Aligning Funding Support with South Africa's National Strategy

Funding the NSP in South Africa: Assessing alignment of partners support to the National Strategy through past expenditure trend analysis Nthabiseng Khoza, National Department of Health, Government of South Africa 10th International AIDS Economics Network Preconference Amsterdam, 20 July 2018 Abt Associates Inc. In collaboration with: Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Acknowledgements Analytical team (FIN-CAP) NDOH (HIV CG team) With data, advice, and funding* from: Department of Health National Department of Basic Education National Department of Social Development National Treasury South African National AIDS Council Global Fund PEPFAR (USAID* + CDC) 2

Outline for rest of presentation 1. Motivation & methods 2. Selected findings 3. Key takeaways and reflections 3

Planning, management, and accountability benefit from routine expenditure analysis We sought to answer numerous questions: 1. How much was spent on HIV and TB by the South African Government, US Government, and Global Fund during FYs 2014/15 through 2016/17? 2. How was spending distributed across geographies and interventions? 3. Which cost categories drove spending? 4. How did spending and outcomes compare across provinces for the key HIV sub-programmes? 5. How did government spending change during PEPFAR s focus for impact that focused investment in 27 of South Africa s 52 districts? 6. How do spending allocations across interventions compare with the newly costed National Strategic Plan for HIV, TB and STIs 2017 2022? 7. What financial and epidemiological data challenges limit analysis and interpretation? Today s focus 4

An 18-month process Analytic Process led by HFG 1. Data collection & compilation DOH: BAS records (HPV included) DBE & DSD: ENE, EPRE, NT records PEPFAR: Expenditure Analysis (EA) data GF: Annual Financial Reports (AFRs) Automation Process (BASLY) led by HE2RO 1. In-depth discussion and demonstration of manual search, crosswalking and analysis methods 2. Adaptation of manual methods into Excel (programming in VBA) 2. Crosswalking & consolidation Six sets of spending categories reconciled with the SAG BAS categories Construction of single database with data from all nine provinces, NDOH, other SAG departments, PEPFAR, and Global Fund for all three FYs 3. Multiple rounds of BASLY testing, troubleshooting and comparison of results with manual process 4. Modification of BASLY code to reach the minimum difference threshold when compared with manual results 3. Preliminary analysis 4. Data validation with partners 5. Finalization of analysis and outputs 5. BASLY pilot demo with NDOH for testing and feedback 6. Finalisation of BASLY and handover to NDOH 5

HIV spending grew while TB was steady in last two years; SAG-DOH leading the way Total HIV and TB spending by source (with SAG split by department) Total HIV and TB spending by disease focus ZAR millions 28,814 28,814 1,170 30,000 806 177 25,810 25,810 2,418 1,066 25,000 1,533 6,015 22,472 151 22,472 2,383 TB/HIV 926 865 TB HIV 231 99 4,730 2,099 2,471 20,000 218 4,219 GLOBAL FUND 2,228 204 USAID (non-PEPFAR) 1,738 15,000 PEPFAR DBE 25,226 22,360 DSD 10,000 19,447 19,114 DOH 16,949 15,347 5,000 0 6 2014/2015 2015/2016 2016/2017 2014/15 2015/16 2016/17

Donors sustained investment, including large shares of some programme areas Share of HIV and TB spending from each source (2014/15 2016/17) Funders relative contributions to HIV programme areas (2016/17) 17,962 3,792 2,043 1,931 28 814 22 472 25 810 0% 2% 3% 4% 6% 6% 15% 21% 19% 19% 33% 34% 1% 1% 1% 41% 8% 9% 9% 12% 83% 68% GLOBAL FUND USG DBE 66% 66% 67% GLOBAL FUND 54% 54% PEPFAR DSD SAG DOH 2014/15 2015/16 2016/17 Treatment Prevention Programme Enablers Care & Support 7

Identifying activities that relied heavily on external funding in 2016/17 Treatment Prevention Adherence (non-BAS) Key Pop (non-BAS) HTS Blood Bank spending (non-BAS) TB/HIV HIV Prevention ND HBC MMC ART PMTCT HIV Treatment ND PEP SDC HTA / SW Palliative / hospice care Youth 0% 20% 40% 60% 80% 100% Condoms SAG USG Global Fund HPV Workplace prevention Enablers STI HSS: PSM 0% 20% 40% 60% 80% 100% Substance abuse prevention GBV / gender empowerment SAG USG Global Fund M&E / HIS RTC / Training HIV C&S Research, surveys (non-BAS) OVC PE: Community Capacity/ Inst. Surveillance (Non BAS) infrast /upgrade / mainten. Policy & Systems Development PM C&S PE: Lab (Non BAS) ACSM 0% 20% 40% 60% 80% 100% 0% SAG 20% USG 40% Global Fund 60% 80% 100% 8 SAG USG Global Fund

DOH led the scale-up of the HIV response Total HIV spending by source (with SAG split by department) ZAR millions 30,000 Includes integrative TB/HIV spending by DOH and GF Sustained spending growth PEPFAR spending increased Modest contributions from DBE and DSD rest of analysis focuses on DOH and, when possible, donors 25,940 777 Global Fund PEPFAR 25,000 23,071 5,558 1,533 DBE DSD DOH 20,001 865 20,000 231 4,375 2,471 3,847 218 2,228 204 15,000 1,738 10,000 16,902 14,717 13,347 5,000 0 2014/2015 2015/2016 2016/2017 Notes: The trend in PEPFAR spending is a function of both the US Government s commitment and to exchange rate fluctuations between the US dollar and South African rand. 9

HIV spending decently aligned to burden; further data improvements needed 2,000 700,000 HIV spending by district and funder (left axis) and number of PLHIV (right axis) (2016/17) PLHIV Population ZAR Millions Global Fund PEPFAR DOH PLHIV Population 1,800 600,000 In some provinces, DOH bulk spending often labeled as whole province rather than split by district Global Fund PRs still do not report spending by district 1,600 District-level disease burden estimates remain uncertain 500,000 1,400 1,200 400,000 1,000 300,000 800 600 200,000 400 100,000 200 - - KZN: uThukela NC: Francis Baard KZN: Ilembe WC: Cape Winelands EC: OR Tambo EC: Chris Hani FS: Mangaung FS: Xhariep NC: Namakawa WC: Central Karoo Not disaggregated LP: Mopani National EC: Amathole EC: Joe Gqabi KZN: Ugu LP: Vhembe MP: Ehlanzeni NC: ZF Mgcawu EC: Nelson Mandela Bay FS: Lejweleputswa KZN: uMgungundlovu KZN: uThungulu KZN: WHOLE PROVINCE LP: Capricorn MP: Nkangala NW: Bojanala Platinum WC: Eden Above National EC: Buffalo City Metropolitan FS: Felize Dabi KZN: eThekwini NW: NM Molema WC: City of Cape Town FS: Thabo Mofutsanyana GP: City of Johannesburg KZN: Zululand KZN: uMzinyathi NC: Pixley ka Seme WC: West Coast WC: Overberg GP: Sedibeng LP: Sekhukhune NC: JT Gaetsewe GP: City of Tshwane GP: Ekhurleni KZN: Amajuba LP: Waterberg LP: WHOLE PROVINCE MP: Gert Sibande EC: Alfred Nzo EC: Sarah Baartman FS: WHOLE PROVINCE KZN: uMkhanyakude NW: Dr K Kaunda NW: Dr RS Mompati GT: WHOLE PROVINCE EC: WHOLE PROVINCE MP: WHOLE PROVINCE NC: WHOLE PROVINCE NW: WHOLE PROVINCE GP: West Rand KZN: Harry Gwala EC FS GP KZN LP MP NC NW WC Other EC FS GP KZN LP MP NC NW WC 10

PEPFAR spending (mostly) matched stated geographic priorities Change in DOH and PEPFAR spending in PEPFAR priority districts between 2015/16 and 2016/17 400 R Millions DOH Change in Spending PEPFAR Change in Spending 350 300 250 200 150 100 50 - (50) (100) LP: Mopani EC: Amathole FS: Lejweleputswa GP: Sedibeng KZN: uThungulu EC: Chris Hani KZN: Zululand GP: City of Johannesburg GP: City of Tshwane KZN: uThukela LP: Capricorn EC: Alfred Nzo KZN: Ugu WC: City of Cape Town KZN: eThekwini MP: Nkangala NW: NM Molema EC: OR Tambo NW: Bojanala Platinum NW: Dr K Kaunda GP: Ekhurleni KZN: uMgungundlovu MP: Ehlanzeni MP: Gert Sibande FS: Thabo Mofutsanyana EC: Buffalo City Metropolitan KZN: Harry Gwala 11 EC FS GP KZN LP MP NW WC

Government often (but not always) filled in where PEPFAR scaled down investment Change in DOH and PEPFAR spending in PEPFAR transition districts between 2015/16 and 2016/17 100 R Millions Series2 PEPFAR change in spending Series1 DOH change in spending 80 60 40 20 - (20) (40) (60) (80) LP: Sekhukhune WC: Overberg NC: ZF Mgcawu EC: Sarah Baartman FS: Felize Dabi LP: Waterberg NC: Pixley ka Seme FS: Xhariep KZN: Ilembe NW: Dr RS Mompati WC: West Coast LP: Vhembe KZN: uMzinyathi NC: Francis Baard EC: Joe Gqabi FS: Mangaung NC: JT Gaetsewe NC: Namakawa WC: Cape Winelands KZN: Amajuba WC: Eden KZN: uMkhanyakude EC: Nelson Mandela Bay WC: Central Karoo GP: West Rand 12 EC FS GP KZN LP NC NW WC

TB spending grew slowly; geographic allocation only partly aligned to burden Total TB spending by source (2014/15 2016/17) Total TB spending by province and source, with number of TB patients (2016/17) ZAR millions ZAR millions 3,500 1,000 70,000 2,874 177 3,000 2,738 900 30 60,000 151 355 2,470 99 800 2,500 457 Global Fund 50,000 700 USAID (non-PEPFAR) 2,000 600 PEFPAR 40,000 500 DOH 1,500 30,000 400 2,211 2,232 2,000 Global Fund 1,000 300 20,000 USG 200 500 DOH # of patients 10,000 100 0 0 0 EC FS GP KZN LP MP NC NW WC N AN ND 2014/2015 2015/2016 2016/2017 N = National; AN = Above National; ND = not disaggregated # of patients includes both drug-sensitive and MDR TB cases. Note: TB-related Global Fund spending in 2014/15 and 2015/16 is classified as TB/HIV integrative spending within the HIV totals. 13

Spending composition in 2016/17 mostly aligned to new NSP (2017-2022) priorities 100% Other 90% Goal 9: Critical enablers 80% 70% Goal 8: Strategic information 60% Goal 6: Leadership & coordination 50% Goal 5: Human rights & stigma 40% Goal 4: Social & structural drivers 30% Goal 3: Key populations 20% Goal 2: Achieving 90-90-90 10% Goal 1: Prevention 0% % Spend in 2016/17 NSP Resource Need % in 2017/18

Review of key takeaways Government continued to lead scale-up of the HIV and TB responses Donor commitment to combatting HIV and TB in remained strong despite long-run expectations of declining support Within the HIV response, government leadership was most pronounced for treatment-related activities, while donors drove significant shares of spending in prevention TB spending continued to rise thanks to growing financing from both domestic and external sources Recent HIV spending was well aligned to priorities in South Africa s new National Strategic Plan for HIV, TB, and STIs (2017-22) 15

Final reflections Consolidated analysis of domestic and donor spending enabled better joint planning, including for resprioritisation of programme funding through donor support Routine expenditure review facilitated programme management and enabled real-time adjustments based on dialogue between national and sub-national actors 16

Thank you Contacts NDOH HFG CEGAA HE2RO Nthabiseng Khoza petrus.khoza@health.gov.za Teresa Guthrie guthriehealthfinancingconsult@gmail.com Nhlanhla Ndlovu nhlanhla@cegaa.org Gesine Meyer-Rath gesine@bu.edu Abt Associates Inc. In collaboration with: Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)