Opinion: SA’s TB recovery doesn’t necessarily need a bigger budget, just reprioritisation
The global theme for World Tuberculosis (TB) Day this year was “Invest to end TB. Save lives”.
The thinking behind the theme, according to the World Health Organization (WHO), is that there is an urgent need to invest resources to ramp up the fight against TB so that all countries can reach their TB elimination goals.
Considering the negative impact of the COVID-19 pandemic, which has stymied the progress of the TB response across the world, the call for investment is important. In a statement released this week, the WHO notes, “More investment will save millions more lives, accelerating the end of the TB epidemic.”
South Africa has already started to heed the call for this increased investment. The National Department of Health has embarked on an ambitious National TB Recovery Plan. The plan has been developed to help the country regain the losses that the TB response has experienced as a result of the COVID-19 pandemic.
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At the core of this recovery plan are five strategies. It will start by finding undiagnosed people with TB through interventions that scale up community screening, introduce Targeted Universal TB Testing, and the use of other technologies. But the plan will also look at how to strengthen the systems that link people to care, strengthen the systems that keep them in care, and scale up initiatives that encourage the use of TB prevention therapy. (Targeted Universal TB Testing involves offering TB tests to people at high risk of TB whether or not they have symptoms.)
While one might think this would require more funding, this is not necessarily the case. It is true that all programmatic work could benefit from additional financial assistance, but the focus right now should be on the strategic use of existing resources to help put the country on the right path.
How health is funded in SA
To understand how we can make better use of existing resources it helps to first set out how health funding works in South Africa.
As a start, the National Treasury allocates financing for the health budget. Nationally collected revenue after debt servicing costs is divided across the different spheres of government –National, Provincial, and Local. The responsibility for health is shared between the National Department of Health and provincial health departments–the latter being the main implementers of healthcare services.
In the case of priority disease programmes such as the response to HIV and Tuberculosis additional funding is provided through a conditional grant. This grant was recently renamed the district health programme grant. The current allocation for this financial year is around R29 billion of which just over R4.8 billion is allocated to the district health programme. The remaining R23 billion supports the national response to HIV.
The district health component allows provinces greater flexibility as to how funds are allocated. So, in theory, this funding could be used to prioritise the implementation of targeted universal TB testing in high-burden TB districts. This has the potential to increase the number of people with TB who are initiated on TB treatment. The district health component also includes funding for community outreach services, notably community healthcare workers.
Improving TB data systems
Access to reliable health management information systems is also critical to the success of the TB recovery plan.
Currently, the National Institute of Communicable Disease (NICD) is able to track the number of TB tests which includes the number of positive cases. Treatment data, as opposed to testing data, is however collected through the TIER.NET system which consolidates TB and HIV treatment data to facility level. There have, however, been some reported challenges with linking the two systems. This makes it difficult to assess how many people diagnosed with TB actually access the treatment needed to cure TB.
Included in the R1.9 billion non-personal services component of the National Health Insurance programme is funding to strengthen patient information systems. Given TB’s status as a leading cause of death in South Africa, some of this funding should be used to prioritise addressing these gaps.
Equitable share
The next layer in the division of revenue is the provincial equitable share allocations. Each province’s share of nationally collected revenue is determined by its share of the population. The equitable share is made up of six components Education, Health, Basic, Institutional, Poverty and Economic Activity.
The health component, at 27%, is the second-largest component. TB services are funded primarily from provincial health budgets and given the unconditional nature of the equitable share allocations, provincial governments have significant discretion in how these resources are allocated.
Let’s take KwaZulu-Natal as an example.
Given its large population, the province benefits significantly from the distribution of revenue. In addition, since it has the highest prevalence of both HIV and TB, it absorbs a large percentage of the conditional grant.
In the 2022 Division of Revenue Bill, KZN’s allocation for health within the equitable share amounted to around R111 billion with the health component making up just over R30 billion. After the addition of conditional grant allocations, the total provincial health budget is just short of R50 billion for the 2022 financial year.
As the bulk of TB services is funded from the provincial district health services budgets it is difficult to determine if TB receives sufficient allocations to meet its programme priorities. Unlike national budgets, there are limited opportunities for public consultation which make it difficult for patient user groups, civil society organisations, and even provincial legislatures to ensure sufficient accountability.
But what does all this mean?
This financing framework places a significant responsibility on provincial health departments. The success of the overall TB programme is highly dependent on their health management systems, their budgets, and their ability to deliver primary healthcare.
The provincial departments will have the flexibility to move elements of their programmes into different categories of their budgets. Within this, they will need to allocate budgets to increase testing as the first strategy of the TB Recovery Plan, as well as outreach services.
19 districts with the highest TB burden are adequately funded to roll out increased testing in line with Targeted Universal Testing for TB. Targeted Universal Testing will mean that a significant number of people who previously would not have been considered for TB testing will be tested – whether they have symptoms or not. This includes people living with HIV, close contacts of TB patients, and anyone who reported having TB in the past two years. All these groups of people are considered at high risk for TB – and the science has shown that in South Africa there is a massive cohort of people who have TB and are asymptomatic.
Doubling the TB testing capabilities in these districts will have financial implications that will have to be considered. But as important as the financing of the testing, is the financing of the outreach services in these communities. These allocations should be channelled to optimise the needs of community healthcare workers. South Africa’s community healthcare workers are already an essential part of the TB response. They are responsible for contact tracing in communities, symptom screening, education on side effects and raising awareness, encouraging people in high-risk groups to test for TB, follow-up counselling, contact tracing in the family, as well as ensuring that patients receive the necessary support to complete treatment.
Accountability is critical
To ensure the success of the TB Recovery Plan, the National Department of Health has a critical role to play. The conditionalities attached to the conditional grants, which they coordinate, present an opportunity for them to fast-track and steer the coordination of the TB Recovery Plan. They can shape the use of the funds.
As the name suggests, conditional grants like the district health programme are subject to conditions that can assist the national TB programme to strengthen both the coordination between provinces as well as ensure sufficient accountability for the implementation of these funds. The flexibilities allowed within the grant also allow that sufficient funding can be allocated to ensure the success of the TB recovery plan.
Ultimately then, the success of the National TB recovery plan is contingent on improved coordination between the National TB Programme and the provincial departments of health responsible for implementing it. Here too, the most crucial element is accountability.
Rensburg is the Director of the Rural Health Advocacy Project, which acts as the secretariat of the TB Accountability Consortium.
The TB Accountability Consortium has launched a new report, ‘The State of TB in South Africa, Shifting Priorities to Regain Momentum in the Fight’. The report can be downloaded here: https://www.wits.ac.za/media/wits-university/faculties-and-schools/health-sciences/images/faculty-news-images/StateOfTB-march2022.pdf