Challenges and Opportunities for HIV/AIDS and TB Budget Monitoring at Local Level in South Africa

MRC/HIVAN Forum – Durban, 30 October 2012

CEGAA & TAC partnership for BMET Project

“Giving power to the community: Community monitoring of HIV/AIDS and TB spending in two districts in South Africa”

•To increase the delivery, accessibility, affordability and quality of treatment for people living with HIV/AIDS and TB

•Budget Monitoring and Expenditure Tracking (BMET) empowers communities and citizens with a common understanding of how budget issues affect health care delivery

•CEGAA builds capacity of the TAC's Community Mobilisers to monitor for improved health budget management and services

•Piloted from August 2009 to July 2011; second phase from August 2011, ending December 2012

•Funded by the Open Society Institute–New York (OSI-NY), Open Society Foundation of South Africa (OSF-SA) and International Budget Partnership (IBP).

Presentation NamePRESENTATION DATE

Project Implementation

BMET capacity development and technical assistance

Coalition-building for an amplified community voice on health service delivery at local level

Generating community evidence for informed health budget advocacy

Establishing community partnerships with government

Participatory approach, methods & tools

Capacity development for social accountability (beyond training workshops):

Problem definition: concept notes and funding proposalsSocial mobilisation: stakeholder identification and

sensitisation; coalition-building Community Needs AssessmentsAdvocacy campaign developmentSkills training: community monitoring; budget monitoring

and expenditure tracking; various forms of research Technical support: analysis of financial info and formulae;

putting learnt skills into practiceParticipants’ direct involvement in these activities, rather than merely knowledge transfer, ensures ownership and sustainability.

Budget Monitoring and Expenditure Tracking curriculum

CEGAA and TAC identified gaps in the skills needed for effective budget and community health monitoring activities:

Fundamental economicsDeterminants of healthHealth financingFour phases of the budget processPrinciples of good budgeting (i.e.

participation, transparency and accountability)

Introduction to citizen monitoring toolsBasics of social research and advocacy

development strategies

Technical Support

Specialist guidance to strengthen partners’ work:

Collection and analysis of secondary data through literature review, desk studies of health, HIV/AIDS and TB plans, budgets, in-year and year-end reports, etc.

Dissemination of data through newsletters or “budget policy briefs” = identifying advocacy issues, defining the research agenda, and proposing corrective actions for decision-makers and service providers to take.

Findings presented to stakeholders at local, district and provincial level for validation, responses and contributions. Stakeholders’ input highlights information gaps and enables referral to other sources for fullness or accuracy of the data.

Design and development of BMET pilot study

Situational analysis: Experiences of citizens’ access to and health workers’ provision of

health care services for HIV/AIDS and TBCEGAA and TAC partnered in:

Identifying the pilot sites for investigationDeveloping research tools and Informed Consent proceduresSelecting research assistants/data collectors from communities under studyPiloting research tools for accuracy and appropriateness of questions, and to

test for biasCEGAA did statistical analysis of data

TAC shared in data validation, and review of preliminary and final survey findings

Specific research methods used

Data collected and analysed: provincial and district budgets, plans and progress reports

Review of AIDS statistics: prevalence, incidence, AIDS and TB deaths records; hospital admissions data for AIDS and TB; other district targets; current coverage of treatment for AIDS and TB patients.

Survey: community and health facility assessments to understand the status quo requiring change; identifying presenting problems and suggesting corrective actions

Sampling

Study participants (respondents) = total 405Community: HIV/AIDS and TB patients Health Facility Information Sources: Clinic Operational Managers, ART Staff, Professional and Assistant Nurses and HIV/AIDS Counsellors

Areas: uMgungundlovu, KZN (203 community members; 14 health worker teams)

Lusikisiki, OR Tambo, EC (202 community members; 10 health worker teams)

District Selection Criteria:UMG had highest HIV in the KZN province (urban setting)LUS is one of the poorest regions of the EC (deep rural setting); investigating progress made on the MSF-initiated ART provision

Strategic advocacy process

Urging for improved resource allocation and better services at health facilities:

Target audiences: government health officials, AIDS Councils, unions representing health workers, partner organisations and community members

Dissemination outputs: reports, briefs, presentations

Dissemination avenues: workshops, conferences, stakeholder meetings and public hearings.

Action Teams: maintaining momentum

Action Teams formed at 2010 Public Hearings in Lusikisiki and uMgungundlovu DistrictsTasked with ensuring that issues are addressed by responsible government agents and/or service providersInclude both governmental and non-governmental stakeholders to promote accountability Have helped to resolve numerous challenges, leading to improved access to quality health care for HIV/AIDS and TB patientsSenior health officials are usually too busy to attend the Action Team meetings ……one-on-one meetings are held with DoH to present concerns to senior officials and advocate for action.

Lessons, Challenges and Accomplishments

Accountability is enabled through participation by an empowered civil society that demands efficiency and

transparency. This takes time and consistent engagement.Project experience reveals barriers and ways to address

them.The process clarifies the key role-players’ challenges, laying

the ground for overcoming them through phased, adaptive means.

Summary of accomplishments

Citizens gained knowledge of and technical skills in budget monitoring; TAC, with support from CEGAA, has expanded the BMET project to four additional districtsReciprocal process between community and government stakeholders has increased transparencyPublic Hearings are powerful platforms for advocacy and relationship-buildingSub-district managers are now more open to sharing budget informationMany presenting problems resolved at provincial level:Improved drug ordering and delivery mechanisms between health facilities and district depots Faster turn-around time on test resultsIncreased health personnel in some facilities, easing patient flow and length

of queuesExtended clinic hours in some areas

Remaining challenges

Staff shortagesOverburdened nursesPoor infrastructureInsufficient space for HIV and TB service integrationLack of medical equipment, materials and clinic stationeryDysfunctional ambulance servicesCitizens must be involved in priority-setting = taking part in budget policy-making and evaluation

Moving forward … the BMET team will:

Monitor the NHI interventions in the 2 districtsAnalyse NHI budget spendingTrack in-year actual spending on HIV/AIDS & TBAssess HR planning and budget implementationInvestigate management and planning support needed at clinics to measure efficiency in use of available resourcesContinue to monitor health service deliveryContribute to increasing social accountability mechanisms at local, provincial and national levels

Join the call for better health budgeting!

Budget monitoring is vital to ensure that good policies are implemented, enough financial resources are allocated for policy

implementation, andavailable resources are used efficiently and effectively

to serve people living with HIV/AIDS and TB

Thank youfor sharing in this presentation.

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