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Spending on ART by Provinces in South Africa_ trends_ cost drivers

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					Spending on ART by Provinces in
South Africa: trends, cost drivers,
(in)efficiencies and sustainability
  Simelela, N., Sipho, S., Sozi, C., Damisoni,
                 H., Guthrie, T.

         XIX International AIDS Conference
       22 – 27 July 2012, Washington D.C., USA
       Presentation Outline
•   Background to NASA in SA
•   Methodology
•   Limitations
•   Findings:
     o Total Provincial Per Capita Spending on HIV/AIDS
       and TB (all sources)
     o Total Provincial Total Treatment Spending (not only
       ART)
     o Provincial DOH Health, HIV/AIDS & TB Public
       Spending
     o PDOH ART Spending and Components
     o PDOH Absorption of Funds by Funding Channel
• Conclusions
• Recommendations
        Objectives of NASA in
            South Africa
• For the years 2007/08, 2008/09 & 2009/10, identified:
• All the sources (public, external and business) of financing for
  HIV/AIDS and TB in SA, by provincial & national levels
  (excluding out-of-pocket expenditure)
• The providers of the HIV/AIDS and TB services in SA
• The activities services delivered in SA
• The beneficiaries of the services

In order to make recommendations for the improved targeting
   of funds and efficiency of spending, according to the national
   and provincial priorities – informing the new NSP and PSPs.
Allowed for detailed analysis of the public ART spending.            3
Analyzing the Public ART Spending
• An indepth analysis of the public sector spending on
  ART being delivered by the provincial Departments of
  Health
• Funding channelled through:
   o An ear-marked condition grant from the national treasury,
     and;
   o Equitable share (discretionary voted) spending of the
     provincial DOHs which comes from their health budget.
• Through analysis of the public expenditure records
   labelled as ART-related, the budget line-items were
   identified
• Total annual provincial DOH ART spending was
   divided by the total number of active patients in the
 .
   same year
                                                                 4
      Limitations of the Analysis
• Public expenditure that was not specifically labelled as
  ART-related was omitted.
• For example, the proportion of the facility
  management and operating costs that could be
  allocated to the ART programme were not included.
• Therefore the figures presented here are an under-
  estimation.
• The budgetary line-item classification may have had
  errors that could not be identified or corrected.
• Some direct donations made by development partners
  to public ART programmes through personnel or ARVs
  could not be identified (eg. In Gauteng) and therefore
  may have resulted in an inaccurately lower unit cost.
  South African Provincial HIV per capita
(total population) spending (2009/10, ZAR)
         & HIV Prevalence (2009, %)




                                             6
South African Provincial HIV per capita (PLWHA)
spending (2009, ZAR) & HIV Incidence (2009, %)




                                                  7
8
Total R8.2b




              9
Provincial Treatment Activities
            (Rm, 2009/10)




                              10
     DOH Spending on HIV/AIDS & TB in SA




11
Provincial DOH Health and HIV/AIDS &
      TB Spending (Rm, 2009/10)




DRAFT - DO NOT DISSEMIATE.             12
Provincial DOH HIV/TB Spending Trends as
      Share of Total Health Spending




                                           13
Provincial DOH ART Spending
& Nos of Patients (Rm, Pts ‘000s, 2009/10)




                                                                   14
    NB. GP also spent PEPFAR funds on public ART, not included above
Provincial Proportional ART Costs
           (%, 2009/10)




                                                                        15
NB. GP also spent PEPFAR funds on public personnel ART, not included above
Provincial DOH ART per patient per annum
 spending & HIV prevalence (ZAR, 2009/10)




                                                                   16
    NB. GP also spent PEPFAR funds on public ART, not included above
SA Public Funding Channels
    • Conditional (Ring-fenced) Grants
 • Voted (Discretionary) spending from the
    equitable share allocations for health
   DOH CG vs Voted Proportional
Spending on HIV/AIDS & TB (%, 2009/10)




                                    18
DOH CG for HIV Budget vs
Spending (Rmill, 2009/10)
DOH Voted for HIV & TB Budget vs
  Spending (R mill, 2009/10)
                  Conclusions
• Provincial spending on treatment has been increasing, of
  which ART is almost half and growing proportionally.
• This may be challenging for sustainability given the
  anticipated increase in numbers of patients at the lower
  CD4 criteria.
• The provinces showed a relatively similar and low unit cost
  for public ART patients, although some costs were omitted
  because they were not labelled as ART-related.
• This would therefore be an underestimation of the
  government’s contribution through ‘hidden’ and higher-
  level management costs – these should be costed more
  carefully.
• The CG is an important mechanisms for ensuring a certain
  degree of service delivery, and half the provinces absorbed
  it completely.
• The voted funds are important for provinces to commit
  additional funds, when required, with similar absorption
  rates to the CG (but of much lower amounts).
           Recommendations
• Within the unit cost, some provinces had savings on their
  lab costs which could be replicated in other provinces.
• The recent country-wide tender achieved much lower
  ARV prices and therefore should reduce spending
  significantly, and equalise these costs between provinces.
• The CG should remain as an important funding channel to
  ensure the minimum level of services are delivered.
• The proposed NHI may mobilise addition funds for key
  health services, but roll-out may be affected by the
  varying provincial capacities.
• Provinces and districts will require improved financial
  management and information systems, to carefully track
  provincial & district spending on ART and other key health
  interventions, so as to pick up any inefficiencies &
  bottlenecks early.
                 Thanks to:
• SANAC for leading the NASA process
• UNAIDS for funding the NASA
• National Treasury and all the provinces for sharing
  their data
• Centre for Economic Governance for conducting
  the NASA and the ART analysis.



Dr Nono Simelela
President’s Office
South Africa

				
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