All over the World, more so in developing countries, we grapple with the understanding of the true and full impact of disease. This has been exacerbated by the advent of HIV and AIDS. South Africa is no exception.
Although we have done a lot to understand the nature and cause of the major communicable diseases such as TB, malaria and HIV and AIDS in our context, we would be the first to admit that the full picture remains unknown. Clearly though, there will be no perfect end point to this journey and we have to continuously act on the basis of the best information and evidence before us whilst continuously improving our systems and better targeting our responses.
The extent of the likely impact of the HIV and AIDS epidemic upon South African society has become clearer in the last year, as the results of primary research and modeling exercises have begun to converge upon an increasingly consistent picture of the likely magnitude and scope of AIDS in our country. This picture is bleak indeed; South African models of likely mortality from HIV and AIDS predict that cumulative deaths will most likely reach between 3.4 and 4.5 million by 2010, in the absence of significant breakthroughs in preventive or curative technologies in the near future (Departments of Health, Education, Public Service and Administration, 2001). It is important to state that a joint exercise has begun between Health and the Dept of Home Affairs to quantify and record the precise numbers of cumulative deaths.
HIV and AIDS will have profound effects on almost every aspect of society, economic activity, family life and even upon national security, requiring a web of inter-sectoral interventions and responses if the impact of the disease is to be mitigated and minimised. This impact falls disproportionately on the poor populations of the Country, raising major challenges for the enhancement and acceleration of our overall poverty eradication efforts if we are to avoid continued downward slide and marginalisation of a significant portion of our communities.
The health sector, and especially the public health sector, is one area in which the impact of HIV and AIDS will be felt very directly, relatively early, and with significant implications for the operation of this sector. HIV and AIDS, and its closely linked co-infection, TB, have a practical and immediate impact on the core business of the public health sector – each year, more people will become seriously sick and present to health facilities requiring care – while skilled health workers themselves increasingly become sick and die in the prime of their productive years. Much has already been done to improve the capability of the health sector to prevent the transmission of HIV; yet more can still be achieved. Meanwhile, appropriate and affordable methods of caring for people who are sick with AIDS-related illnesses and TB now need to be developed urgently. This document outlines the components of an enhanced health sector response to HIV and AIDS, STIs and other opportunistic infections together with the closely related, spillover impact for TB, and sets out the a consolidated funding requirements of such a response over the forthcoming MTEF cycle from 2002/03 to 2004/05.
It is important to stress a few issues around data and data availability. At this point in time, the Health Sector does not have all the data available at our disposal to make very precise assessments of the extent of the burden and hence, inform some of the calculations made in this document. However, it must be stressed that the Dept of Health is doing everything that is possible to improve data collection systems and the reliability of our statistics.
Conservative models of HIV prevalence rates in South Africa suggest that, already, over 3 million South Africans are infected with HIV, with upper estimates exceeding 4 million. According to the more conservative models, this number could have reached 6.9 million by 2010. At the same time, South Africa faces a serious and growing TB epidemic, with 237,000 TB cases in the year 2000 (South African Health Review 2000). The two epidemics are closely linked, and as such a consolidated approach is adopted in this report, as HIV infection considerably increases the likelihood of an individual acquiring TB – nearly 50% of TB cases are currently likely to be HIV positive, and growing numbers of HIV positive individuals will further drive up TB caseload in years to come. Growing numbers of TB cases due to HIV in turn expose a greater number of HIV negative individuals to TB infection, creating the circumstances for an escalating epidemic in both the HIV positive and negative populations if effective control cannot be established. Meanwhile, multi-drug resistant strains of TB pose a growing threat in South Africa.
The impact of HIV and AIDS, related opportunistic infections and TB on the health sector is manifested both in the form of increased demand for service, and, increasingly, through a degraded capability to deliver services on the supply side. These mechanisms are summarised briefly below.
(a) Health Service Demand and Utilisation
After becoming infected with HIV, an individual will experience a period (often lasting several years) in which they manifest few or no symptoms of HIV-related illness. As time passes, however, they will increasingly become prone to a range of opportunistic infections and illnesses which are likely to become ever more severe. These illnesses are likely to lead ultimately to significantly premature death. Where anti-retroviral therapy is available, progression to death is likely to be delayed by months or years, but current therapies will ultimately fail in most individuals, so that their effect is to delay, but not to prevent, premature death from AIDS-related illnesses. There are other interesting, more affordable and safer options being explored such as immune boosters, but it is still early to make definitive conclusions. This area though needs closer follow-up.
During the period of more frequent illness (Stages 3 and 4), individuals will experience episodes of severe and acute illness. These episodes lead them to present to health service providers, both at primary care level and, frequently, for hospitalisation due to acute sickness. Most of the conditions and opportunistic infections encountered in Stage 3 sickness can be effectively treated with essential drugs and basic interventions which current health policy requires being universally available in the public health system. In Stage 4, treatment options become progressively more limited, but individuals will require palliative and personal care, including chronic pain relief in the period before death.
People with AIDS tend to come from the age group (people in early and middle adulthood), which, prior to the advent of HIV and AIDS, traditionally made the least demand upon health care services. AIDS demand therefore tends to be additional demand for health care, on top of a largely unchanged demand profile from children and older people. As more individuals develop AIDS-related illnesses each year, clearly total demand for health care will tend also to rise on an annual basis.
The largest single impact of HIV and AIDS on the public health sector lies in the hospital sector. Research commissioned by the Department of Health (Abt Associates, 2000) indicates that, in the year 2000, an estimated 628,000 admissions to public hospitals were for AIDS-related illnesses, which amounts to 24% of all public hospital admissions. Other local studies (Bateman, 2001) tend to report even more acute impacts at particular hospitals. Modeling indicates very clearly that, as more people who are already HIV positive become sick each year, this demand for hospitalisation will increase steadily every year in the absence of significant alternative interventions. In financial terms, the cost of hospitalising AIDS patients in public facilities is already likely to be at least R3.6 billion in the current financial year, or 12.5% of the total public health budget.
Clearly, demand for primary health care is also driven upwards by growing numbers of AIDS. Some evidence is available that there is an upward trend in utilisation of PHC facilities that can be directly related to HIV infection.
Impact on Health Care Quality
Evidence from other African countries already facing a mature AIDS epidemic points to serious and complex effects of AIDS upon the quality of clinical care which can be sustained in the public health system (e.g. Gilks, 2000). Evidence from systematic, longitudinal tracking of hospitalisation in Nairobi over a ten year period indicates that, as increasing numbers of HIV positive people become sick with opportunistic infections and late-stage AIDS related illnesses, these individuals have represented an ever greater proportion of admissions to hospital, with significant "crowding out" of other workload. Evidence from Hlabisa (KwaZulu Natal) over a seven year period showed these trends to be even more pronounced, with a major shift in the ranking of cause of admission. In Nairobi, however, some years after the initial shock impact of AIDS, it became clear that people with end-stage AIDS were no longer being admitted to hospital – implying that hospitals had "coped" with the impact of AIDS by, in effect, choosing not to provide care to the dying, in order to deal with patients with "treatable" conditions. Both these phenomena imply a degradation of care quality and an application of crude rationing which is both preventable and unacceptable in the South African context.
and TB cases. In particular, rising levels of multi-drug resistant TB have a significant cost impact; each case of MDR TB requires a drug regimen costing R31, 000, and six months hospitalisation – neither of which cost can be avoided, due to the imperative need to prevent further spread of MDR infection.
Supply Impacts
To date, the public health sector has felt most of the impact of HIV and AIDS in the form of increased demand. Increasingly, however, the ability of the health system to provide effective care will itself be degraded due directly to HIV and AIDS. Fundamentally, health workers are not immune to HIV infection. Many health workers are already likely to be HIV positive, and more will probably become infected. Over time, they will become sick and die. This tendency will increasingly create staffing gaps – through their own sickness absence, absence to care for sick relatives and funeral attendance, and ultimately through staff deaths. Productivity will decline, and the ability of smaller units (e.g. clinics) to operate effectively may be seriously compromised by the loss of even one key worker. Loss of colleagues and friends, combined with increasing demand pressure, is likely to have substantial negative impacts on the morale of surviving staff.
Current Response to HIV and AIDS and Priority Areas for Improvement
Significant resources are already devoted to controlling HIV and AIDS and TB in South Africa, both deliberately via the existing framework of the Government AIDS Action Plan, the Integrated Plan on HIV and AIDS, and the national TB control programme, and by default through health service utilisation by infected individuals. This paper estimates overall expenditure levels on HIV and AIDS, and identifies a focused set of specific activities for expansion and development, and the resources required to do so. Before discussing specific estimates, however, it is important to spell out the underlying factors which require the commitment of further financing to combat HIV infection and AIDS and TB epidemics.
HIV Prevention
Increased expenditure on prevention remains a very high priority in order to minimise the number of new infections and hence minimise the ultimate human, social and economic impact of the disease. Effective primary prevention remains the most effective method for minimising future AIDS care costs. It is too late to prevent significant growth in health care demand amongst people already infected, but long-term demand for care can still be minimised by prevention activities undertaken today. Recent work on the impact of HIV and AIDS on health workers also spells out starkly the vital need for considerably greater efforts to change the personal behaviour of health workers – both to minimise the loss of valuable professionals, and to enhance their ability to work as advocates of HIV prevention in the wider community.
Treatment, Care and Support for People with AIDS
As described above, increasing demand for care and support is emerging and will continue to grow for at least eight to ten years. This demand manifests itself currently in presentation to primary care and admission to hospital. To date, this demand has been accommodated by three main mechanisms:
Crowding out of care for persons with non-HIV related needs
Provision of inadequate quality of care for many of those presenting with HIV related needs
Not providing any meaningful care for a proportion of those sick with HIV and AIDS, especially in areas with generally poor access to health care
These current coping mechanisms are likely to become increasingly unsustainable as absolute numbers of people sick with AIDS grow rapidly over the next few years. In particular:
The sheer rate of growth in demand for care by people with AIDS will mean that crowding out of non-AIDS care will rapidly reach unacceptable proportions - which will become unsustainable politically and will result in major inefficiencies in health provision (e.g. as AIDS cases start to encroach onto surgical wards, operating lists will be disrupted leading to inefficient use of theatre, surgical and anaesthetist time, falling surgical output and resultant rising unit costs)
Continuing to provide low quality care becomes self-defeating, as it results in re-admission and revolving-door patients, when, for example, better drug availability could ensure that a patient will not require repeat hospitalisation as part of the same care episode. Absolute numbers of acutely sick people will continue to grow and will continue to present at health facilities, presenting a real risk that delivery systems and staff morale will buckle unless concomitant increases in essential drugs and supplies are made available
Failing to provide care for population sub-groups (primarily the rural poor with poor access to health care) will become increasingly politically dangerous as the absolute number of people sick with AIDS rises among poor and vulnerable groups. Increasing inequality in access to very basic care will result if investment in key services does not occur in resource-poor areas
Providing sub-standard care or failing to provide basic care is clearly also unacceptable from a human rights perspective, and in the current environment is likely to lead increasingly to legal challenge
Effective interventions are available which provide cheap, cost-effective and flexible means of providing basic symptomatic and palliative care for people with AIDS. Foremost amongst these are home-based care (HBC) and step-down care. These provide a mechanism to achieve the following objectives:
Diverting increased demand for care away from acute hospitals and into a lower-cost environment, allowing acute hospitals to focus on more patients requiring more complex care
A low-cost and flexible option for expanding service provision in areas, which are currently under-served. Both HBC and step-down care require little or no medical input, and can be led by nurses with most activity undertaken by nursing assistants or community workers with basic training only
HBC also provides a powerful platform through which to extend TB DOTS care and social care and support, through assistance in accessing benefits, identification of children at risk of being orphaned etc.
The area of tuberculosis is very important, and hence, to some extent, needs to be highlighted separately. It is important firstly, in its own right, because TB is a major cause of morbidity and mortality in South Africa. South Africa faces a serious and growing TB epidemic, with 237,000 TB cases in the year 2000 (South African Health Review 2000). Secondly, it is important because of the complex relationship that exists between TB and HIV, especially in the South African context. The nature of the TB epidemic means that a large percentage of the healthy and non-HIV positive population carry a component of TB infection. This component lies inactive within our system and only becomes active when the state of our immunity seriously declines. A typical situation would be the onset of HIV, which severely depletes our immune system, opening us up to development of active TB.
Hence, HIV infection considerably increases the likelihood of an individual acquiring TB – it is estimated that nearly 50% of TB cases are currently likely to be HIV positive, and growing numbers of HIV positive individuals will further drive up TB caseload in years to come. Growing numbers of TB cases due to HIV in turn expose a greater number of HIV negative individuals to TB infection, creating the circumstances for an escalating epidemic in both the HIV positive and negative populations if effective control cannot be established. This further emphasises the fact that the South African tuberculosis epidemic will continue to grow in tandem with HIV and AIDS. TB poses a particular risk, as its increasing incidence puts both HIV-infected and HIV negative persons at risk. Given the critical need to contain the growth of TB, adequate provision must be made to ensure that drug availability keeps pace with the growth in TB caseload at all times.
Meanwhile, multi-drug resistant strains of TB pose a growing threat in South Africa. Particular efforts and expenditure are required to contain the growth of Multi-Drug Resistant TB, mainly by ensuring through DOTS that patients complete a full first course of drugs, but also through ensuring rapid identification and effective management of MDR cases. Drug treatment for MDR TB is extremely expensive; failure to contain MDR TB would result both in drastic impacts on future drug expenditures, and the inadvertent transformation of a curable and preventable communicable disease into a sub-epidemic that killed increasing numbers of people.
Current Response to TB
The number of active TB cases treated in 2000/1 was 75,652. This represents an increase on active cases in the previous year, despite the fact that cure rates for TB have increased steadily in the last few years (from just over 55% to over 60% in 2000). The fact that it is estimated that approximately 50% of TB patients are also HIV positive indicates the degree to which compromised immunity fuels the TB epidemic.
TB remains a curable disease even where there is co-infection with HIV. The revised National TB Control Programme, launched in 1996, adopted the World Health Organisation (WHO) strategy of directly observed treatment short-course (DOTS) and began standardising procedures relating to diagnosis, treatment and reporting.
So the Dept of Health has focussed on reinforcing community-based treatment by:
Focusing on community-based treatment and was implemented through an expanding number of Demonstration and Training Districts. This was initially slow, but by March 2001, 134 Demonstration and Training Districts had been established. During 2000/01 the number of Districts meeting the target cure rate of 85% increased to 10 and a further 31 were reporting cure rates between 75% and 84%.
We hope to roll-out DOTS to all Districts by 2002/03
Recruiting and training large numbers of volunteers to support patients during the six-eight month treatment programme.
Pioneering the use of the combination tablet for TB. A four-drug combination pill was introduced for the intensive phase of treatment in all provinces, making South Africa the first country to adopt this form of treatment.
Building community food projects to improve nutritional status of TB patients
Though there has been uneven progress in Provinces, overall there has been an improvement in cure rates, a decrease in interruption and a significant improvement in laboratory test results turn-a-round time.
In addition, successful pilot projects for the integrated management of HIV and TB were introduced during 2000/01. At the pilot facilities, patients who tested positive for HIV and are at risk of developing active TB are placed on a preventive drug regime.
The Impact of STIs on the Public Health Sector
Tuberculosis
The area of Sexually Transmitted Infections (STIs) is another important area that needs to be stressed if we are to take a comprehensive look and enhancing our response. International and national studies illustrate indisputable evidence that one of the most effective health sector responses that would deal with the issue of HIV transmission is by radically and robustly treating STIs. This significantly reduces the probability of transmission of HIV infection by up to 40%.
Current Response to STIs
The effective management of STIs remains a cost effective intervention in the prevention of HIV and AIDS. Since the adoption in 1996, South Africa has been managing a National STD Programme in line with the WHO-recommended system of syndromic Case Management. This programme is widely used in the Public Sector and 80% of clinics have at least one health worker recently trained in this approach.
The halving of syphilis prevalence over the past 2 years (established through the Ante-natal surveillance system) attests to considerable success. However, other STIs have not shown a similar decline.
The Dept of Health is currently engaging with the private sector around partnerships to ensure adequate responses. The South African tuberculosis epidemic will continue to grow in tandem with HIV and AIDS. TB poses a particular risk, as its increasing incidence puts both HIV-infected and HIV negative persons at risk. Given the critical need to contain the growth of TB, adequate provision must be made to ensure that drug availability keeps pace with the growth in TB caseload at all times. Particular efforts and expenditure are required to contain the growth of Multi-Drug Resistant TB, mainly by ensuring through DOTS that patients complete a full first course of drugs, but also through ensuring rapid identification and effective management of MDR cases. Drug treatment for MDR TB is extremely expensive; failure to contain MDR TB would result both in drastic impacts on future drug expenditures, and the inadvertent transformation of a curable and preventable communicable disease into a sub-epidemic that killed increasing numbers of people.
Developing an Enhanced Health Sector Response
The remainder of this document summarises the key components of an enhanced public health sector response to HIV and AIDS and TB, presents a brief rationale for each, and sets out the funding requirements of this response for the three financial years 2002/03 to 2004/05, relating expanded activities to "baseline" estimated expenditure in 2001/02.
It is important to stress a few issues around data and data availability. At this point in time, the Health Sector does not have all the data available at our disposal to make very precise assessments of the extent of the burden and hence, inform some of the calculations made in this document. However, it must be stressed that the Dept of Health is doing everything that is possible to improve data collection systems and the reliability of our statistics.
Nevertheless, there is sufficient data to start us moving in the right direction. It is the belief within the Health Sector, that the document tables interventions that are fairly conservative and therefore it is important for us to see that in spite of us not having a totally accurate picture, we are confident that the proposals are consistent with the broad direction and that as better, improved data becomes available a more precise picture will unfold, but will not significantly differ from what is being presented here.
The core principles of the proposed enhanced response are:
To strengthen and accelerate the implementation of a core package of activities of proven cost-effectiveness
To focus on a limited set of realistic priorities which will have the largest pay-back (Ainsworth 2000)
To ensure efficient use of resources and to develop more efficient and appropriate models of care
To initiate research and development activities to address particular areas where current evidence is inadequate to guide policy
The approach adopted identifies four focus areas – prevention; treatment, care and support; tuberculosis control; and programme management. Interventions in each of these four focus areas are then grouped into three categories, reflecting differing levels of certainty or contingency:
Core interventions – interventions of proven effectiveness and cost-effectiveness which can be adopted or expanded with confidence (e.g. improved availability of essential drugs; home-based care)
Lower cost / higher certainty interventions – interventions for which there is less evidence than for the "core" package, but which show promise pending current research results (e.g. future national roll-out of prevention of mother to child transmission pilot programme)
Higher cost / lower certainty interventions – interventions which both have significant likely cost implications and which require substantial further research prior to adoption, but for which policy-relevant answers will be required in the medium-term (e.g. affordability and effectiveness of different therapy options in SA public health sector)
The combined costs of the interventions are presented below. Their content is described in more details, their underlying rationale and evidence base, and the method of estimating the funds required for each are summarised as a detailed appendix.
As table 1 indicates, very significant expenditure is already being incurred by the public health system on HIV and AIDS in the current financial year, in the order of R 4.4 billion (a more detailed breakdown of estimated current spending is provided in Group A – Core Intervention Package). The National Department of Health spends some R 219 million of this amount, primarily on prevention, with the remainder accounted for by provincial health departments, who already spend very substantial sums on treatment care and support. The enhanced response would increase funding in real terms by over R 800 million per year (table 2), with the aim of ensuring that resources for treatment, care and support keep pace with demand and ensuring that the relative weight accorded to expenditure on prevention increases. Table 4 presents these funding requirements in nominal terms, assuming an annual inflation rate of 5%; hence, it represents the specific additional funds requested in the next three-year MTEF period. The "additional funds for provinces" effectively represent net additional funds required in excess of current levels of equitable share funding for provinces specifically to fund the enhanced response to HIV and AIDS and TB – although these funds could be routed to provinces either via the equitable share, or via a recurrent conditional grant. Funding mechanisms are discussed later in the document.
1. Combined Intervention Package - Total Cost
|
R millions (2001 prices) |
2001/02 |
|
2002/03 |
|
2003/04 |
|
2004/05 |
|
|
Sub-Totals |
Total |
% |
Total |
% |
|
% |
|
% |
|
A Prevention |
201 |
5% |
280 |
5% |
472 |
8% |
734 |
10% |
|
B Treatment Care & Support |
3,971 |
89% |
4,629 |
88% |
5,265 |
86% |
5,815 |
81% |
|
C Tuberculosis |
224 |
5% |
287 |
5% |
324 |
5% |
557 |
8% |
|
DC Programme Management |
48 |
1% |
71 |
1% |
76 |
1% |
71 |
1% |
|
Sub-Total |
4,2214,445 |
10095% |
4,9795,266 |
10095% |
5,8136,137 |
10095% |
7,1776,620 |
10092% |
|
Tuberculosis |
224 |
5% |
287 |
5% |
324 |
5% |
557 |
8% |
|
Total Funding Requirement |
4,445 |
100% |
5,266 |
100% |
6,137 |
100% |
7,177 |
100% |
NOTE: DUE TO THE FACT THAT THE ALLOCATION FOR STIs IS A SMALL FIGURE, IT HAS BEEN INCLUDED UNDER B: TREATMENT & SUPPORT
2. Additional Funding Required
|
(R millions 2001 prices) |
2002/03 |
2003/04 |
2004/05 |
|
Year on year |
822 |
870 |
1,040 |
|
Cumulative |
822 |
1,692 |
2,732 |
3. Total Expenditure by National and Provincial Health Departments
|
Rands |
2001/02 |
2002/03 |
2003/04 |
2004/05 |
|
National Dept. of Health |
219,279,700 |
340,542,092 |
340,249,292 |
344,309,292 |
|
Provincial Depts. Of Health |
4,225,502,270 |
4,925,803,665 |
5,796,312,785 |
6,832,313,717 |
(n.b. 2001/02 provincial total includes R34.1 million conditional grant funding)
4. Proposed Total Funding Requirement – Nominal Prices
|
|
2001/02 |
2002/03 |
2003/04 |
2004/05 |
|
National Dept. of Health |
219,279,700 |
357,569,197 |
375,124,844 |
398,581,044 |
|
Additional funds for Provinces (relative to 2001/02) |
0 |
735,316,464 |
1,731,818,593 |
3,017,710,101 |
Group A - Core Intervention Package "Baseline" figures in shaded cells are estimates only
|
|
Combined National & Provincial Total |
Baseline |
Total Funding Requirement (2001 Rands) |
|||
|
Focus |
Intervention |
2001/02 |
2002/03 |
2003/04 |
2004/05 |
|
|
A Prevention |
1. Condoms -– male |
42,620,000 | 80,500,000 | 93,072,975 |
97,699,180 |
|
|
|
2. Condoms – female |
7,000,000 | 24,418,800 | 25,627,025 |
26,900,820 |
|
|
|
3. Improved STD drug availability in public sector |
8,336,598 |
16,673,195 |
16,673,195 |
16,673,195 |
|
|
|
4. Expanded IEC / campaign activities |
50,000,000 |
71,000,000 |
90,000,000 |
90,000,000 |
|
|
|
5. National roll-out of Voluntary Counselling & Testing |
22,000,000 |
26,000,000 |
41,453,625 |
57,325,800 |
|
|
|
6. NGO Support |
28,000,000 |
32,000,000 |
36,000,000 |
40,000,000 |
|
|
|
7. EU capacity building programme |
15,534,700 |
0 |
0 |
0 |
|
|
|
8. MTCT Pilot & Research Programme |
28,000,000 |
23,000,000 |
0 |
0 |
|
|
B Treatment, Care |
1. Improved availability of essential drugs for non-TB |
375,215,388 |
711,871,886 |
852,729,727 |
995,790,038 |
|
|
and Support |
opportunistic infections and AIDS-related conditions |
|
|
|
|
|
|
|
2. Roll-out Community & Home Based Care |
12,100,000 |
120,009,700 |
351,238,800 |
573,677,600 |
|
|
|
3. Hospitalisation of AIDS-related illnesses - marginal cost |
3,583,629,061 |
3,755,360,052 |
3,937,218,743 |
4,121,438,378 |
|
|
DC Programme Management |
1. Enhanced national management team (NDoH) |
43,125,000 |
45,323,292 |
45,323,292 |
45,323,292 |
|
|
|
2. Enhanced provincial management teams |
0 |
6,709,053 |
8,386,317 |
8,386,317 |
|
|
|
3. Strengthen integration of HIV and AIDS care and support into district and hospital management functions. |
0 |
2,000,000 |
2,000,000 |
0 |
|
|
|
Improving co-ordination of strategies at the District level |
|
|
|
|
|
|
|
4. Research transfer payments, including surveillance systems |
5,000,000 |
10,000,000 |
5,000,000 |
5,000,000 |
|
|
Sub- Total Funding Requirement |
|
4,444,781,9704, |
5,206,770,7574924, |
5,823,691,5435, |
6,435,123,0096, |
|
|
Tuberculosis |
1. Expanded DOTS drug availability to meet estimated |
179,553,383 |
204,943,032 |
232,020,406 |
259,734,863 |
|
|
|
Growth in TB caseload (incl. MDR) |
|
|
|
|
|
|
|
2. DOTS delivery and supervision |
44,667,841 |
50,984,073 |
57,720,164 |
64,614,743 |
|
|
|
3. DOTS Volunteer Stipends |
0 |
23,452,674 |
26,551,275 |
29,722,782 |
|
|
|
4. NGO Support |
0 |
2,525,000 |
2,676,000 |
2,836,000 |
|
|
Total Funding Requirement |
|
4,444,781,970 |
5,206,770,757 |
5,823,691,543 |
6,435,123,009 |
|
Group B - Lower Cost and/or Higher Certainty Interventions
|
|
Combined National & Provincial Total |
Baseline |
Total Funding Requirement (2001 Rands) |
||
|
Focus |
Intervention |
2001/02 |
2002/03 |
2003/04 |
2004/05 |
|
A. Prevention |
National roll-out of PMTCT intervention package |
|
|
|
|
|
1. - excluding free infant formula |
|
0 |
87,095,534 |
254,950,000 |
|
|
2. - plus infant formula |
|
0 |
69,825,000 |
135,000,000 |
|
|
3. STD drug availability for syndromic management by private practitioners |
|
5,000,000 |
10,000,000 |
15,000,000 |
|
|
B. Treatment, Care and Support |
1. Develop and roll-out successful models of step-down / intermediate care to substitute for hospital admission |
30,000,000 |
100,000,000 |
100,000,000 |
|
|
CD. Programme Management |
1. Develop protocols and care pathways for integrated management of HIV and AIDS between primary, CHBC, Step-down and hospital levels |
|
2,000,000 |
10,000,000 |
0 |
|
2. Research transfer -– validation of HIV testing methods |
5,000,000 |
5,000,000 |
0 |
||
|
Sub-Total Funding Requirement |
46,800,00042, |
281,920,534287, |
504,950,000 |
||
|
Tuberculosis |
1. Upgrade facilities for acceptable quality care of patients with Multi-Drug Resistant TB |
|
4,800,000 |
5,400,000 |
0 |
|
Sub-Total |
46,800,000 |
287,320,534 |
504,950,000 |
||
Group C - Higher Cost and/or Lower Certainty Interventions
|
|
Combined National & Provincial Total |
Baseline |
Total Funding Requirement (2001 Rands) |
||
|
Focus |
Intervention |
2001/02 |
2002/03 |
2003/04 |
2004/05 |
|
A. Prevention |
Operational research on appropriate models for implementation of a future HIV vaccine |
|
1,000,000 |
2,000,000 |
0 |
|
B. Treatment, Care and Support |
RCT of treatment strategies in selected district health system
settings |
|
11,775,000 |
23,550,000 |
23,550,000 |
|
DC. Programme Management |
Develop protocols and care pathways for patient management with alternative treatments |
|
0 |
0 |
12,000,000 |
|
Sub-Total Funding Requirement |
12,775,000 |
25,550,000 |
236,550,000 |
||
|
Tuberculosis |
Conversion of acute hospital beds for TB care |
|
0 |
0 |
200,000,000 |
|
Total Funding Requirement |
|
|
12,775,000 |
25,550,000 |
236,550,000 |
Appropriate Funding Vehicles
Different options for the specific routing of the funds proposed above are possible, and considerable thought will need to be given to achieving the most effective routing of funds. Four main channels are available:
Direct expenditure / procurement by the National Department of Health
Expansion of the current HIV and AIDS conditional grant
Creation of a new recurrent conditional grant for HIV and AIDS and TB funding for provinces
Expansion of the health component of the equitable share revenue pool
Although HIV and AIDS and TB have costed out and represented separately, it would start to become quite cumbersome if the vehicles used for the additional funding for HIV and AIDS and TB were to begin to be separated. However, broad output / outcome targets would be set for different components of the funding as set out earlier in this document.
Direct national-level expenditure will remain desirable for the broad range of activities currently undertaken in this manner (e.g. condom procurement, campaigns, research funding etc.), and can be expanded relatively safely. Clearly, though, the vast majority of HIV and AIDS and TB funding must be channelled to provinces, where service delivery actually takes place. The existing HIV and AIDS conditional grant has, however, proved problematic, due largely to its restrictive and time-consuming procedural requirements (bids and business plans for specific projects), and is unlikely to be a suitable vehicle by which to channel larger sums of money to provinces. Creation (or conversion) of a new HIV and AIDS and TB recurrent grant, which is much more "permissive" in that funds are released prospectively on a recurrent basis subject only to broad output / outcome targets, would allow ear-marking of funds, but may cause artificial divisions between "AIDS" and "non-AIDS" services. Expanding equitable share funding to address HIV and AIDS and TB would require explicit guidance to provinces on desirable areas of spending, but would allow a better fit with existing services. Either of the two latter options would require the development of some form of resource allocation formula for provinces, which should be more or less directly based on AIDS-related service needs.
While further discussion of funding mechanisms is clearly required, this debate need not prevent the tentative identification and allocation of additional funds at the global national and provincial budget level.
This paper sets out the case for a reasonable but significant increase in funding to enable the public health sector to respond more effectively to the growing HIV and AIDS and TB epidemics. This enhanced response will significantly upgrade prevention activities in areas of proven effectiveness, thus "pulling down" the ultimate peak of HIV and TB infections in South Africa and hence minimising the ultimate direct impact of these epidemics. It also sets out the implementation activities and funding required to stabilise treatment, care and support for people with AIDS, improve quality of care, and to shift treatment and care away from acute hospital to more efficient, sustainable and appropriate alternative settings, where long-run health system costs can be minimised. The proposed "enhanced response" therefore itself represents an intervention, whose aim is to invest resources to shift the public health system from its present unsustainable and ultimately self-destructive coping responses to HIV and AIDS, and to move it towards more sustainable and cost-effective models of service provision which will enable the public health sector to confront the challenge of HIV and AIDS without prejudicing its ability to provide health care to meet the needs of all South Africans.
A: Core Intervention Package – Description
|
Focus |
Intervention |
Description |
|
A |
1. Condoms - male |
Expand male condom availability through distribution in non-traditional and higher-risk outlets |
|
2. Condoms - female |
Expand female condom availability through distribution in non-traditional and higher-risk outlets |
|
|
3. Improved STD drug availability in public sector |
Improved availability of essential drugs for syndromic management of STIs, to ensure all PHC and STD clinics have guaranteed availability and improved uptake |
|
|
4. Expanded IEC / campaign activities |
Enable government campaigns to target specific risk groups more effectively |
|
|
5. National roll-out of Voluntary Counselling & Testing |
Ensure that all public health facilities can offer Voluntary Counselling and Testing for HIV by end of FY 2004/05, with a target of 20% of adults to know their HIV status by that point |
|
|
6. NGO Support |
Expand capacity of NGOs to conduct HIV prevention and to provide contract services to government |
|
|
7. EU capacity building programme |
2001/02 only |
|
|
8. MTCT Pilot & Research Programme |
Fund the 18 PMTCT pilot sites effort during FY 2002/03 |
|
|
B |
1. Improved availability of essential drugs for non-TB opportunistic infections and AIDS-related conditions |
Improve availability of essential drugs for treatment and care of HIV and AIDS related illnesses to keep pace with growth in demand, and to ensure that all PWAs presenting to a public health facility can have immediate access to relevant drugs from the EDL. |
|
2. Roll-out Community & Home Based Care |
Expand HBC to provide an effective substitute for inpatient admission and to extend basic care to under-served communities as per joint Health & Social Development CHBC policy |
|
|
3. Hospitalisation of AIDS-related illnesses - marginal cost |
Fund the marginal costs of additional demand for hospital care (i.e. non-staff items such as consumables, food, lab tests) in the period before HBC and step-down care are fully established |
|
|
DC |
1. Enhanced national management team (NDoH) |
Ensure National DoH HIV and AIDS and TB head office teams are adequately staffed and skilled to manage the national programmes effectively |
|
2. Enhanced provincial management teams |
Ensure provincial DoHs can manage HIV and AIDS and TB programmes effectively |
|
|
3. Strengthen integration of HIV and AIDS care and support into district and hospital management functions |
Develop operational and clinical policy guidelines to ensure that PHC and district hospitals provide adequate quality of care and scope of service for HIV and AIDS and TB, and undertake training and roll-out of policy to district level |
|
|
4. Research transfer payments |
Fund SA AIDS Vaccine Initiative and PMTCT Pilot Research Programme |
|
|
TB |
1. Expanded DOTS drug availability to meet est. growth in TB caseload (incl. MDR) |
Ensure that TB drug supplies keep pace with workload, to guarantee availability of DOTS medication at all times in all public health facilities |
|
|
2. DOTS delivery and supervision |
Fund the additional costs of supervising an expanding number of TB cases and DOTS volunteers |
|
|
3. DOTS Volunteer Stipends |
Fund stipends for full-time DOTS volunteers on a consistent basis with HBC volunteers |
|
|
4. NGO Support |
Develop NGO advocacy and DOTS support programmes |
A: Core Intervention Package – Rationale
|
Focus |
Intervention |
Rationale |
|
A |
1. Condoms - male |
Expansion to 500 million condoms p.a. can avoid up to 660,000 new infections |
|
2. Condoms - female |
EU funded distribution has proved highly popular, with comparable or better impact per condom than male |
|
|
3. Improved STD drug availability in public sector |
Effective syndromic management of STDs is highly cost-effective in reducing HIV transmission (World Bank 1997); frequent stock-outs of drugs and poor uptake need to be remedied to maximise impact |
|
|
4. Expanded IEC / campaign activities |
Build on successful urban campaigns to target poor rural and specific highly vulnerable groups |
|
|
5. National roll-out of Voluntary Counselling & Testing |
Knowledge of HIV status is a key lever in changing behaviour and ensuring access to necessary care; roll-out of VCT campaign therefore acts as a multiplier for prevention and care activities |
|
|
6. NGO Support |
NGOs have great enthusiasm but limited capacity, therefore development support required |
|
|
7. EU capacity building programme |
N/a |
|
|
8. MTCT Pilot & Research Programme |
Existing pilot programme requires continued funding to deliver critical results by end 2002/03 |
|
|
B |
1. Improved availability of essential drugs for non-TB opportunistic infections and AIDS-related conditions |
Current quality of AIDS care is severely compromised by poor availability of essential drugs at PHC and district hospital level, leading to unacceptable practice and failure to treat opportunistic infections adequately; requires substantially increased supplies and improved inventory management |
|
2. Roll-out Community & Home Based Care |
HBC now a proven care platform (Johnson et al, 2001), but requires major scaling-up if it is to be able to pick up significant proportion of AIDS care demand |
|
|
3. Hospitalisation of AIDS-related illnesses - marginal cost |
Significant spare capacity does exist in SA public hospitals (i.e. occupancy rates well below 80%), so fixed costs do not need to increase, but additional variable costs will be incurred and must be funded |
|
|
CD |
1. Enhanced national management team (NDoH) |
Limited managerial and administrative capacity has been a significant brake on programme implementation and spending to date; modest staffing increases will ease these constraints greatly |
|
2. Enhanced provincial management teams |
Ditto |
|
|
3. Strengthen integration of HIV and AIDS care and support into district and hospital management functions |
Poor management coordination and poor implementation of guidelines compounds quality problems, while low status of district health services hampers attempts to improve quality |
|
|
4. Research transfer payments |
Two critical research programmes which require continued support to deliver results |
|
|
TB |
1. Expanded DOTS drug availability to meet est. growth in TB caseload (incl. MDR) |
Failure to meet TB programme targets will result in a runaway TB epidemic; therefore drug availability must keep pace with projected epidemic growth. |
|
|
2. DOTS delivery and supervision |
Growing TB caseload imposes growing burden on PHC staff who must oversee DOTS programme |
|
|
3. DOTS Volunteer Stipends |
Failure to provide stipend will introduce major disparities vis-à-vis HBC, with impact on retention |
|
|
4. NGO Support |
Develop more effective DOTS models and experimental approaches |
B: Lower Cost and/or Higher Certainty Interventions - Description
|
Focus |
Intervention |
Description |
|
A. |
National roll-out of PMTCT intervention package |
Scale up to universal access PMTCT service as per current pilot sites |
|
1. - excluding free infant formula |
VCT, Nevirapine |
|
|
2. - plus infant formula |
Free infant formula |
|
|
3. STD drug availability for syndromic management by private practitioners |
Provide drugs for syndromic management of STIs free to private GPs |
|
|
B. |
1. Develop and roll-out successful models of step-down / intermediate care to substitute for hospital admission |
Fund pilot projects to develop step-down care, focussing on appropriate skill-mix, patient management and referral protocols; minor capital works for conversion and upgrading of hospital facilities to provide step-down care |
|
DC. |
1. Develop protocols and care pathways for integrated management of HIV and AIDS between primary, CHBC, step-down and hospital levels |
Ensuring that new models of care are closely integrated with mainstream services to ensure that their full benefits are realised |
|
2. Research transfer - validation of HIV testing methods |
Funding of research proposed by Presidential AIDS Advisory Panel on verification of current HIV testing methods – MRC will be lead agency |
|
|
TB |
1. Upgrade facilities for acceptable quality care of patients with Multi-Drug Resistant TB |
Capital works to upgrade facilities to provide acceptable environment for long-term care and improved infection control |
B: Lower Cost and/or Higher Certainty Interventions - Rationale
|
Focus |
Intervention |
Rationale |
|
A. |
National roll-out of PMTCT intervention package |
Allows action if PMTCT pilots provide positive result, and ensures funds are earmarked for this purpose without prejudging results |
|
1. - excluding free infant formula |
Research results may indicate that free formula is not safe / cost-effective |
|
|
2. - plus infant formula |
|
|
|
3. STD drug availability for syndromic management by private practitioners |
Private practitioners consistently provide lower quality STI care than public clinics and fail to prescribe appropriately, yet treat large numbers of STI cases – hence need to facilitate improved quality of care (Schneider 2001; Wilkinson 2001) |
|
|
B. |
1. Develop and roll-out successful models of step-down / intermediate care to substitute for hospital admission |
Step-down care offers a cost-effective means of harnessing existing spare capacity and using more efficient skill mixes to deliver lower cost and more appropriate care for PWAs, but requires some jump-starting and encouragement of innovation |
|
CD. |
1. Develop protocols and care pathways for integrated management of HIV and AIDS between primary, CHBC, step-down and hospital levels |
New models of care are very promising, but they must be tied closely into the existing hospital referral system if they are to reduce pressure on acute hospital beds |
|
2. Research transfer - validation of HIV testing methods |
Required to bring certainty to the ongoing questioning of the validity of HIV testing by some members of Presidential AIDS Advisory Panel |
|
|
TB |
1. Upgrade facilities for acceptable quality care of patients with Multi-Drug Resistant TB |
Current MDR facilities are frequently deplorable, leading to unnecessary mortality and problems of infection control; excellent models exist which can be rolled-out nationwide |
C: Higher Cost / Lower Certainty Interventions - Description
|
Focus |
Intervention |
Description |
|
A. |
Operational research on appropriate models for implementation of a future HIV vaccine |
Modeling of appropriate target groups, delivery systems and models for future HIV vaccines under different plausible scenarios |
|
B. |
RCT of different forms of therapy in selected district health system settings |
RCT to investigate feasibility, effectiveness, cost-effectiveness, compliance and appropriateness of different therapy options in three rural / resource-poor district health settings |
|
Reformulation of Prescribed Minimum Benefits package to incorporate different forms of therapy |
If different therapy options or other alternative treatments is ultimately adopted by public health sector, PMB must reflect this change in mandating medical schemes to provide equivalent care |
|
|
DC. |
Develop protocols and care pathways for patient management with different therapy options |
National guidelines and protocols for the use of different therapy or other alternative treatments in the public sector, if this treatment is ultimately adopted |
|
TB |
Conversion of acute hospital beds for TB care |
Funding minor works and capital conversion of acute beds and staff training to provide more appropriate TB care if need for TB hospitalisation increases; funding for rehabilitation of SANTA facilities when taken over by government |
C: Higher Cost / Lower Certainty Interventions - Rationale
|
Focus |
Intervention |
Rationale |
|
A. |
Operational research on appropriate models for implementation of a future HIV vaccine |
Vaccines may ultimately possess significant variations in effectiveness of protection (from 80% to 99%), and these differences may require very different targeting and delivery strategies, which should be considered in advance of implementation |
|
B. |
RCT of different therapy options or other alternative treatment strategies in selected district health system settings |
Urgent need to obtain firm data on feasibility and cost-effectiveness of different therapy or other alternative treatments under "field" conditions outside urban academic centres in resource-poor settings |
|
Reformulation of Prescribed Minimum Benefits package to incorporate different therapy options or other alternative treatment strategies if adopted by public sector |
Ensure consistency between public and private sector coverage |
|
|
DC. |
Develop protocols and care pathways for patient management with different therapy or other alternative treatment strategies |
Ensure that any adoption of different therapy or other alternative treatment in public sector achieves minimum quality standards and yields maximum benefits |
|
TB |
Conversion of acute hospital beds for TB care |
TB inpatient demand may increase significantly, but acute hospital wards are not ideal settings for longer periods of TB care |
Source or Basis for Calculation / Costing
A: Core Package
|
1. Condoms -– male |
Chief Directorate: HIV and AIDS - planning estimates for expansion of barrier methods |
|
2. Condoms - female |
Chief Directorate: HIV and AIDS - planning estimates for expansion of barrier methods |
|
3. Improved STD drug availability in public sector |
Based on North West Province STD costing – indicated that doubling uptake of syndromic management of STIs ( and quadrupling treatment of syphilis) would require drug expenditure of R 0.50 per capita |
|
4. Expanded IEC / campaign activities |
Based on current costs of mass-media campaigns, scaled up for greater impact |
|
5. National roll-out of Voluntary Counselling & Testing |
5000 health facilities have trained staff, using rapid HIV tests, as per VCT plan presented to Health MINMEC |
|
6. NGO Support |
Limited scale up current activities - CD: HIV and AIDS |
|
7. EU capacity building programme |
|
|
8. MTCT Pilot & Research Programme |
Current committed programme budget for pilots |
|
1. Improved availability of essential drugs for non-TB opportunistic infections and AIDS-related conditions |
Based on Abt report estimates of drug requirements for non-ARV treatment of Stage 3 and 4 illness using Standard Treatment Guidelines. 2001/02 baseline estimate scales down Abt estimate (drugs consume 12% of total costs of AIDS care) to reflect NHA finding that drugs represent only 9% of current expenditure. |
|
2. Roll-out Community & Home Based Care |
Based on joint Health & Social Development policy on CHBC, rolling out 200 CHBC teams in 2002/03, 600 in 2003/04, 1000 in 2004/05, volunteers to be paid R 500 stipend |
|
3. Hospitalisation of AIDS-related illnesses - marginal cost |
Marginal cost of a bed day proxied by non-staff variable costs excluding drugs (captured in 1 above), approximately 20% of cost per bed day |
|
1. Expanded DOTS drug availability to meet estimated growth in TB caseload (incl. MDR) |
Cost per completed drug course: first treatment R 256, re-treatment R 523, MDR R 31322, mid-case TB caseload projections, 1.6% of cases develop MDR |
|
2. DOTS delivery and supervision |
Health system supervision costs of R 200 per case (Floyd 1997) |
|
3. DOTS Volunteer Stipends |
Volunteers receive stipend of R 500 as per CHBC; manage caseload of 30 patients per month |
|
4. NGO Support |
CD: HIV and AIDS planned activities |
|
1. Enhanced national management team (NDoH) |
Additional staff above present team - 3 x director, 3 x Senior Admin Offr, 3 x Admin Asst, 80% in year 1 to allow for recruitment |
|
2. Enhanced provincial management teams |
Each 1 x director, 2 x Senior Admin Offr, 2 x Admin Asst, 80% in year 1 to allow for recruitment |
|
3. Strengthen integration of HIV and AIDS care and support into district and hospital management functions, including support for co-ordination of implementation strategies |
Estimated costs of consultancy to develop guidelines and undertake
training activities |
|
4. Research transfer payments |
Current commitments over 3 year period |
B: Lower Cost and/or Higher Certainty Interventions
|
National roll-out of PMTCT intervention package |
Pilot site budgets scaled up to cover all births in public facilities |
|
|
1. - excluding free infant formula |
Ditto |
|
|
2. - plus infant formula |
Ditto |
|
|
3. STD drug availability for syndromic management by private practitioners |
Manageable expansion of programme from standing start over three years, given costs of STD drugs |
|
| Treatment, Care & Support |
1. Develop and roll-out successful models of step-down / intermediate care to substitute for hospital admission |
Integrated Health Planning Framework estimates of Step-down care recurrent and capital costs |
| TB |
1. Upgrade facilities for acceptable quality care of patients with Multi-Drug Resistant TB |
Capital costs of recently upgraded specialised MDR unit at Klerksdorp Hospital, rolled out to allow 2 per province |
|
1. Develop protocols and care pathways for integrated management of HIV and AIDS between primary, CHBC, step-down and hospital levels |
Estimated costs of consultancy to develop guidelines and undertake training activities |
|
|
2. Research transfer - validation of HIV testing methods |
Estimated cost from MRC |
C: Higher Cost / Lower Certainty Interventions
|
Operational research on appropriate models for implementation of a future HIV vaccine |
Based on recent research tenders of similar nature |
|
RCT of different therapy options or other alternative treatment strategies in selected district health system settings |
500 patients per arm (different strategy option vs. standard care) at three sites, research overheads as observed in similar clinical trials |
|
Reformulation of Prescribed Minimum Benefits package to incorporate different therapy options or alternative treatment strategies if adopted by public sector |
Estimated costs of consultancy and consultation process |
|
Conversion of acute hospital beds for TB care |
Integrated Health Planning Framework estimates of capital costs |
|
Develop protocols and care pathways for patient management with different therapy options or other alternative treatment strategies |
Estimated costs of consultancy to develop guidelines and undertake training activities |
References
Abt Associates. Projected impacts of the HIV and AIDS epidemic on the South African health sector. Johannesburg, 2000.
Ainsworth M, Teokul W. Breaking the silence: setting realistic priorities for AIDS control in less-developed countries. Lancet 2000; 356:55-60.
Bateman C. Can KwaZulu Natal hospitals cope with the HIV and AIDS human tide? South African Medical Journal 2001; 91(5):364-8.
Departments of Education, Health, Public Service and Administration. Report on the Sectoral Studies of the Likely Impacts of the HIV and AIDS Epidemic on Three Government Departments by Abt Associates & Metropolitan Life – Appraisal of Methods and Data Used. Pretoria, 2001.
Floyd K, Wilkinson D, Gilks C. Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa. British Medical Journal 1997:315:1407-11.
Gilks C. Costing the demands for HIV and AIDS care and managing interventions. Paper presented to the Henry J. Kaiser Family Foundation AIDS 2000 Forum "The impact of HIV and AIDS on national budget priorities", KwaZulu Natal, July 2000.
Health Systems Trust. South African Health Review 2000.
Johnson S, Modiba P, Monnakgotla D, Muirhead D, Schneider H. Home-based care for people with HIV and AIDS in South Africa: what will it cost? Centre for Health Policy, 2001.
Schneider H, Blaauw D, Dartnall E, Coetzee D, Ballard R. STD care in the South African private health sector. South African Medical Journal 2001; 91:151-6.
Wilkinson D, Abdool Karim S, Lurie M, Harrison A. Public-private health sector partnerships for STD control in South Africa – perspectives from the Hlabisa experience. South African Journal of Obstetrics and Gynaecology 2001; 7(2):36-40.
World Bank. Confronting AIDS: public priorities in a global epidemic. Washington, 1997.
Annex 1: Proposed Routing of Funds for Enhanced Response Interventions
|
A. Core Intervention Package |
Direct National Expenditure or Procurement |
Recurrent Conditional Grant to Provinces |
Include in Provincial Equitable Share |
|
|
Item |
||||
|
A Prevention |
1. Condoms - male |
Yes |
Yes (logistics) |
|
|
2. Condoms - female |
Yes |
Yes (logistics) |
||
|
3. Improved STD drug availability in public sector |
Yes |
|||
|
4. Expanded IEC activities e.g. Life Skilss |
Yes |
|||
|
5. National roll-out of Voluntary Counselling & Testing |
Yes |
|||
|
6. NGO Support |
Yes |
|||
|
7. EU Capacity Building Programme |
Yes |
|||
|
8. MTCT Pilot & Research Programme |
Yes |
|||
|
B Treatment, Care and Support |
1. Improved availability of essential drugs for opportunistic infections and AIDS-related conditions (no ARVs) |
Yes |
||
|
2. Roll-out Community & Home Based Care |
Yes |
|||
|
3. Hospitalisation of AIDS-related illnesses - marginal cost |
Yes |
|||
|
D Programme Management |
1. Enhanced national management team |
Yes |
||
|
2. Enhanced provincial management teams |
Yes |
|||
|
3. Strengthen integration of HIV and AIDS care and support into district and hospital management functions |
Yes |
|||
|
4. Research transfer payments |
Yes |
|||
|
C Tuberculosis |
1. Expanded DOTS drug availability to meet estimated growth in TB caseload (incl. MDR) |
Yes |
||
|
2. DOTS delivery and supervision |
Yes |
|||
|
3. DOTS volunteer stipends |
Yes |
|||
|
4. NGO support |
Yes |
| B. Lower Cost / Higher Certainty Interventions |
Direct National Expenditure or Procurement |
Recurrent Conditional Grant to Provinces |
Include in Provincial Equitable Share |
|
|
Item |
Item |
|||
|
Prevention |
National roll-out of PMTCT intervention package |
|||
|
- excluding free infant formula |
Yes |
|||
|
- plus infant formula |
Yes |
|||
|
STD drug availability for syndromic management by private practitioners |
Yes |
|||
|
Treatment, Care and Support |
Develop and roll-out successful models of step-down / intermediate care to substitute for hospital admission |
Yes (R&D) |
Yes (Implement) |
|
|
Programme Management |
Develop protocols and care pathways for integrated management of HIV and AIDS between primary, CHBC, step-down and hospital levels |
Yes |
||
|
Tuberculosis |
Upgrade facilities for acceptable quality care of patients with Multi-Drug Resistant TB |
Yes |
||
|
C. Higher Cost / lower Certainty Interventions |
Direct National Expenditure or Procurement |
Recurrent Conditional Grant to Provinces |
Include in Provincial Equitable Share |
|
|
Item |
Item |
|||
|
Prevention |
Operational research on appropriate models for implementation of a future HIV vaccine |
Yes |
||
|
Treatment, Care |
RCT of alternative treatments |
Yes |
||
|
and Support |
Reformulation of Prescribed Minimum Benefits package |
Yes |
||
|
Programme Management |
Develop protocols ARV therapy |
Yes |
||
|
Tuberculosis |
Conversion of acute hospital beds for TB care |
Yes |
||