Periodic Review ccm request template

Please comment on the three dimensions of value for money listed below, demonstrating how the Programme is maximizing the health impact that can be achieved with available resources.

The value for money principles for the public sector in SA is included in the Public Financial Management Act (PFMA) (No.1 of 1999 as amended by Act 29 of 1999). The Act promotes the objective of good financial management in order to maximise service delivery through the effective and efficient use of the limited resources.

Economy: is the Programme minimizing the cost of resources and inputs whilst maintaining quality of services?

South Africa’s HIV/TB programme has sought to minimize costs for a given output/outcome through a number of efforts, including:

1. 
   Changes made through the NDOH’s procurement unit (now known as the Central Procurement Unit) to tendering practices that resulted in 50% and 30% reductions in the price of ARVs in 2010 and 2012 respectively. One of the major influencing factors in the regard was introducing reference prices into tenders. The latest tender also introduced 28 day (4 week) rather than 30 day pill packs, saving on two wasted pills per month.
   
2. 
   Introducing multi-month rather than monthly script collection for stable ART patients (a recent development). A 2010 report estimated that this change would save as much as 31% of personnel costs in ART clinics. This is an important development given personnel makes up about 50% of total ART costs in South Africa, and given the scale of the ART programme in South Africa (see above).
   
3. 
   Task shifting introduced into the national HCT programme. Efficiency gains in this area are evident in the programmatic gap analysis in this document.
   
4. 
   Recent shifts in the TB programme which include a total rollout of GeneXpert, which is cost effective through rapid testing turnaround times and much more accurate diagnoses; as well as plans to move towards a decentralized TB treatment model, given that hospitalization costs are by far the greatest driver of second line treatment at present in South Africa.
   

Further savings are also envisaged going forward, including through high-volume male circumcision centres operated by PEPFAR, and through optimizing staff and staff time allocation through the development of staffing benchmarks, an issue that is currently high on the NDOH’s agenda.

Efficiency: Is the Programme maximizing the output that can be achieved from available resources and achieving its results at the lowest possible cost?

This issue has begun to be addressed through the Annual Planning Tool (APT, see above), which tracks all government and Development Partner spending, budgets and outputs on an annual basis. This information is used to determine how much is being spent per programmatic output (‘unit expenditures’), and how this compares across multiple partners and with estimates of what services ‘should’ cost. The following figure shows, as an example, that at present there is variation across unit expenditures for HCT, and that there are likely opportunities to improve upon the efficiency of Development Partner spending in particular. While some of the variation is explained by different prices associated with accessing rural vs. urban populations, for example, NDOH is leading a process to try and rationalize spending across partners to achieve maximum value for money.

Figure 9: Unit Expenditures on HCT for various Donors and Government (2011/12) ⁷⁴

Issues of cost effectiveness also fall under the area of maximizing outputs, or rather more importantly outcomes, of service delivery. This issue is increasingly being considered in South Africa’s approach to tackling HIV/TB, especially under the current, constrained funding environment. Even as ART becomes increasingly cost effective, with reduced drug prices and increased understanding of the importance of treatment as prevention, prevention programmes continue to save the most number of lives per given dollar (see figure below). For this reason, while treatment is still a priority of the government, prevention programmes are increasingly being stepped up, both by the South African government, and through programmes such as PEPFAR and Global Fund.

Figure 10: Cost Effectiveness of Southern African HIV Programmes⁷⁵

Effectiveness: Was the Programme approach and activities well designed to achieve the objectives and correspond to what needs to be done given the disease and local context?

The local disease context requires a balance between prevention for key populations and the provision of ART and both of these are adequately addressed in the proposal. To improve the effectiveness of the provision of ART, we have included a focus on monitoring and evaluation, drug resistance testing and monitoring, pharmacovigilance, adherence support and care and support for PLHIV. To improve the effectiveness of the prevention programmes we are focusing on the key populations identified to be most at risk amongst the many key populations identified in the NSP. We are then also mapping these key populations and conducting baseline incidence studies to ensure an appropriate package of services is delivered where most needed. Finally, the prevention focus is also supported by the provision of support to OVC, strengthening of community systems and supporting victims of gender based violence.

Effectiveness is also addressed through the implementation of a multi-sectoral approach at many levels - from the deployment of government and non-government PRs to the many stakeholder platforms where effectiveness is monitored and discussed (e.g., the ODA platform for all development partners, SANAC secretariat and DOHs; the involvement of Provincial Council on AIDS in many SANAC structures; the Civil Society Forum, etc.

Have any major risks been identified related to value for money? Yes

If yes, describe how you plan to address those risks and monitor progress in the next Phase/Implementation Period.

The risks that have been identified include the following:

Lack of Donor Co-ordination: This risk is currently being mitigated through the government donor forums and the USG Partnership Framework for Implementation Plan. Coordination will continue to strengthen as the full impact of the SANAC restructuring is felt (i.e., broader stakeholder involvement in the various SANAC committees and the integration of policy into implementation plans under the guidance of technical task teams. The APT has already highlighted differences in unit costs across programmes among different partners, and these need to be further discussed and interrogated. This APT project also highlighted the need for a common tool that measures expenditure and unit costs across all government departments. These new tools will provide clarity of programme costs across funders and will align these costs to ensure better, more standardised unit costs, as well as more effective monitoring of quality of programmes and their outcomes.

Costing of the NSP and provincial plans for the implementation of the NSP: The costing of the NSP needs to be updated to present more accurate costs for certain interventions that were not fully programmes and costed when the NSP was completed at the end of 2011. This is an on-going process that is monitored and supported by SANAC secretariat and the many technical task teams, specifically the costing technical task team. More accurate costing and information sharing will enable appropriate allocation of budgets and will facilitate evaluation of outcomes and value for money.

Insufficient understanding of optimum support package for key populations: A collation of stakeholders will be involved in a review and evaluation of the package of services to be provided to each key population. This will be done at many levels including, for example, the SANAC programme review committee, the stakeholder platforms being initiated and/or supported through the work of this proposal, and the work of a group focused on improving the services provided to OVC. In the case of OVC the Department of Social Development (DSD) will employ data capturers through this proposal to collect, analyse and verify data from NGOs providing services to OVC while the USG will provide these data capturers with training and assist in setting up of an appropriate database and conducting operational research studies. These data collection activities will inform a standard for what services are needed by OVC and how best to provide those services in an integrated manner. This will all be done with the support of the NDOH, as ultimately they need to work with the DSD to ensure the optimum identification and support of OVC through an appropriate policy framework and funding allocation.

4.4 Quality of Services Assessment