Success depends on increased and efficient spending
South Africa’s Constitution states clearly that all citizens have the right to access health services. This means that our government has a constitutional responsibility to provide healthcare, and an obligation to plan, cost and implement public health programmes. Monitoring budget allocations and expenditure related to the National Strategic Plan on HIV, STIs and TB (the NSP) is therefore vital because such indicators help to tell us whether the government is succeeding or failing to meet these duties.
The Budget and Expenditure Monitoring Forum (BEMF), a group of civil society organisations that provides an ongoing evaluation of the NSP, recognises that considerable progress has been made since 2004 to increase levels of access to treatment for HIV & AIDS, STIs and TB. By mid-2012, for example, over 2 million people of the estimated 6.4 million people living with HIV/AIDS in South Africa were on antiretroviral therapy (ART). In addition, civil society and political pressure has led to a reduction in the costs of medicines and medical supplies. A more competitive bidding process has allowed the South African government to reduce the cost of ART drug procurement to the lowest price anywhere in the world (approximately R1170/US$113 per person per year for fixed-dose combination treatment). As a result, antiretroviral treatment expenditure has been reduced by 53% since the last tender.
But the first NSP of 2007-2011 was marred by a failure to properly cost or budget for specific spending on HIV, STIs and TB. Both nationally and provincially, costings were incomplete, and poorly coordinated resulting in what appeared to be nothing short of a random approach to financing NSP related programs. Ultimately, these weaknesses hampered the achievement of the NSP targets, a failure that South Africans could ill afford given the scale of the challenges the NSP sought to address.
The global financial crisis has also impacted upon the achievement of the NSP’s objectives and the Treasury has continued to look for ways to limit spending. In the national and provincial departmental budget guidelines in 2012 and 2013, for instance, programmes agencies were told that they would need to reduce their budget “baselines” – in other words, that they faced medium-term budget reductions.
In its medium-term budget policy statement of 2012, the Treasury claimed that is was committing itself to protecting the health budget against cuts. But analysis of the 2013/14 health budget conducted by The Centre for Economic Governance and AIDS in Africa (CEGAA) reveals that the opposite has occurred: in real terms (i.e. adjusted for inflation), the consolidated (national and provincial) health budget allocation has fallen by 3.4%. This translated to a 2.2% decline, in real terms, in the total provincial-level health budget allocations for 2013/14 financial year.
Other health sector data raise additional important questions about the government’s ability to achieve the targets of the NSP. For instance, the percentage of government expenditure on health remains at 11.3%, well below the 15% pledged by South Africa in the Abuja Declaration of 2001.
The BEMF acknowledges that the total share of the health budget spent on HIV & AIDS has increased, and that this will rise to approximately 10% in 2015/16. But unless the overall health budget grows to accommodate such increases, other health services are likely to suffer. Spending on HIV/AIDS, STI and TB cannot be seen in isolation, and other spending priorities in the health sector remain vital, such as infrastructure and maintenance, support for rural health, emergency medical services, non-communicable diseases, and preventive and rehabilitative services.
The government, as a matter of urgency, must ensure that any cost-cutting measures (often referred to by Treasury as “maintaining expenditure ceilings”) are not at the expense of South Africa’s health services. The BEMF recommends that Treasury revise the budget ceilings set for health and introduce above-inflation budget increases to both protect and enhance the delivery of health services, including HIV & AIDS, STI and TB. Without real increases in the overall health budget, it is unlikely that the NSP will be fully implemented. The BEMF believes that to pursue a policy of containing expenditure s in health-related budgets would be both retrogressive, unlawful, and a breach of the government’s constitutional obligations to provide access to healthcare services.