As programs phase-out use of D4T and increase use of TDF, average ARV costs will increase (CHAI projections) TDF-based drug regimens are the “gold standard” in the U.S. and one of two preferred first-line treatment options in the 2010 WHO guidelines * Regimen splits based on MATCH study data, as measured during 2009/2010 costing period 12

13. We can improve outcomes at little additional cost, increasing value for money Average attrition (at 12 months) for established patients Percent Retention rates at 12 months for new patients by CD4 level at initiation Percent, CD4 count Average retention (at 12 months) for new patients Percent % of patients in category 24% 29% 18% 9% 20% 13

14. Resource tracking, aggregating expenditure analysis across funders, should identify efficiencies Some examples: Resource Tracking Work Analyses …by funding source/ implementing organization …by cost category (e.g. medicines, HR) … by programme area (e.g. PMTCT) Overview of Health Sector Resource Tracking through the Annual Planning Tool, South Africa, June 2012.

15. Accurate knowledge of resources allows maximizing of efficiencies • Countries will have different opportunities across these efficiency areas • Need unit costing data, ideally on a regular basis to track change over time and not just as one-off studies • Prioritized and well-costed national strategic plans offer a framework for aligning funding to make greatest impact “The AID Effectiveness Framework must ensure that the ODA Planning Forum has access to high quality data and analysis to inform its decisions related to ODA co-ordination. Detailed health expenditure data from all funding sources (government, development partners, and private sector) will be essential to understanding the overall landscape of funding and identifying opportunities for more efficient allocations. The ODA Planning Forum will institute a formal process to collect this crucial data from government, development partners and implementing agencies.” DOH AID Effectiveness Framework, 2011

16. Overview • Optimizing spending – alongside increasing funding commitments – will help us identify the resources we need to end AIDS • Country ownership of the HIV response means country ownership of the funding envelope • Targeting HIV spending towards interventions that will most effectively drive reductions in mortality and incidence • Pursuing improvements in technical efficiency of services, to find savings and/or drive value for money by improving outcomes • Attention will need to focus on structural costs • Driving change will require: • Political will and strong government ownership • Transparency across donors • Partnerships with civil society, with affected communities and other stakeholders like the HIV professionals

17. Why aren’t national strategies always evidence-based and prioritized to maximize impact? • Inertia of continuing to fund existing programs, despite lack of evidence on efficacy • Constituencies support different aspects of programming, making it politically expedient to turn the strategy into a “laundry list” • Lack of alignment on strategic priorities across key partners (government, major donors) • Not enough research yet on what is working It will take strong political will and engagement of other stakeholders to manage a well-coordinated strategic planning process that produces an evidence-based, prioritized national plan that is then implemented well

18. A new global compact on shared responsibility: Domestic financing potential and international investment needs in sub-Saharan Africa Efficiency, Effectiveness, and Financial Sustainability: The Importance of Country Ownership, Bernhard Schwartländer, UNAIDS (IAS, Nairobi).

19. E2 necessary, not sufficient to drive change: • Optimize service delivery models • Harmonize and involve different actors • Need to identify bottlenecks • Make equity concerns more explicit Map research needs: • Develop/consolidate research network • Develop/sharpen definitions and research tools • Focus E2 research on measuring quality of live and cost benefit • More research on sustainability

20. A new global compact • Countries take the lead – national vision and plan; partners pulled into alignment • Resources are reallocated according to country needs and priorities, for greater, more sustainable results • Partners and countries fill the investment gap together – ‘fair share’, based on capacity • Programs are implemented as efficiently as possible (without parallel structures, stand-alone services or higher than necessary program costs)

21. Acknowledgments • Mats Ahnlund and EllyKatabira (IAS) • The participants of the Nairobi IAS consultation • My colleagues from CHAI (who requested not be named) • Colleagues whose work I used • People I work with especially the front line health workers