Genesis Analytics has been awarded a three-year grant by the Bill & Melinda Gates Foundation to support the male circumcision programme of the Department of Health in South Africa.
Medical male circumcision (MMC) has been shown to reduce the risk of HIV transmission from women to men by about 60%. MMC has been a part of the South Africa National Department of Health’s combination prevention package for reducing new HIV infections in the country since 2010. Now in its eighth year, the programme has successfully and safely circumcised 3.4 million men in the country.
As the programme matures, it continues to have ambitious targets to circumcise an additional 2.5 million men by 2022 in order to reach 80% coverage and contribute towards epidemic control.
To achieve this goal, the National Department of Health faces several challenges. The MMC programme is in a transitional phase as international donor funding declines and South Africa, as a middle-income country, is expected to support the programme through domestic funding. Similar to other hot-button healthcare topics, like National Health Insurance, the Department of Health will need to build its capacity to appropriately manage external contracts and optimise the use of domestic funding to have a sustainable, high quality and well-run MMC programme.
The Scale and Sustainability to Avert New HIV Infections for the medical male circumcision programme (MMC SUSTAIN) in South Africa will provide a suite of technical support to the Department of Health to strengthen the MMC programme. The Genesis Analytics health practice leads a consortium with the Foundation for Professional Development (FPD), and will partner the Department of Health to map a path to a sustainable MMC programme through an iterative process of co-learning, co-design and co-implementation.
The Genesis Health practice will work with our Applied Behavioural Economics practice to encourage positive organisational change at the DOH. Our Infrastructure and Private-Public Partnership practice will assist in developing best practice processes for optimising domestic resource funding.
This project is the largest implemented at Genesis Analytics and builds on our existing partnership with the foundation.
Our support for the MMC national programme will focus on technical assistance in eight districts across three provinces, namely KwaZulu-Natal (eThekwini, Amajuba, iLembe, uMgungundlovu), Mpumalanga (Gert Sibande), and Gauteng (City of Johannesburg, West Rand and Ekurhuleni).
As the future of donor assistance for health services is uncertain, it is important for the South African NDOH to start building on the progress made thus far and thinking about what will be required for transition to a more sustainable and integrated MMC programme. Activities for sustainability have been aligned to our workstreams and to the priorities of the DOH. Through our various workstreams the MMC SUSTAIN team will focus on the following key sustainability enablers in year one:
- Increase provincial and district involvement and capacity in planning, designing, implementing, monitoring and assessing MMC activities;
- Ensure that the MMC Operational Plan FY2019/2020-FY2021/2022 is more sustainability focused;
- Ensure that the Health Systems Strengthening (HSS) model is applied to strengthen and work with the resources that are available;
- Package findings from the baseline assessment and identify innovative channels to share to non-supported districts and key stakeholders;
- Document the process of establishing an intervention;
- Influence national procurement processes by capacitating the relevant sub-national levels with contract management skills and the correct behaviour to contract out services;
- Strengthen quality assurance processes in relation to DOH kits and medical devices and link with existing processes in other health areas;
- Ensure that costing activities are included in the micro-planning process;
- Focus behavioural interventions in problematic districts and sites.
The MMC programme has to address issues of alignment, integration and coordination. There is inadequate alignment of national planning, financing, implementation and monitoring, as well as a disconnect between national strategies and district implementation. Furthermore, the MMC programme operates as a siloed health initiative with sub-optimal integration of MMC into the broader health system. Currently, the MMC programme is not achieving the coverage required to reach the full prevention benefit. The programme is also heavily donor-dependent with approximately 70% of circumcisions funded by donors, such as PEPFAR. As donors have begun to reduce their funding and transition out of districts, the national programme needs to urgently address programmatic issues and capacity concerns and improve the use of domestic resources. While the country has already successfully managed the transition of 24 districts, the changing environment threatens the continuity of service provision.
More specifically the programme suffers from:
- Limited ownership of, and motivation to, implement the MMC programme at sub-national levels;
- Poor planning and coordination of demand creation efforts at sub-national levels of government and between various MMC service providers;
- Poor involvement of, and joint planning with, non-health stakeholders such as the DBE and HEAIDS at all levels;
- Inability of provinces to develop costed multi-year plans that adequately address all the elements of the MMC programme and ensure that financial resources are allocated optimally and equitably across activities and geographies;
- Poor analysis of expenditure against budgets at all levels;
- Poor use of, and integration with, existing DOH systems and structures to plan, monitor and implement course correction for responsive MMC programmes;
- Poor contractual management of domestic resources and transversal contracts by provinces and delayed payments to suppliers;
- Weak capacity, skills and incentives of users in the system to implement the MMC programme;
- Weak systems and processes in place to ensure quality and safety and to monitor AEs;
- Sub-optimal compliance with quality-control processes, including CQI and EQA of MMC;
- Inadequate flow of data into the DHIS from implementing partners, poor compliance with data reporting standards and poor use of data for decision-making at sub-national levels;
- Irregular dissemination of methods, tools, and good practice to various stakeholders, especially in geographies not directly funded by PEPFAR; and,
- The national programme’s current transition policy does not address all the elements and considerations for transition to sustainability.
In order to address the challenges experienced within the national MMC programme, the MMC SUSTAIN team comprises several workstreams. The first two workstreams are overarching and will be included in the package of assistance for all geographies of focus.
National, provincial and district coordination and ownership, motivation and support are aligned to our UCD approach and our strategy to lead from behind. Through these workstreams we will embed organisational change at all levels of DOH and ensure that there is a resilient MMC programme in place at a national and sub-national level.
Knowledge management cuts across the system to ensure that there is regular dissemination to the DOH of lessons learned and approaches to increase programme sustainability and effectiveness.
The remaining workstreams will be tailored to the geographical needs for more targeted outcomes at the different levels of the DOH. Our focus is on building sub-national capacity to ensure that the MMC programme meets its targets for each year, is economical, efficient, cost effective, and that financial resources are allocated optimally and equitably across activities and geographies.
Our focus will also be on ensuring quality of services and that there is high quality data available that can be used to inform planning and the implementation of the programme at national and sub-national levels.