Red lights flash on funding for HIV, TB and STIs

Within four years South Africa will be short of R7.2bn in overall funding needed to contain HIV, TB and sexually transmitted infections (STIs), according to a leading health economist.

That’s the projection by Steve Cohen, of Genesis Analytics, who heads the costing & financing task team at the South African National Aids Council (Sanac).

Addressing the Aids conference in Durban last week on the financing of the latest National Strategic Plan (NSP) for HIV, TB and STIs (2023-2028), Cohen said a combination of negative factors signalled the shortfall by the 2027/2028 financial year.

He cited real GDP declining at an accelerating rate for 10 years, medium-term growth projection at 1%, slow recovery from Covid, debt service costs at nearly 20% of government revenue (R350bn a year), large accumulation of accruals and payables by provincial health departments, medical legal claims and inflationary pressures.

The government’s fiscal position pointed to constrained spending and austerity with no new money from traditional funding sources, said Cohen.

“South Africa will have to look at other fiscal space levers, namely efficiency drivers, external funding, innovative funding sources and political leadership to ensure sufficient budgets over the medium term.”

Cohen expects the private sector to play an increased financing role.

Among the levers available to the government were the co-ordination of sufficient and complementary investments from development partners and an impending “resource mobilisation strategy”.

Evidence-based advocacy, including investment cases and budget bids and prioritisation will be essential. Another efficient strategy will be to build on the success in lowering drug prices and cost-effective drug regimens, he said.

If operational efficiencies are achieved, these can allow money to be invested in under-resourced areas. Strategic buying, precision targeting, integration and better provincial budget planning and execution and the use of digital technologies are other levers — as are social impact bonds, development impact bonds and public-private partnerships.

Cohen said Sanac and provincial Aids councils are gearing up to develop provincial sustainability road maps, with milestones and routine monitoring of progress.

Investment co-ordination with development partners in supporting South Africa’s move to an integrated HIV programme within a strengthened public health system will continue to provide complementary and targeted investments at each phase of implementation of the country’s sustainability road maps.

“There must be increased domestic financing of key population programmes with an increase in social contracting via nonprofit providers,” he said.

Most of NSP funding comes from the government (R34bn in 2023/2024 rising to R42bn in 2027/2028). The next biggest are Pepfar (US President’s Emergency Plan for Aids Relief) and US Aid (R7.58bn in 2023/2024 decreasing to R6.88bn in 2027/2028). The third-largest is the Global Fund at a constant R38bn over the same period. Private sector funding, projected to remain constant, was the smallest contributor.

The national department of health’s district health programmes are the biggest contributors towards HIV/TB and STI control, at an average of 80% of all funding from 2023/2024 to 2025/2026.

Taking inflation into account, HIV treatment and care accounts for about 54% of costs followed by HIV prevention at 17% trailed by “programme enablers”, TB treatment and care, and STI service delivery, at a fraction of these percentages.

Costs will rise from R47bn in 2023/2024 to R60bn in 2028/2029 with the five-year total at R268bn. Annual resource needs in the fifth year (2028/2029) are R13bn higher than the current fiscal year (after inflation), and R3bn in real 2023 prices.

Cohen said South Africa has committed to financing the world’s largest HIV treatment programme.

Dr Dino Rech, CEO of Audere, a digital health nonprofit company, speaking in the same session as Cohen, said digital technology was an invaluable tool in decisively ending the pandemic.

He said artificial intelligence (AI) expands access to care, increases the quality of care and leads to improved outcomes and the best use of resources. But he warned that “even if AI systems learn from accurate representative data, there can still be problems if that information reflects underlying biases and inequalities in the health system”.

Rech said risk identification and mitigation are essential, with security in design, de-identified data, and data protection rules essential to ensure privacy and data security.

He recommended automating rote tasks for more face-to-face time with patients.

Quoting Trevor Mundel, the president of Global Health and the Bill & Melinda Gates Foundation, he said that by engaging local communities in AI development, “we can ensure the technology is tailored to their specific needs and cultural contexts and empower them to determine the safety and acceptable thresholds for system bias”.

Published in Financial Mail 29 June 2023 and online