Addressing the recent 11th SA AIDS conference in Durban on the financing of the latest National Strategic Plan, (NSP), for HIV, TB and STI’s (2023-2028), Cohen said a strong confluence of negative factors signaled significant shortfalls and threatened health care
delivery by the 2027/2028 financial year.
He cited these as real GDP per capita having declined at an accelerating rate for 10 years, medium term growth projection at one percent, the slow recovery from the economic shock of Covid-19, debt service costs at nearly 20% of government revenue (R350 billion per annum), the large accumulation of ‘accruals and payables” by provincial health departments, medico legal claims and inflationary pressures.
Austerity, no new money
The macro-economic environment and the government’s fiscal position pointed to a period of constrained spending and austerity with no new money from traditional funding sources.
“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,” he asserted.
Cohen said he expected the private sector to play an increased financing role.
Among the levers available to 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 prioritization would be essential. Another efficient strategy would be to build on the success in lowering drug prices and cost-effective drug regimens. If operational efficiencies were achieved, they could enable money to be invested in under-resourced areas. Strategic purchasing, precision targeting, integration and better provincial budget planning and
execution and the use of digital technologies were other levers – as were social impact bonds, development impact bonds and public private partnerships.
Cohen said SANAC and provincial AIDS councils were gearing up to develop provincial sustainability roadmaps, with milestones and routine monitoring of progress.
Investment co-ordination with development partners in supporting SA’s move to an integrated HIV program within a strengthened public health system would continue to provide complementary and targeted investments at each phase of implementation of the country’s sustainability roadmaps.
“There must be increased domestic financing of key population programs with an increase in social contracting via non-profit providers,” he told nearly 2000 conference delegates.
With the bulk of NSP funding coming from government (R34 billion in 2023/4 rising to R42 billion in 2027/8), Pepfar and US Aid were the next biggest contributors, (R7,58 billion in 2023/4 decreasing to R6,88 billion in 2027/28). The third largest funder was the Global Fund at a constant R38 billion over the same period. Private sector funding, projected to remain constant, was the smallest contributor.
The National Department of Health’s District Health Programs via conditional grants were the biggest fiscal contributor towards HIV/TB and STI control at an average of 80% of all funding from 2023/24 to 2025/26.
HIV costs highest
Taking inflation into account, HIV treatment and care accounted for some 54% of costs followed by HIV prevention at 17% trailed by “program enablers,” TB Treatment and Care and STI service delivery, at a fraction of these percentages.
Costs would rise from R47 billion in 2023/24 to R60 billion in 2028/29 with the five-year total at R268 billion. Annual resource needs in the fifth year (2028/29) were R13 billion higher than the current fiscal year (after inflation), and R3 billion in real 2023 prices.
He emphasized that South Africa had committed to financing the largest HIV treatment program in the world.
Dr Dino Rech, CEO of Audere, a digital health non-profit company,” illustrated Cohen’s assertion that digital technology was an invaluable lever during the same plenary session, entitled, 'Acting Decisively to End the Pandemic.'
He said Artificial Intelligence, (AI), cost-effectively expanded access to care, increased the quality of care and led to improved outcomes.
It supported resource optimization, reduced choice architecture, increased decision support, quality assurance and confidence while increasing self-efficacy. However, 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 were 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 and 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.”