Show us the money: Can government deliver on its health promises?

Show us the money: Can government deliver on its health promises?
Members of the organisation Grandmothers Against Poverty and AIDS (GAPA), which provides food and day care for children with HIV/AIDS in South Africa. Photo by Omar Eid, courtesy of Photoshare.


If you want to know a government’s real priorities, you’ll find them in the budget

Some would argue that a government’s most important policy document is its budget. A budget not only makes promises, it outlines what resources are available to fulfill those promises. If there is no budget, or if the budget is insufficient for a particular health priority then that priority is nothing more than an empty promise.

This is why budgets can provide some of the most valuable information for anyone who wants to hold public institutions to account for HIV service delivery. In South Africa we are lucky that our government, at both national and provincial levels, generally publishes a great deal of high-quality budget information. In fact, on the 2010 Open Budget Index (OBI), which compares countries in terms of budget transparency and accountability, South Africa gets top ranking out of 94 nations.

But all this information is only as useful as we make it. If we do not understand the budget and how we can engage with it, we miss important opportunities. Budget information can help us pressure the government to deliver on its commitments and to respect the promises made in our Constitution and Bill of Rights.

What do we spend on HIV?

Even though our government comes out on top in the OBI, it has been surprisingly difficult to find out exactly what South Africa spends on its response to HIV.

The 2010 mid-term review of the previous NSP (2007-2011) was particularly critical about this problem. The review argued that a major failing in the implementation of the NSP was the ’scattergun‘ approach to financing. Countless government, private and donor sources all funded interventions but without sufficient coordination. As a result there was no way to properly monitor and evaluate what was spent, where and how.

In the last two years, however, there have been attempts to improve monitoring and evaluation. The recently completed National AIDS Spending Assessment (NASA) for South Africa, prepared by the Centre for Economic Governance and AIDS in Africa (CEGAA) on behalf of UNAIDS, tried to pinpoint actual HIV expenditure by the South African government, the private sector, NGOs and development partners. Unfortunately, the final results of the NASA country report are not yet publically available. But what we do know about the NASA suggests that although the review of government expenditure was thorough, private sector and development partners were often unwilling to participate fully in the project. As a result data from these sources is limited.

The lack of complete data is frustrating. Over the last decade South Africa has relied heavily on donor funding to supplement money from the public purse. The exact amount provided by donors is unknown, but Treasury estimates place it somewhere between R5 billion and R6 billion annually.

We know even less about private sector spending on HIV. This expenditure is highly fragmented and diverse. It comes from sources such as private medical aid schemes, workplace insurance programmes and out-of-pocket payments by individuals funding their own treatment.

However, government is by far the largest service provider, spending a lot more on its HIV programmes than the private sector.

Bridging the funding gap

Indeed, the South African government is becoming more important to our response to HIV as donors like PEPFAR and the Global Fund start to cut back on their funding. Fortunately it does appear that government is stepping up to bridge the funding gap with domestic contributions.

Since 2006 South Africa has dramatically increased funding for HIV services. Estimates suggest that total HIV-specific allocations from the public sector rose from approximately R2.5 billion in 2005-06 to more than R11 billion in 2010-11. This amounts to an increase of more than 400%. HIV spending has become perhaps the biggest budget item of all.

Government’s commitment to expanding HIV services is also clearly visible in its most recent budget. Even though expenditure was cut in other important areas due to the slow recovery of the global economy, altogether government allocations for HIV programmes have once again risen substantially. For the 2012-13 financial year government has earmarked more than R8.76 billion through the HIV and AIDS Conditional Grant alone. This translates to an increase of around R1 billion or 13% on last year’s allocation. The trend looks set to continue over the next two years with allocations from the Grant increasing by 20% (R1.77 billion) in 2013-14 and by a further 16% (R1.68 billion) in 2014-15.

Many of these gains are due to the efforts of civil society organisations. These include groups such as the Treatment Action Campaign, Médecins Sans Frontières (MSF), CEGAA and SECTION27.

Expanding domestic funding

But our fight for sustainable resources is by no means over. Government needs to secure additional domestic funding to further grow its HIV programmes. Yet South Africa is approaching the limit of what can be found through sources such as tax revenue. Therefore in the medium-term civil society will need to push for government to consider new financing mechanisms. These could include additional ‘sin taxes’ or an AIDS levy such as the one used in Zimbabwe. There are moves within government and the South African National AIDS Council to begin investigating such options. So far, however there is no indication that any particular mechanism will be introduced in the near future.

It is not enough for us to fight for more money, though. An equally important challenge is to ensure that the money we have is used properly. Endemic corruption and poor financial management are now perhaps the greatest threats to our HIV programmes. Each year millions of rands are wasted through improper tender procedures and through government’s failure to guarantee that the money it earmarks for specific interventions is used only for its intended purpose.

A number of civil society organisations already monitor the assignment of resources. They also help to track expenditure and to push for greater government accountability in the use of resources for managing HIV.

SECTION27, for example, currently scrutinises the allocation of resources for HIV at the policy level. The organisation analyses these allocations using the national and provincial health budgets.

CEGAA is involved in similar work. It not only examines the allocation of resources through the budget but has also carried out a NASA report on South Africa (see above). The NASA project tracked the flow of resources from their source right down to actual spending at the point of service delivery.

The BMET project

It is important to remember that budget monitoring and expenditure tracking are not only for organisations with specialised technical expertise. The Treatment Action Campaign (TAC), in partnership with CEGAA, is currently conducting a Budget Monitoring and Expenditure Tracking (BMET) project in several of its model districts throughout South Africa. This BMET uses various tools including citizen report cards and direct monitoring of expenditure on the ground. In this way TAC aims to hold government to account for what actually happens with our money.

In addition to this regular work, organisations such as TAC, CEGAA and SECTION27 are part of a civil society coalition known as the Budget and Expenditure Monitoring Forum (BEMF). The purpose of BEMF is to bring diverse organisations together to share information about health financing.

Pooling expertise

The coalition also aims to strengthen joint advocacy by pooling the diverse expertise of these groups. Some such as CEGAA have strong technical know-how while others like TAC are adept at monitoring what happens on the ground and are able to mobilise those people who are worst affected by poor financial management.

To date BEMF has successfully united civil society organisations to advocate on a number of important issues including:
  •  The release of the Integrated Support Team Reports into provincial health financing;
  • The negotiation of significant cost reductions in the 2010 ARV tender;
  • The full costing of the NSP (2012-2016);
  • The cancellation of the Global Fund’s Round 11 funding; and
  • The Gauteng Budget crisis

We must build on this success to achieve even more in future. With regard to the NSP, South Africans have a chance to ensure that departments and provinces develop realistic implementation plans that are properly costed and budgeted. Once these plans are in place and the resources have been allocated we will have the difficult task of making sure that the money is spent appropriately.

by Daygan Eagar