Periodic Review ccm request template
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- Figure 4: HIV TB Spending by Public Depts (ZAR millions, 07/08 – 2009/10)27
- Efficient and sustainable service delivery models
- Integrating of HIV prevention, care and support services into the primary health care system and school education curriculum
- Integrating care and support services into the poverty reduction programmes
- NASA Findings Recommendations
- Expand the HIV and TB response beyond the health sector: DOH
- Avoid crowding out by ART spending
- Increase priority given to prevention
- Develop Investment Framework Allocations: “
- Measure the Impact and Expand DBE’s interventions
- Increase support to NGOs and CBOs
- Service Delivery including Public Private Partnerships and community level service delivery
- Monitoring and Evaluation
- 65 The specific health system constraints and how it will be addressed in this proposal is summarised in “1.3.1 Summary of Request”.
3.3 Health Systems AnalysisPlease comment on the status of the HSS (Health System Strengthening) actions undertaken with the Global Fund and/or other domestic or partner support and how the identified health system constraints have been addressed. The importance of Health System Strengthening (HSS) to improve health outcomes for the general population is acknowledged and actively supported by the South African Government and led by the NDOH. In 2010 President Zuma signed performance agreements with his cabinet to enhance service delivery in South Africa. The key performance areas of these agreements are enumerated and described in the Negotiated Service Delivery Agreement (NSDA) with each Minister in every government sector. These NSDAs are seen as a charter that reflects the commitment of key sectoral and inter-sectoral partners to improved delivery of identified outputs as they relate to a particular sector of government. They are designed to facilitate accountability and resourcing towards achievement of 12 key outcomes for the whole country, which align to departmental mandates for the period 2010 – 2014. Each outcome area is linked to a number of outputs that inform the priority implementation activities that will have to be undertaken over the given timeframe to achieve the outcomes associated with a particular output. The focus for the health sector is geared towards Outcome 2: A long and healthy life for all South Africans. The NSDA for Health therefore focuses on four key outputs, in turn linked to the health-related Millennium Development Goals, namely:
The section below reflects on some of these challenges and how they have been addressed through the building blocks in the health system.
To redress inequities in access to health care between users of the public and private health sectors and to ensure universal coverage for all South Africans, the government adopted the policy on National Health Insurance (NHI) to transform the health system and grant all citizens access to good quality health services irrespective of their socio-economic status. In 2012, the first NHI pilot sites were identified and specific support and attention is given to these districts to improve services as a platform for the roll out of NHI. Key achievements recorded during the reporting period towards enhancing the effectiveness and performance of the health system include: (i) The completion of the Human Resources Strategy (ii) An audit of all public health facilities (iii) The finalisation of the Re-engineering of Primary Health Care (PHC) policy document and implementation plan. The three pillars of the PHC Re-engineering plan are: the deployment of ward based PHC outreach teams; the establishment of district clinical specialist teams; and strengthening of school health services. During 2010 and 2011, various reviews and research was conducted on the progress made in the national response to HIV and TB by SANAC and the NDOH. These included the end-term review of the 2007-2011 National Strategic Plan, the National AIDS Spending Assessment and the Know-Your-Epidemic/Know-Your-Response report. These reviews and assessments informed the development of the NSP 2012-2016. The South African government and the European Union have established several layers of health dialogue, including annual Development Partner Consultation Forums chaired by the SA Minister of Health and the bi-annual Planning Forum meetings chaired by the SA Director-General of the NDOH. Both meetings are held between the SA Department of Health, SA National Treasury, provincial representatives and Development Partners (bilateral and multilaterals). The main objective of these high-level meetings is to discuss the alignment and harmonisation of Official Development AID (ODA) to the SA Government's priorities for the health sector, and to assess aid effectiveness. The SA Minister of Health has approved an Aid Effectiveness Framework31 for the health sector, based on the Paris Declaration on Aid Effectiveness, which describes in detail the structure of the health dialogue and the concrete expectations on the side of the SA Government with regards to ODA. The EU and the SA government also discuss health in the AIDS and Health Development Partners Forum, where the Department of Health (DOH) participates as an observer and in the National District Health Systems Committee meetings (NDHSC), where the EU delegation participates as an observer.
According to the Council of Medical Schemes, eight million (17%) South Africans are covered by private medical schemes (insurers). The remaining 83% of the population not covered by medical aid rely mainly on public health services. Gauteng (26.6%) and Western Cape (25.5%) have the highest private medical aid coverage rates, while Limpopo (8.7%), Eastern Cape (11.4%) and KwaZulu-Natal (12.5%) have the lowest 32. However, although only 17% of the populations is covered by private medical schemes and hence use the private medical service delivery system, certain parts of this private medical service delivery system like General Practitioners (24.3%) and pharmacies are utilised by a larger proportion of the population through private out of pocket once-off payments. According to Statistics South Africa, approximately 29.2% of South Africans used private services at their last health visit. The South African Government spent R110bn on public health care in 2010/11, using a broad definition. Spending increased at an average annual rate of 5.6% in real terms from 2007/08 to 2013/14. Provincial health department spending, at 44.3% of the total, exceeded that of medical schemes for the first time in 2009/10, making it the largest funding flow for health services – and this trend is likely to continue. Provincial health department expenditure is projected to increase in real terms by 6.1% per annum from 2006/07 to 2013/14. Over recent years, total spending levels have converged, although on a per capita basis private sector spending is still substantially larger. The Green Paper on National Health Insurance (NHI) released by the SA Government in August 2011 for public comment represents the most far reaching proposal for changes to the health-financing arrangements in SA for decades. The NHI aims to provide an improved universal coverage system for a predefined comprehensive package of services. Key parts of the proposal, which the Government intends to implement in phases over a 14-year period, include:
The UNAIDS 2012 report reflects that SA’s facility level HIV treatment costs (including commodities and service delivery) were at US$ 682 in 2011, reflecting higher salary levels and more frequent laboratory testing than the other four countries in the study (Ethiopia, Malawi, Rwanda and Zambia). SA has increased funding for HIV five-fold over the last 5 years. With an estimated US $2 billion spent in 2011, it is the top funder among middle and low income countries33. NASA reported that the South African government has progressively allocated new resources to fund the response to HIV and AIDS in the 2009/10–2011/12 medium term period through conditional grants and equitable share allocations. SA also sourced an additional R900 million from PEPFAR for the AIDS Treatment programme, to cover a budget shortfall expected in 2009/10. In 2007/08, South Africa spent almost R8 billion on HIV/AIDS and TB, which increased by 39% to R11 billion in 2008/09 (from public, private and external sources). In 2009/10, the amount increased again by 18% to reach R13 billion (US$1.6 billion)34. The largest proportion of the external funds was spent at the national level (73% of which is central-level spending). The provinces showed greater dependence on public sources: the highest being in Eastern Cape (90% public) and lowest in Western Cape (69% public) with Western Cape having the highest proportion of external sources (21% donor aid). In total, public sources contributed 75%, external sources (donors) contributed 16%, and the private sector, primarily through medical insurance spending, contributed 8% to HIV and TB in SA. During the NASA review it was found that most of the HIV/AIDS and TB funds in SA were spent on treatment activities, which included ART, TB treatment, palliative care, home-based care and other treatment activities. In 2009/10, 63.4% of total funds went to these treatment activities, followed by social protection, which included a proportion of the Child Support Grant (12.6%), prevention interventions (10.1%), research (4.8%), and programme management and co-ordination (4.2%). The remaining categories were: care for orphans and vulnerable children (OVC) receiving only 1.8% (in addition to the Foster Care Grant and the Child Support Grant), enabling environment (human rights protection, advocacy, etc.) receiving 0.3%, and human resource capacity-building (training, etc.) receiving only 2.8% of the total HIV/AIDS and TB spending in 2009/10 in South Africa. In the NASA report, it was reported that over the three-year period, public funding towards HIV and TB increased by 27% on average, from R6 billion in 2007/08, to R8 billion in 2008/09, reaching R9.8 billion (US$1.2 billion) in 2009/10. The public funds come either from the Conditional Grants from National Treasury, given to the Departments of Health (Comprehensive HIV/AIDS grant) and Education (Life-Skills grant), or from the province’s Equitable Share (Voted) funds which are allocated from the DOH, DSD and other departments’ budgets. See Figure below for a breakdown of public spending. 
Figure 4: HIV & TB Spending by Public Depts (ZAR millions, 07/08 – 2009/10)27 The NSP contains a high level costing, which has been complemented by more detailed “bottom up” costs from each of the nine provinces, in the form of the Provincial Strategic Plans (PSP). The NSP estimates that total required resources for South Africa to fight HIV and AIDS and TB amount to ZAR 18.7 billion (US$ 2.2 billion) in 2012, rising to ZAR 32.3 billion (US$3.8 billion) by 2017. Over the five-year period, the total is ZAR 130.7 billion (US$ 15.6 billion). This represents a substantial investment in efforts to prevent new infections, prolong and improve the lives of those living with HIV, and address the social and economic consequences of the epidemic Initiatives to cut the costs of antiretroviral drugs have led to savings of US$ 640 million between 2011 and 2012. Actions undertaken to reduce cost and improve efficiencies included:
NASA Findings & Recommendations The following key findings and recommendations were made after the National AIDS Spending Assessment (NASA): Adequacy: There was adequate spending on the treatment interventions in SA in the year of 2009/10, but less than adequate spending on prevention interventions. New NSP cost estimates for 2012/13 and 2013/14, has shown there could be a funding gap in the order of R3 billion and R5 billion respectively; Prioritisation: There is need to carefully balance treatment funding with adequate prevention and mitigation spending; Expand the HIV and TB response beyond the health sector: DOH response to HIV and TB should be balanced with increased spending on integrated HIV and TB services in all the other departments, particularly the Department for Social Development (DSD) and the two Departments of Education (DBE and DHET). Spending on support for orphans and other children made vulnerable by HIV (OVC), community development, enabling environment, and human and legal rights activities should be increased in South Africa and would be best provided through NGO services; Avoid crowding out by ART spending: While recognising the preventative effects of scaled-up ART access, it is equally critical that the DOH and the other departments ensure that prevention spending, and other key activities (mitigation, research, etc.) are not crowded out by ART. In addition, attention must be paid to other treatment requirements, such as treatment of opportunistic infections, in-hospital care, home-based care and palliative care; Increase priority given to prevention: Although increasing the coverage of ART will reduce HIV transmission rates, it is nevertheless important to continue to reduce the number of persons needing treatment; it is vital that budgets are increased for those key prevention interventions that have been shown to have the greatest impact e.g. Medical male circumcision, PMTCT, condoms and post-exposure prophylaxis (PEP) remain effective interventions to be expanded, and while it may be difficult to prove the effectiveness of social mobilisation, advocacy and behavioural change campaigns, they are nevertheless “critical enablers”, without which the impact of biomedical interventions would be reduced. This is in line with the Investment Framework; Develop Investment Framework Allocations: “Strategic investment framework that incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission”. Maximum effectiveness and programmatic efforts in other health and development sectors related to HIV/AIDS such as:
Measure the Impact and Expand DBE’s interventions: The Department of Basic Education’s Life Skills programme is the main intervention targeting youth-in-school, yet its impact is yet to be examined. Such effort should focus on how the programme could be enhanced and expanded for greater impact; and Increase support to NGOs and CBOs: Nongovernmental and community based organisations are providing valuable home-based care, community mobilisation, adherence monitoring and other services, which offer critical support for people living with HIV. Funding for NGOs and CBOs should therefore be increased, coupled with technical support to improve their management of, and accounting for, funds received. More detail on Financing is included in section 4 of this proposal.
The Human Resources (HR) Strategy for Health for 2012-2016 was launched by the Minister of Health in October 2011. The launch of the HR strategy coincided with a WHO-AFRO workshop on finding solutions to the HR challenges facing the continent. The HR strategy will be linked to the output of a health workforce from tertiary institutions to ensure that these institutions respond to the burden of disease facing South Africa. As part of interventions to enhance the quality of care, the NDOH commissioned an independent comprehensive audit of 4 210 public health facilities to assess their infrastructure, human resources and the quality of the services they provide. Preliminary findings of the audit revealed major challenges concerning the management of these facilities, as well as the quality of services provided. The final report is however still pending and will be released in 2013. The Development Bank of Southern Africa (DBSA) completed an assessment of the functionality, efficiency and appropriateness of the organisational structure of hospitals and the appropriateness of the delegations given to hospital managers and district managers. Following this report, the NDOH published the regulations of the National Health Act of 2003 aimed at providing clear designations to managers and chief executive officers (CEOs) of different categories of hospitals and the required skills and competencies for managing hospitals. These regulations seek to strengthen the governance of health facilities. In April 2010, the President of South Africa launched the largest HCT campaign in the world. This campaign intended to provide an opportunity for community members to be tested for HIV, screened for TB, and chronic diseases such as diabetes and hypertension. The HCT campaign was transformed from the campaign mode and incorporated into the routine services provided in the public sector. Even as part of routine services, the uptake rate of HCT showed a sharp increase. By the end of March 2012 an HCT uptake rate with a total of 9 602 553 people had undergone counselling. Of these, 8 772 423 people accepted HIV testing, resulting in a testing rate of 91%36. South Africa is one of the high burden countries globally and there is a high proportion of TB-HIV co-morbidity, which is estimated to be as high as 60%. On World TB Day, in 24 March 2011, the Department of Health launched an active case-finding programme to trace all persons diagnosed with TB, screen their family members, and counsel them to be tested for HIV in their homes. By the end of the reporting period for the previous NSP, 180 000 households had been visited. This social mobilisation approach forms part of the PHC Re-engineering model and will assist in reducing levels of TB and HIV infections in households, families and the community at large. The DOH acquired the latest technology in the diagnosis of TB, the GeneXpert. The use of this equipment allows the results of a TB test to be ready in two hours and will massively improve access to treatment for people diagnosed with TB. The GeneXpert System has provided the possibility of a rapid diagnosis of tuberculosis, while simultaneously providing a rapid screen for rifampicin (RIF) resistance. The assay is highly sensitive and specific for M. tuberculosis (MTB) infection and has received a strong recommendation from the World Health Organization (WHO) in December 2010, as the initial test in individuals suspected of MDR-TB or those with HIV co-infection. The intended scale-up of the GeneXpert System will lead to the placement of 65 GX4, 169 GX16, and 4 GX48 (“Infinity”) instruments, with a total national test capacity at full Xpert coverage in 2013 of 11 428 tests per day. Total capital cost (including instruments, additional space, security, and training) between 2011/12 and 2016/17 will be
The National Health Laboratory Service (NHLS) share of total diagnostic cost increases by 298 million ZAR in 2013/14, 345 million ZAR in 2014/15, 397 million ZAR in 2015/16, and 444 million ZAR in 2016/17 (Accelerated scale-up only). The incremental NHLS cost per suspect is between ZAR 129 and ZAR 141 at full Xpert coverage, the incremental cost per patient diagnosed is between ZAR 485 and ZAR 650. These results do not take into account a reduction of transmission and, hence, new TB cases (including MDR-TB cases) as a result of earlier identification of TB and initiation on appropriate treatment. The analysis is restricted to the full and incremental cost of the new diagnostic algorithm only and as such does not fully capture the benefits or opportunity cost of the GeneXpert technology 37 Access to antiretroviral therapy (ART) is a key programme activity of the HIV response. Not only does ART reduce morbidity and mortality among people infected with HIV, it also reduces the incidence of AIDS related TB, and has public health benefits in terms of reducing the onward transmission of HIV. Procurement and distribution have been identified as programme enablers. In 2010 and 2011, landmark studies were published strengthening the evidence base on the preventive effects of antiretroviral drugs. People living with HIV receiving antiretroviral therapy are less likely to transmit HIV, and HIV-negative people who take antiretroviral pre-exposure prophylaxis orally in tablet form or topically in a vaginal gel reduce their risk of acquiring HIV38. South Africa has the largest ARV programme in the world and the rollout of antiretroviral therapy (ART) continues to be successful, with more than 2 million persons ever started on ART since the commencement of the treatment programme. Treatment initiation rates have reached 30 000 per month on average. This can be attributed to the revision of the treatment guidelines in 2009 which increased the threshold for ART treatment in pregnant women and patients co-infected with TB and HIV to CD4+ count 350, and the provision of safer and effective antiretroviral therapy regimens for adults and children39. In 2011, the estimated number of adults in need of treatment was 2 300 000 (UNAIDS Spectrum 2008-2011), but this estimation has now substantially increased. A total of 617 147 new patients were placed on ART during the 2011/12 reporting period. This figure was significantly higher than the 418 677 patients initiated on ART during 2010/11. An estimated 2 million people were on treatment at the end of December 201240. However, the NDOH has always maintained that South Africa cannot treat itself out of the HIV epidemic and that HIV prevention remains the mainstay of efforts to combat this condition. Although government has allocated approximately R24 billion for HIV/AIDS programmes from 2012 through 2016, there is still a gap based on the number of people in need of treatment. Health systems strengthening efforts that supported the expansion of access to treatment was the implementation of Nurse Initiated Management of ART (NIMART). Over 10 000 professional nurses have since been trained to initiate and manage patients on ART41. The UNAIDS report 2012 indicated an additional efficiency can be gained by task-shifting where the costs of antiretroviral therapy managed by NIMART trained nurses at decentralized facilities were 11% lower than those managed by doctors in hospitals42. Private sector data indicates around 86% survival rate of adults and children who are on ART, following 12 months of the initiation of therapy. Discovery Health reported an increase in survival rates among its patients by 8% in the last two years, from 76% in 2010 to 84% in 201143. People who received their CD4 test result at the same time as they were diagnosed with HIV infection were twice as likely to start treatment within three months as those who had to wait an extra week to get the same results44. Since 2008, South Africa has rapidly scaled-up it its PMTCT and Early Infant Diagnosis (EID) programmes. By 2010, PMTCT was offered at 98% of health facilities. Data from the NHLS show a 15% increase from 2010 (39.2%) to 2011 (54.4%) in the percentage of infants testing for HIV within 2 months of birth45. More than 95% of women eligible to receive antiretroviral therapy to reduce HIV transmission during pregnancy received treatment46. Based on the 2011 Effectiveness of SA National PMTCT Programme Survey results, an estimated 104 000 out of 117000 (89%) babies were saved from HIV infection in 2010, and an additional 3 000 babies were saved in 2011, increasing the proportion saved to 91% or 107000 out of 117000 babies. The perinatal MTCT rate of 3.5% in 2010 and 2.7% in 2011 suggests SA is potentially on track to reach the target of <2% perinatal HIV transmission by 2017. Based on the 2010 SAPMTCT evaluation the National PMTCT programme resulted in 3.5% national MTCT rate in pregnancy and Intrapartum. A reduction is noted from the approximately 30% transmission that would occur during pregnancy, labour and delivery in the absence of PMTCT interventions47,48. The Department of Basic Education’s Draft Integrated Strategy on HIV, TB and Stis 2012-2016 has seven imperatives that provide the basis for the development of the three key strategic outcomes of the Strategy that will fundamentally shift the relationship between schooling in South Africa and the country’s response to HIV, STIs and TB. These outcomes are themselves closely aligned with best international thinking and the current and emerging recommendations of global agencies. These outcomes are: (1) Increased HIV, STIs and TB knowledge and skills among learners, educators and officials (2) Decrease in risky sexual behaviour among learners, educators and officials; and (3) Decreased barriers to retention in school, in particular for vulnerable learners. The Strategy will thus guide the development and implementation of interventions beyond the HIV and AIDS Life Skills Education Programme (which was the primary intervention instituted by the Department in response to the National Policy on HIV and AIDS for Learners and Educators in Public Schools and Students and Educators in Further Education and Training Institutions) to provide a more holistic response to the challenge of HIV and TB, ensuring safe and caring schooling and work environments, free from discrimination and stigma. It recognises the heightened vulnerability of girl children and adolescent girls, and the need to tackle gender inequality and gender-based violence that lie at the root of this. Support for HIV positive and TB infected learners, educators and officials will be paramount, as will support for those within the education system made vulnerable by HIV and TB, especially orphans and children with disabilities. The Department of Higher Education and Training (DHET) and the collective leadership of Higher Education Institutions (HEIs), as represented by Higher Education South Africa (HESA), have recognised the importance of implementing a coordinated, comprehensive and effective response to HIV and AIDS among Higher Education Institutions and Further Education and Training colleges (FETs). The Higher Education HIV/AIDS Programme (HEAIDS) is South Africa’s nationally co-ordinated, comprehensive and large-scale effort designed to develop and strengthen the HIV mitigation programmes of the 23 public Higher Education Institutions and 50 FET colleges. The HIV/AIDS response of the Higher Education sector cuts across all aspects of its core mandate: teaching and learning, research and innovation, and community engagement. And a key strategy is to use these platforms to effectively respond to the drivers of the epidemic. The interventions undertaken recently include a Sero-prevalence survey for the sector; the adoption and implementation of the HIV/AIDS Policy Framework; the First Things First and HIV Counselling and Testing (HCT) campaigns; and the scaling up of routine HIV testing at campus clinics. HEAIDS has also facilitated the training of nurses in Nurse Initiated Management of ART. Studies conducted in 2011 in the 23 public universities indicated the mean HIV prevalence rate for the 938,201 undergraduate and post-graduate students was 3.4%. The prevalence among the academic staff was 1.5%, with administrative staff at 4.4% and service staff at 12.2%. Given these prevalence rates, a total of 34,279 students and staff are currently HIV-positive. However, this does not yet include information on students attending the FET Colleges. The government plans to expand the number of FET Colleges available as well as increasing their geographical coverage, as a key step to creating employment through the creation of apprenticeships and hence the number of youth attending various forms of higher educational instirutions is expected to increase. The Department of Social Development is mandated by both the Constitution of South Africa (Section 28 of the Bill of Rights) and the Children’s Act (Act No 38 of 2005) to provide services for the care and protection of children especially vulnerable children. Their goal is to create safe and caring families and communities that meet children’s needs and respect their rights, through the delivery of high-quality integrated community-based services by trained child and youth care workers and they currently promote the implementation of the Isibindi model throughout the country to be able to best meet this goal. This model includes service delivery elements and specific monitoring and evaluation tools and platforms. The service delivery element ensures comprehensive rights-based services to OVC in their homes by highly trained Community Youth Care Workers who are then mentored, supervised and cared for to ensure sustainability and continuous improvement of the services delivered. The model also includes the delivery of a package of specialised services each with their own specific benefit: A Disability program which focuses on meeting the needs of children with disabilities; A Child Protection program, in partnership with Childline, which provides a short-term residential-based therapeutic services during school holidays for children who have been sexually abused; Young Women and Young Men Empowerment programs addressing gender equity and other gender-related issues; and Safe Parks which are places where children affected by poverty and HIV/AIDS can access developmental opportunities, be with caring adults and have fun. The Safe Parks are run by trained CYCWs on areas of land specifically set aside for the recreational or educational pursuits of children in areas where children live and play. The role of CYCWs in the Safe Park is to supervise children to keep them safe while playing; engage with children directly while they play; organise and facilitate games and developmental activities; observe children to identify their strengths and weaknesses, assess any developmental delays and identify and respond to cases of neglect or abuse. Evidence has emerged that male circumcision can reduce HIV transmission in men by up to 60% and in South Africa local researchers found the risk of HIV transmission in circumcised men was reduced by 76% with no significant increase in sexual risk-taking behaviour. Scaling up voluntary medical male circumcision has the potential to prevent an estimated one in five new HIV infections in Southern Africa by 2025. South Africa has begun to address male circumcision at both policy and programme level. The current guidelines do not provide sufficient guidance on how to address socio cultural barriers to implementation of the MMC programme, and do not offer strategies for achieving high MMC coverage, e.g. introducing circumcision in both areas with high and low HIV prevalence, and creating demand for circumcision in traditionally non-circumcised communities49. SANAC has drafted male medical circumcision guidelines in line with WHO and UNAIDS recommendations. These guidelines aim to further the NSPs prevention goal through the provision of safe, accessible, and voluntary male circumcision. The draft guidelines suggest a dual strategy that promotes and institutionalizes both neonatal and young adult circumcision50. The introduction and scale up of medical male circumcision services as part of male sexual and reproductive health resulted in more than 230 000 men having undergone MMC nationally. In the reporting period 2011/12 a total of 347 973 male medical circumcisions were conducted, against an annual target of 500 00051. Community systems strengthening Community health systems are seen as an integral part of the Primary Health Care approach in South Africa and the importance is emphasised in policy documents such as the NSDA and DOH Strategic Plan. As also indicated in the UNAIDS Report, 2012 integrating HIV testing into routine health services assisted to increase the uptake of testing but not sufficiently and too often, people who take HIV tests do not return to learn the results. Rapid tests and community-based approaches to testing may help to increase accessibility and uptake. People who test HIV-positive need to enrol and remain in care until they become eligible for treatment, but many do not. In a review of studies in sub-Saharan Africa, 31–77% of people living with HIV stayed in care until they initiated antiretroviral therapy. Many people living with HIV (including in high-income countries), regardless of whether they are aware of their HIV status), commence treatment only after they begin experiencing AIDS-related illnesses. This is a major reason why late initiation is still associated with high rates of mortality during the first months following the initiation of HIV treatment. There are practical ways around these barriers. For example, people who received their CD4 test result at the same time as they were diagnosed with HIV infection were twice as likely to start treatment within three months as those who had to wait an extra week to get the same results52. Exposure to South Africa’s HIV prevention communication through media campaigns is high, with 80% of those surveyed knowing at least one of the initiatives, in particular among the 15-24 year olds age group. The Second National HIV Communications Survey of 2009 indicates that there have been significant messaging achievements in particular areas of HIV. It found that many of HIV communication programmes have been impressive, with 90% of the population aged 16-55 years exposed to one or more Health Communication Programmes (HCP). Exposure to HCPs was highest in the segments of the population that HCPs intended to reach – segments comprising individuals who are most likely to be HIV-infected or at highest risk of infection. HCPs have shown success in a number of areas related to HIV in terms of building knowledge and developing appropriate attitudes and beliefs. The survey also found low levels of knowledge about the HIV risk-reduction which male circumcision provides, and about exclusive breastfeeding as part of the strategy for reducing the risk of mother-to-child transmission53. Adherence support is a key contribution to the HIV prevention programme to translate mass media campaigns into peer and community prevention. There is a need to intensify community treatment adherence and combined HIV prevention by building on linkages with community leaders and combining treatment follow up and prevention activities54. The financial, economic and social costs of treatment were significantly decreased for people who enrolled in community antiretroviral therapy groups. Other practical examples of links between treatment services and communities include establishing referral systems for patients who experience side effects, providing support for buddy systems and introducing community assisted outreach to locate people who stop treatment. Treatment literacy and support groups have become vital to treatment and care programmes, along with the networks of community health workers that support these programmes Evidence indicates that people who receive support from community health workers tend to have better treatment outcomes than those who rely only on formal clinic services55. Decentralized ART services (at the primary and secondary levels) showed similar drug costs but lower non-drug unit costs compared with ART centres at the tertiary level. The satisfaction of service users and treatment adherence improved and travel-related costs decreased. A key factor underlying the high rates of patient retention and treatment compliance in the ART services may be the widespread use of treatment literacy training for patients, often delivered by lay or peer counsellors. Research is revealing the importance of other social determinants of treatment adherence, including community support initiatives (including treatment “buddies” and community health workers) and the ability to sustain strong social networks. A high level of adherence to ART is crucial for treatment success among HIV patients and is a prerequisite for maintained viral suppression and a lower risk of drug resistance. Facility and community based ART adherence clubs are a long-term retention model of care catering for stable ART patients. The model has been evaluated by Médecins Sans Frontières (MSF) in the Western Cape and has been adopted for phased rollout by the Health Department in that province as a strategy to retain stable patients in care. Evaluation of this model demonstrated that club participation was associated with sustained virological suppression and immunologic recovery. Over 40 months, 97% of club patients remained in care compared to 85% of those who qualified for clubs but remained in mainstream care. Club participants were also 67% less likely to experience virological rebound, indicating better adherence in clubs compared to mainstream care56. In 2010 the Department of Basic Education has developed the Integrated HIV, STIs and AIDS Strategy to guide the response among over 12 million leaners and their educators. With South African youth aged 15-24 experiencing among the highest HIV prevalence in the world, with girls more affected than boys, the development of effective HIV prevention programmes is a top public health policy priority. Comprehensive sexuality education is considered an important means of addressing adolescent risk behaviours, although little evidence supports its direct impact on biological measures of prevention success, particularly HIV and other sexually transmitted infections57. Community structures and services, central in the care component of the comprehensive response to HIV and AIDS, are provided mainly through non-governmental and community-based organisations. They form part of the new PHC Re-engineering model for NHI. Institutional services and systems must be strengthened and expanded to support the care-giving capacities of families and households by providing basic care-giving education, materials and psychological help. Young single people (who are not married or cohabiting) and young people reporting multiple sexual partners are most likely to report using condoms. People above 50 and married people are least likely to report condom use. The distribution of male condoms increased from 308.5 million in 2007, to 495 million in 2010 (a 60% increase). However, this translates to only 14.5 condoms per adult male per year (15-49) in 2010 against 12.7 per adult male in 2008. The number of free female condoms distributed has increased from 3.6 million in 2007 to 5 million in 2010 (a 39% increase)58. In 2011/12 6 353 000 female condoms were distributed, significantly more than the
The current legislative framework provides the government with a basis for combating alcohol and substance abuse. The Bill of Rights enshrines the rights of all South Africans, including those abusing substances and affirms the democratic value of human dignity, equality and freedom. The National Drug Master Plan 2006 to 2011 is aligned to the stipulations of the 1992 Prevention and Treatment of Drug Dependency Act, which enables cooperation between government departments and stakeholders in the field of substance abuse and promotes cooperation in combating the illicit supply of drugs and abuse of substances. The Prevention of and Treatment for Substance Abuse Act 1992 was enacted by Parliament in 2008 and seeks to combat substance abuse through prevention, early detention, treatment and reintegration programmes. Regulations to bring this Act into operation are being finalised. Cabinet has established an Inter-Ministerial Committee to support the national campaign to combat alcohol and substance abuse launched in October 2010 (“No Place for Drugs in my Community”). In 2011, the alcohol-related debate is on tighter monitoring of alcohol trading outlets, pushing up the legal drinking age from 18 to 21 years, the banning of alcohol advertisements, and law enforcement especially around taverns and shebeens59 The SANAC LGBTI sector was established in 2011, with LGBTI representation on several SANAC sectors and technical task teams. There has also been support from several provincial Departments of Health and the national Department of Justice to improving access to services for MSM; however no national government supported national men who have sex with men (MSM) programme exists. On a limited level there is some programming which is provided in certain provinces, with support from provincial health departments, but current coverage is severely limited in terms of numbers of MSM reached and geographic availability of services. No national Behaviour Change Communication (BCC) campaigns for MSM have been launched60. There is currently no MSM-related messaging included in the existing HIV communication strategies aimed at the general population or young people specifically. General messaging around risks of unprotected anal sex in HIV transmission for sexually active people is not widely disseminated. Elicitation of anal sexual practices is also not included in standard HIV counselling and testing procedures for all. MSM targeted services are lacking in most areas of the country. Those that do exist are based in major cities and are provided by civil society organisations, some of which obtain support from provincial government. Many organisations are involved in advocacy and information dissemination efforts and many also provide HCT services. However, there are very few which provide HIV prevention, treatment, care and support services for MSM. The role of civil society in providing targeted services may be the best model, with support and linkage with government services, should this form part of an overall health and justice service which is sensitive to the needs of key populations, including MSM. Focus needs to be placed on ensuring that organisations which provide MSM specific services are located in at least one major urban area per province. The role of outreach and use of mobile and support services to broader regions may be a feasible way to increase coverage61. Services for transgender populations are limited however Gender DynamiX provides support groups, legal assistance in regards to Act 49, and support in terms of medical treatment (hormones and surgeries etc.). The Alteration of Sex Description and Sex Status Act No. 49 of 2003 allows for individuals to legally change their gender, provides for those who are in various stages of transition, and is not limited to those who have undergone reassignment surgery. Criminalisation of sex work increases the overlapping vulnerabilities of sex workers (SW) including violence, abuse, harassment, HIV and lack of access to services and justice. Criminalisation of the clients of SWs may result in further increases in vulnerability of SWs to HIV and impact on public health. Discrimination towards SWs by society compound the stigma attached to sex work. Pilot outreach activities in South Africa have demonstrated success in improving SW access to HIV testing, treatment and support services, and are models which could be used for national rollout to increase coverage. Some donor restrictions, most notably the President’s Emergency Plan for AIDS Relief (PEPFAR), on sex work programme activities limit the breadth and range of organisations working with SWs and their services. Department of Correctional Services (DCS) has made great strides in addressing various aspects of HIV in prisons, including condom availability, HCT and ARV treatment. Sentenced offenders reportedly have 100 % access to primary health care services. Initial research has identified disproportionately higher levels of HIV among prisoners compared to the general population. Awaiting-trial detainees are in greatest need of improved HIV prevention and sexual and reproductive health services. Accurate data around drug use, sex between men and other sexual practices is needed in order to improve services within the prison system. In 2010 there were 12 accredited ART sites, 7 640 inmates were on ART, 72 227 inmates attended HIV awareness sessions, there were 103 functional support groups, 14% of the offender population participated in comprehensive HIV and AIDS programmes and sentenced offenders reportedly had 100% access to primary health care services. Relevant policies around ART provision, PEP and HCT were reported to have been distributed. Prisons have been identified as strategic points to increase access to HIV prevention, treatment, care and support services to offenders. Additional focus needs to be placed on prevention programmes and for the utilisation of peer-led programmes. Condoms are irregularly available within the prison system. Condom-compatible lubrication is not provided. A shortage of doctors and other health care professionals within the correctional service system limits its ability to provide quality and coverage of services. Funding for HIV interventions in prisons are currently limited. Stigma and discrimination by prisoners and prison staff around HIV, drug use and sex between men is not appropriately addressed. Historically there has been little attention from the DCS on preventing sexual violence and the department currently lacks a comprehensive framework for dealing with the problem. Existing legal frameworks and policies that ensure the right to access HIV prevention, treatment and services for all migrant groups need to be implemented and monitored. Existing legislation is not effectively implemented.
The NDOH, through the National Health Information Systems Committee of South Africa (NHISSA), a sub- committee of the Technical Advisory Committee chaired by the Director- General (DG), has been assigned a number of responsibilities, including:
Successful implementation of these interventions will ensure improvement in the assessment of progress towards attaining the goals of the NSDA. The District Health Management Information System (DHMIS) policy (2011) was developed to provide an overarching regulatory framework in terms of the NHA of 2003, and focuses on the routine DHMIS. The goal of the policy is to standardise implementation of the DHMIS and create uniformity across SA. The policy has seven priority focus areas: health information coordination and leadership; indicators; data management; data security; data analysis and information products; data dissemination and use; and HIS resources. An eHealth Strategy has been developed for SA. It provides guidance on infrastructure, mobile health technology (mHealth), telemedicine and electronic health records. SA has the largest antiretroviral therapy (ART) programme in the world. In March 2011 in an attempt to standardise facility-level ART data management the National Health Council approved the adoption of a three-tiered strategy for monitoring provision of ART in all provinces. This strategy was renamed the Systematic Monitoring of ART, Evaluation and Reporting (SMARTER) by NHISSA. This World Health Organization-derived strategy comprises the following:
A sub- committee of NHISSA has been established to oversee and govern the implementation process and a national implementation team of national M&E staff, governmental partner staff, and the University of Cape Town’s Centre for Infectious Disease Epidemiology and Research (CIDER), provide on-going implementation support. Pilot training was conducted in July 2011 and subsequently rolled out across the country. Tiers 1 and 2 Master Training of provincial staff and development partners has started and is being rolled out country-wide62. The NDOH completed the first phase of the development of the National Health Information Repository and Data Warehouse (NHIRD) in 2011. As a central repository for data, information from multiple sources will be stored in the NHIRD and updated regularly. The NHIRD is a crucial step towards evidence based health planning and decision-making in order to improve the health outcomes of the country. A web-based pivot reporting system with a GIS platform based on the District Health Information System, which is the common health information system in the country, forms part of the NHIRD. This allows for data to be visually demonstrated in the form of interactive graphs and maps. The system also allows for the comparative analysis of data and information. Access to the NHIRD was rolled out to eight provinces during the past financial year. On average six managers from the planning, monitoring and evaluation and information management units per province were trained on the use of the NHIRD. Further access to the NHIRD will be rolled out to the NHI pilot districts during the 2012/13 financial year63. M&E supports the generation of the data that flows in this system, and strengthens the quality as well as the analysis, interpretation, and use of information produced thus critical to the ART programme - for programme planning and decision making. The NDOH has developed a new 3-tiered patient-based monitoring system for ART, which is being implemented throughout the country in phases. This will enable certain health facilities with larger numbers of ART patients use of an electronic monitoring system. The NDOH and DSD are responsible for reporting against most of the targets detailed in the 20012-2016 NSP. Given this responsibility, these Departments need to have rigorous monitoring and evaluation systems in place. The NDOH has a Health and Management Information System (HMIS) that links different components of the health system. At the district level, the HMIS collects data on a wide range of indicators at primary health care and district health care levels. The main weakness of the system is that it only registers utilization, providing little information about actual coverage and use (a function of the data collection tools). This limited its value in the management of HIV/AIDS, which necessitated the development of the electronic national ARV patient register, which was started in Phase 1 of the NSOH GF SSF grant. This register, when fully operational will assist the country to properly assess uptake of HCT, uptake of ART, and treatment discontinuation through death or default and trends in drug resistance. To date over 1075 facilities are using the electronic register, exceeding the agreed upon target of 3501.
During 2010/2011, the department achieved a significant reduction in the price of antiretroviral medicines. The department awarded a tender for the supply of antiretroviral medicines to the value of R4.2 billion over two years, which resulted in savings of R4.4 billion (53%) – when compared with previous tender prices. The lower prices enabled the health sector to re-allocate more resources towards enrolling people on antiretroviral treatment (ART) with its existing budget. Access to ART was expanded to an additional 650 000 people in 2011, which culminated in 1.6 million people living with HIV receiving treatment by the end of that financial year64. However, the health system has experienced an on-going challenge of drug stock-outs. Given the high burden of disease for HIV and TB, it is essential to maintain a proper procurement and supply management system for drugs forecasting, procurement, distribution and stock management at all levels of the health system. Building from the single stream funding phase 1 program, this proposal will enhance the capacity for procurement and supply chain management. The newly established central procurement unit (CPU) will procure and regulate ARV supply, and work with provinces to fill any ARV gaps due to high demand at the facility level or short supply caused by financial shortfalls or vendor delays. The CPU functions as the procurement brain, collecting, processing and reacting to information in the best interests of the entire health system. It will further contribute towards the scaling up of antiretroviral treatment in the country. In November 2012 a tender was awarded for a single-dose antiretroviral (ARV) treatment in SA. The R5.9-billion tender mean that the majority of South Africans on state-sponsored ARV treatment for HIV would, from April 2013, need only one tablet instead of the current multiple pills per day. The NDOH also managed to reduce the cost of the tender - for a single dose of the triple combination of Tenofovir, Emtricitabine and efavirenz - by 38%, an estimated saving of R2.2-billion. There is currently no structured response or national programme to evaluate the emergence of HIV Drug resistance (HIV DR). There are however coordination efforts underway, bringing all the academic, non-government and national health laboratory role-players together. Resources to conduct well-structured surveillance and cross-sectional projects are currently not provided for in the NDOH funded programme. Further capacity development may be required, ahead of adjustments in the HIVDR guidelines for clinical care. Training and monitoring and evaluation capacity is required. South Africa has emerged as an important clinical hub in Africa. Many new medications, devices and biological products are being introduced adding to the already existing products on the market. Therefore, there is a need for a vibrant and robust pharmacovigilance system in the country to protect the population from potential harm. South Africa joined the WHO pharmacovigilance programme in 1992. Since then the country has submitted approximately 16,000 Individual Case Safety Reports (ICSRs) to VigiBase, almost half (48%) of the total submission from the African continent. VigiBase is the WHO Global Individual Case Safety Reports database system. The National Pharmacovigilance Centre (NPC), hosted in the Medicines Control Council (MCC) of the NDOH in Pretoria is responsible for monitoring pharmacovigilance in South Africa. A national ICSR database is maintained by NADEMC (a unit of the NPC). The NPC, having successfully trained health care workers and established a robust patient-focused pharmacovigilance process for the HIV/AIDS treatment programme, envisages it to be a model and driver of other pharmacovigilance activities in South Africa. A rollout of this process has the potential of achieving the desired cohesive and dynamic system that will meaningfully impact on clinical care and patient safety in the whole country. A programmatic and institutional pharmacovigilance plan will be incorporated into a cohesive national system. A number of programmatic pharmacovigilance priorities have been identified and include:
The NPC, having successfully trained and established a decentralized pharmacovigilance process in Mpumalanga will provide on-going and follow-up training and support as the need arises. More importantly, the NPC have planned a rollout of the process to the other provinces in South Africa based on a similar structure. Provinces will be divided into districts, which will in turn be divided into clusters. The first point of call will be with HIV/AIDs and TB treatment programme and then later, other South African programmatic pharmacovigilance priorities.
SA is heavily investing in research and development, spending US$ 2.6 billion in 2008 and committing to spend more than US$ 10 billion by 2018. Emphasizing infectious diseases and research and development for prevention and drug development, SA greatly contributes to the global AIDS response and is now the second largest funder for microbicides research and development. In 2011, it invested US$ 10 million, including US$ 2.5 million for the CAPRISA 004 study, the first to demonstrate that microbicides can reduce a person’s risk of becoming HIV-positive.65 The specific health system constraints and how it will be addressed in this proposal is summarised in “1.3.1 Summary of Request”. Yüklə 2,41 Mb. Dostları ilə paylaş:
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