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Is there enough money to meet the National Strategic Plan treatment target? Will it be spent properly?

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Joint statement by the Treatment Action Campaign (TAC) and AIDS Law Project (ALP)

30 October 2009

President Zuma's speech

President Zuma's landmark speech on 29 October 2009 has acknowledged the extent of the AIDS epidemic and put the period of state-supported AIDS denialism behind us. The TAC and ALP unreservedly welcome it. In this context we comment on the health and HIV aspects of the budget speech.

Minister Gordhan's budget

Minister of Finance Pravin Gordhan has delivered the Medium Term Budget Policy Statement (MTBPS) on 27 October. [1]

Despite the difficult economic conditions, Gordhan's budget commits to an increase in social welfare and education. We regard his commitments to health as significant, including:

  • An additional R900 million will be given to the Department of Health to cover AIDS programmes for the remainder of the financial year. This is a much bigger adjustment to the health budget than the one provided in last year's MTBPS and much closer to what the Department of Health requested. The Department actually requested R1.2 billion, but a further R240m will be provided by the US President's Emergency Fund for AIDS Relief (PEPFAR), so the shortfall is relatively small.

  • A further R213 million will be given to the Department of Health for this financial year to cover several goods and services including measles vaccinations and vaccines and antivirals for pandemic flu.

  • The conditional AIDS grant, which includes the cost of antiretroviral medicines, condoms, diagnostics, monitoring and some salaries, will increase from R4.4b in 2009/10 to R7.3b in 20012/13, an increase of 19% on average per year.

Effective budgeting depends on greatly improved monitoring and evaluation of antiretroviral treatment and prevention programmes

The central question for the work of the TAC and ALP is whether enough money has been allocated to the AIDS programme to meet the National Strategic Plan (NSP) treatment and prevention targets. [2] The answer is unclear. There is not enough information available and given the plethora of problems we are encountering, we believe it is unlikely that there is enough money. But it is also clear that a lack of managerial capacity and competence in all the departments of health (national and provincial) is at least as big a problem as lack of money.

There are three state-run antiretroviral treatment and prevention programmes: (1) highly active antiretroviral treatment (HAART) for people with HIV who have progressed to AIDS, (2) prevention of mother-to-child transmission (PMTCT) and (3) post-exposure prophylaxis (PEP) for health workers and rape survivors. HAART is by far the largest expense of these and the cost of PEP is negligible.

The Department of Health does not have accurate data for the number of people on HAART. Figures are occasionally published, but for a variety of reasons they are unreliable. Data on the PMTCT programme is even worse and is barely ever published. The Department's Monitoring and Evaluation systems are not working. This is the fault of the former Director-General of Health, Thami Mseleku and former Minister Tshabalala-Msimang.

Recently, the newly formed Budget and Expenditure Monitoring Forum, which includes TAC and the ALP met with the Department of Health. The department emphasised that steps are being taken to rectify data collection on the HAART programme. We are encouraged by this. But until this happens we cannot know if there is enough money in the system to cater for the number of people currently on treatment, how much the shortfall is or how close we are to meeting the NSP targets.

The antiretroviral tender

The TAC and ALP have received, encountered or investigated numerous reports of problems with the HAART and PMTCT programmes. These have included the moratorium on initiating new patients on HAART in the Free State, as well as drug stock-outs and dozens of individual cases of people being denied access to treatment across the country. Studies in the Free State and Durban have found that the average waiting time to go onto treatment are four months and 3.5 months in these two areas respectively, with massive patient mortality occurring during these waiting periods (over a quarter of patients waiting for HAART in the Free State die without ever taking an ARV pill). [3,4] Furthermore, we have received reports of stock-outs of ARVs and erratic procurement.

It is unclear why this should be happening. The NSP provides for approximately 800,000 people on treatment in 2010. The current public sector antiretroviral tender (see Table 1) runs from June 2008 to May 2010 and it provides for enough ARVs to approximately meet this target. It also includes procurement of tenofovir and paediatric abacavir, two medicines which although not yet provided for in published Department of Health treatment guidelines are important drugs that will improve treatment outcomes. We welcome these aspects of the tender.

However, the volumes of drugs to be bought on tender are estimates, not what is actually being bought. We have tried unsuccessfully to obtain information on what volumes have actually been bought to date. It appears that National Treasury is the main obstacle to finding out this information. From our preliminary investigations though, it seems the predicted volumes are not being purchased.

Put simply, if the predicted tender volumes were purchased, it is unlikely we would be seeing such chronic shortages of ARVs and such long queues. The shortage of health workers is also likely a major cause of this problem.

Assuming our preliminary investigations are correct, why are the predicted volumes not being purchased? The cost of the tender is approximately R2.1 billion a year, or less than half what has been allocated to the conditional AIDS grant (see Table 2). So there really should be enough money earmarked to fill the predicted tender volumes. One possibility is that provincial governments are spending a disproportionately large part of the conditional grant on health worker salaries. Certainly some of the conditional AIDS grant money can be used to cover salaries, but the primary purpose of the grant is to ensure that the HAART, PMTCT and PEP programmes are implemented. This cannot be done without purchasing the drugs. If there is not currently enough money to pay salaries, the budget should be appropriately amended.

We note that the Minister said little about National Health Insurance (NHI). We await the green paper on NHI. The planning and implementation of NHI depends on improving the public health system including controlling and treating AIDS. In this respect we welcome the growing budgetary commitment to HIV.

References

1. Government of South Africa. 2009. Medium Term Budget Policy Statements. http://www.treasury.gov.za/documents/mtbps/2009/default.aspx

2. Government of South Africa. 2007. HIV & AIDS and STI Strategic Plan for South Africa 2007-2011. http://www.tac.org.za/documents/NSP-Draft10-2007-2011.pdf

3. May M. 2009. Determinants of waiting times for ART in the Free State Province, South Africa: prospective cohort study with retrospective database linkage. http://www.ias2009.org/pag/Abstracts.aspx?AID=3708

4. Bassett I. 2009. Who starts ART in Durban, South Africa?...Not everyone who should! http://www.ias2009.org/pag/Abstracts.aspx?AID=1921

Table 1: Summary of public sector ARV tender, June 2008 May 2010
Item
Dose
Company
Volume
Total Cost
ABC
240ml
GSK
1,747,000
234,849,210
ABC
300mgx60
GSK
43,000
13,765,590
DDI
25mgx60
Sonke
37,000
2,003,550
DDI
50mgx60
Sonke
26,000
1,464,580
DDI
100mgx60
Sonke
683,000
46,327,890
EFV
200mgx90
MSD
1,104,000
328,130,880
EFV
600mgx30
Adcock
7,000,000
756,210,000
EFV
600mgx30
Aspen
3,000,000
347,880,000
3TC
240ml
Aspen
3,138,000
67,184,580
3TC
150mgx60
Aspen
9,735,200
290,887,776
3TC
150mgx60
Sonke
2,433,800
72,794,958
PEP Starter
3TCx6,AZTx18
GSK
15,000
855,000
3TC/AZT
150mg+300mgx60
Aspen
20,000
1,835,800
3TC
300mgx30
Cipla
1,601,000
68,042,500
Lop/Rit
5x60ml bottle
Abbott
1,066,000
340,128,620
Lop/Rit
133.3mg&33.3mgx2x90
Abbott
256,000
81,681,920
Lop/Rit
200mg&50mgx120 HS
Abbott
617,000
196,823,000
NVP
20ml
Cipla
10,000
128,000
NVP
240ml
Aspen
45,000
1,633,500
NVP
200mgx60
Aspen
8,801,000
282,600,110
Ritonavir
90ml
Abbott
50,000
3,186,500
Ritonavir
100mgx84
Abbott
200,000
14,888,000
D4T
15mgx60
Aspen
489,000
8,288,550
D4T
20mgx60
Aspen
770,000
13,051,500
D4T
30mgx60
Aspen
8,728,000
147,939,600
D4T
30mgx60
Sonke
2,182,000
38,512,300
TDF
300mgx30
Aspen
3,687,000
588,039,630
AZT
20ml
Aspen
731,000
9,393,350
AZT
200ml
Aspen
200,000
4,530,000
AZT
100mgx100
Aspen
70,000
4,957,400
AZT
300mgx60
Aspen
4,000,000
284,360,000
Total
 
 
 
4,252,374,294

 
Table 2: Conditional AIDS grant by province (numbers are approximate, as these have been updated)
Province
2008/9
2009/10
Eastern Cape
441
480
Free State
207
275
Gauteng
803
933
Kwazulu-Natal
1,338
1,463
Limpopo
244
301
Mpumalanga
228
272
Northern Cape
352
375
North West
135
145
Western Cape
276
310
Total
4,023
4,554