HEALTH AND HIV FUNDING Budget Monitoring Forum Presenter: Mark Blecher | National Treasury | November 2011 Mortality beginning to drop 2 Numbers on AIDS treatment 3 Health personnel 4 Primary care visits 5 National service delivery agreement Table 1: Summary of outcomes and targets of the NSDA Outcome Target for 2014, with baseline values from 2009 1 Increase life-expectancy Increase life-expectancy from 53.9 to 58 years for males and 57.2 to 60 years for females 2 Decrease maternal and child mortality Decrease maternal mortality rate from 625 to ≤ 100 per 100 000 Decrease under-five mortality rate from 104 to ≤ 20 per 1000 Decrease infant mortality rate from 53 to ≤ 18 per 1000 3 Combat HIV and AIDS and decrease the burden of Reduce new HIV infections by 50% disease from TB Of all those eligible for highly active antiretroviral therapy (HAART), 80% must have access to it Increase TB cure rate from 64% to 85% 4 Strengthen health system effectiveness Re-engineering of PHC Implement NHI system Source: National Department of Health (NDoH), 2010. 2 6 Middle income health financing 7 Health spending 8 Public and private health spending (real) 9 Provincial DOH spending (real) Real spending growth per annum Provincial health funding trends R million real 10/11 prices 120,000 100,000 80,000 60,000 R million 40,000 20,000 0 Per capita health spending (real 10/11) Health spending as % of GDP Health spending as % of GDP 10.00% 9.00% 8.00% 7.00% Public h ealth 6.00% Private T otal 5.00% 4.00% 3.00% 2.00% 10 Hospital workloads 11 Health infrastructure Total R10b pa Improve delivery capacity R134m for NDOH 11/12 Partnerships with DBSA, CSIR Managing engineers Project monitoring tools Project intervention teams 5 large PPPs New Health Infrastructure grant (R1.7b rising to R1.9b) 4,500 4,000 3,500 3,000 2,500 Budget Expenditure 2,000 Under-exp 1,500 1,000 500 0 03-04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 • • • • • • • • • 12 Budget 2012 • • • • • • • • Difficult fiscal position Holding budget – no increase in deficit Only contingency reserve available for allocation Function committee approach Reprioritisation Non-discretionary areas Policy priorities (minimal fiscal space) Savings (partly to fund economic stimulus package, enterprise support, EPWP type jobs, NHI pilots) 13 Budget 2012 • • • • • • • • Difficult fiscal position Holding budget – no increase in deficit Only contingency reserve available for allocation Function committee approach Reprioritisation Non-discretionary areas Policy priorities (minimal fiscal space) Savings (partly to fund economic stimulus package, enterprise support, EPWP type jobs, NHI pilots) 14 Fiscal position 15 Government borrowing 16 Health and social protection diagram National Social Development: Programme 1,4 &5 R767 million Women, Children and People with Disabilities R63 million Soc Dev provincial dept. R12 billion The Commission on Gender Equality R55 million Health & Social Protection Function MTEF 2011/12 Social Development & welfare services R13 billion National Development Agency R175 million Road Accident Fund R17 billion National Social Development: Programme 3,excl.SASSA R101 million CCOD R110 million Compensation Fund and Reserve Fund R5 billion Social Security R31 billion National Youth Development Agency R398 million UIF R10 billion Public Entities & Agencies: -SASSA RAF -NHLS -CCOD -Council for Medical Schemes -Compensation Fund and Reserve -Unemployment Insurance fund -National Development Agency -National Youth Development Agency -The Commission on Gender equality Provincial Social development PDs Health PDs Health CGs Health & Social Protection R266 billion National Departments: -Health -Labour -Presidency - Social Development -Defence and Military Veterans -Women , Children and People with Disabilities Council for Medical Schemes R94 million National Social Development, programme 2 R98 billion NDoH R1.4 billion Social Assistance R104 billion Health R118 billion Health PDs and CGs R110 billion SASSA R6 billion Defence and Military Veterans R3 billion National health Laboratory Services R4 billion 17 Health Baseline Ex p e n d itu re O u tc o m e s Ad ju s te d Ap p ro p ria tio n 2 0 0 8 /0 9 2 0 0 9 /1 0 2 0 1 0 /1 1 6 ,0 3 9 ,0 3 7 7 ,0 8 4 ,3 3 6 7 ,8 1 3 ,3 6 5 H e a lt h 1 ,1 2 0 ,5 5 7 Ad m in is tra tio n 2 4 1 ,0 2 1 H e a lth P la n n in g a n d S ys te m s E n a b le m e n t 1 1 9 ,6 7 3 H IV a n d AID S , TB a n d Ma te rn a l, C h ild a n d 5 0 9 ,0 1 7 P rim a ry H e a lth C a re S e rvic e s 1 0 8 ,6 6 0 H o s p ita ls , Te rtia ry S e rvic e s a n d W o rkfo rc e D e ve lo p m e n t 4 1 ,5 8 7 H e a lth R e g u la tio n a n d C o m p lia n c e Ma n a g e m e n t 1 0 0 ,5 9 9 1 ,3 0 9 ,3 1 2 2 6 9 ,9 2 5 1 1 1 ,6 1 7 5 4 7 ,3 5 4 2 7 3 ,2 9 5 2 ,2 9 1 1 0 4 ,8 3 0 H e a lt h P u b lic E n t it ie s C MS - C o u n c il fo r Me d ic a l S c h e m e s N H LS -N a tio n a l H e a lth La b o ra to ry s e rvic e s 2 ,7 4 1 ,5 4 0 5 8 ,2 6 1 2 ,6 8 3 ,2 7 9 D e fe n c e a n d M ilit a r y v e t e r a n s Milita ry H e a lth S u p p o rt 2 ,1 7 6 ,9 4 0 2 ,1 7 6 ,9 4 0 R th o u s a n d N a t io n a l P r o v in c ia l H e a lt h (In c lu d in g c o n d it io n a l g r a n t s ) Ad m in is tra tio n D is tric t H e a lth S e rvic e s E m e rg e n c y Me d ic a l S e rvic e s P ro vin c ia l H o s p ita l S e rvic e s C e n tra l H o s p ita l S e rvic e s H e a lth S c ie n c e s a n d Tra in in g H e a lth C a re S u p p o rt S e rvic e s H e a lth F a c ilitie s Ma n a g e m e n t Min u s th e NHLS d o u b le c o u n t To t a l 7 2 ,3 7 2 ,8 5 5 7 5 ,0 5 6 ,1 3 4 2 ,6 3 8 ,3 9 7 3 1 ,4 7 7 ,9 0 4 2 ,8 9 9 ,3 8 4 1 7 ,4 7 5 ,7 5 4 1 0 ,9 9 9 ,6 3 2 2 ,5 8 6 ,1 6 4 1 ,2 1 4 ,4 5 4 5 ,7 6 4 ,4 4 5 2 ,6 8 3 ,2 7 9 7 8 ,4 1 1 ,8 9 2 Ave ra g e g ro w th fo r MTEF p e rio d 1 1 /1 2 to 1 4 /1 5 5 .0 % 2 0 1 2 /1 3 2 0 1 3 /1 4 2 0 1 4 /1 5 8 ,1 7 1 ,1 5 3 8 ,4 4 7 ,4 4 4 8 ,9 2 9 ,7 5 2 9 ,4 5 0 ,7 6 6 0 8 /0 9 to 1 1 /1 2 1 0 .6 % 1 ,4 0 3 ,6 9 9 1 2 4 ,5 0 2 2 2 3 ,2 2 3 6 1 6 ,8 7 1 1 4 2 ,9 3 0 7 2 ,9 5 0 2 2 3 ,2 2 3 1 ,4 2 3 ,0 9 5 3 2 6 ,0 7 1 1 6 0 ,3 8 7 5 3 3 ,5 6 6 1 3 9 ,6 3 2 9 8 ,3 8 1 1 6 5 ,0 5 8 1 ,4 8 7 ,7 0 4 3 2 5 ,3 2 4 1 7 7 ,5 5 9 5 5 2 ,4 6 1 1 4 3 ,0 3 2 9 3 ,9 1 2 1 9 5 ,4 1 6 1 ,5 6 4 ,0 7 2 3 4 4 ,3 8 9 1 8 9 ,3 4 7 5 8 1 ,5 6 2 1 5 0 ,1 2 6 9 5 ,1 2 7 2 0 3 ,5 2 1 1 ,6 5 8 ,1 7 4 1 9 5 ,9 2 2 3 1 4 ,7 3 4 6 1 6 ,4 5 6 1 5 9 ,1 3 4 9 5 ,5 3 5 3 1 4 ,7 3 4 8 .3 % 1 0 .6 % 1 0 .3 % 1 .6 % 8 .7 % 3 3 .2 % 1 7 .9 % 5 .2 % -1 5 .6 % 2 5 .2 % 4 .9 % 4 .5 % -1 .0 % 2 4 .0 % 3 ,1 6 6 ,8 9 6 6 4 ,3 5 8 3 ,1 0 2 ,5 3 8 3 ,3 6 0 ,0 9 7 8 2 ,2 1 9 3 ,2 7 7 ,8 7 8 3 ,7 0 3 ,9 1 9 9 4 ,0 4 0 3 ,6 0 9 ,8 7 9 3 ,6 3 1 ,7 0 4 1 0 0 ,3 8 7 3 ,5 3 1 ,3 1 7 3 ,8 4 6 ,0 0 5 1 0 5 ,9 0 8 3 ,7 4 0 ,0 9 7 4 ,0 6 1 ,7 3 7 1 1 1 ,2 0 4 3 ,9 5 0 ,5 3 3 1 0 .5 % 1 7 .3 % 1 0 .4 % 3 .1 % 5 .7 % 3 .1 % 2 ,6 0 8 ,1 2 8 2 ,6 0 8 ,1 2 8 3 ,0 4 9 ,5 6 9 3 ,0 4 9 ,5 6 9 3 ,0 4 4 ,1 3 9 3 ,0 4 4 ,1 3 9 3 ,3 2 8 ,0 3 6 3 ,3 2 8 ,0 3 6 3 ,5 1 9 ,6 7 5 3 ,5 1 9 ,6 7 5 3 ,7 3 0 ,8 5 6 3 ,7 3 0 ,8 5 6 1 1 .8 % 1 1 .8 % 7 .0 % 7 .0 % 1 0 6 ,4 2 0 ,6 6 3 1 1 4 ,8 7 3 ,4 0 6 1 2 3 ,0 3 1 ,4 6 4 1 3 0 ,4 2 7 ,3 2 2 1 1 0 ,0 3 0 ,5 4 2 1 1 8 ,4 0 4 ,7 2 3 1 2 6 ,7 7 1 ,5 6 1 1 3 4 ,3 7 7 ,8 5 5 3 ,2 0 4 ,9 4 4 3 ,5 4 3 ,0 8 7 3 ,6 9 7 ,4 7 6 3 ,9 1 9 ,3 2 5 4 7 ,4 3 8 ,2 0 4 5 1 ,7 4 7 ,3 5 8 5 6 ,4 2 9 ,2 0 2 5 9 ,8 1 4 ,9 5 5 4 ,5 3 8 ,3 0 9 4 ,8 5 9 ,3 5 5 5 ,0 8 8 ,5 8 9 5 ,3 9 3 ,9 0 4 2 3 ,4 0 7 ,6 3 0 2 5 ,0 2 1 ,2 2 8 2 6 ,7 4 6 ,1 7 5 2 8 ,3 5 0 ,9 4 5 1 6 ,6 2 7 ,7 2 5 1 7 ,8 6 2 ,5 4 5 1 8 ,9 0 2 ,7 0 0 2 0 ,0 3 6 ,8 6 2 3 ,6 9 2 ,9 3 6 3 ,8 4 5 ,0 4 2 4 ,0 4 3 ,6 8 3 4 ,2 8 6 ,3 0 4 1 ,7 5 9 ,1 3 9 1 ,8 5 1 ,3 7 0 1 ,9 1 5 ,3 8 6 2 ,0 3 0 ,3 0 9 9 ,3 6 1 ,6 5 4 9 ,6 7 4 ,7 3 9 9 ,9 4 8 ,3 4 9 1 0 ,5 4 5 ,2 5 0 3 ,6 0 9 ,8 7 9 3 ,5 3 1 ,3 1 7 3 ,7 4 0 ,0 9 7 3 ,9 5 0 ,5 3 3 1 1 4 ,5 9 1 ,8 1 6 1 2 3 ,3 2 0 ,8 5 0 1 3 1 ,9 6 1 ,2 1 6 1 3 9 ,8 7 8 ,0 8 8 1 3 .6 % 1 3 .6 % 6 .7 % 1 4 .7 % 1 6 .1 % 1 0 .2 % 1 4 .8 % 1 2 .6 % 1 3 .1 % 1 7 .5 % 1 0 .4 % 1 3 .5 % 6 .9 % 6 .9 % 6 .9 % 8 .0 % 5 .9 % 6 .6 % 6 .4 % 5 .1 % 4 .9 % 4 .0 % 3 .1 % 6 .9 % 8 5 ,5 1 6 ,2 0 5 9 4 ,8 1 9 ,0 7 9 8 8 ,6 1 8 ,7 4 3 9 8 ,0 9 6 ,9 5 7 3 ,4 2 1 ,9 2 2 2 ,7 1 0 ,6 8 6 3 7 ,1 9 0 ,8 2 2 4 2 ,7 2 2 ,7 1 7 3 ,4 7 9 ,0 4 5 3 ,8 8 2 ,4 6 0 2 0 ,3 3 5 ,8 2 3 2 2 ,7 5 3 ,3 0 4 1 3 ,2 0 1 ,6 8 7 1 4 ,6 7 0 ,2 2 7 2 ,9 5 4 ,2 2 2 3 ,3 5 8 ,9 8 1 1 ,3 3 0 ,6 1 4 1 ,4 1 8 ,0 3 2 6 ,7 0 4 ,6 0 8 6 ,5 8 0 ,5 5 0 3 ,1 0 2 ,5 3 8 3 ,2 7 7 ,8 7 8 9 2 ,6 0 0 ,5 4 1 1 0 2 ,6 3 2 ,4 4 4 2 0 1 1 /1 2 Me d iu m -te rm e x p e n d itu re e s tim a te s Ave ra g e g ro w th fo r h is to ry p e rio d 18 Reprioritisation • • • • • • • • • • Very difficult fiscal climate requires reprioritisation Focus on efficiency, improving value for money Wider call to restructure expenditure Huge variability in unit costs across hospitals of similar type, districts, economic classification Was supposed to be first step of budget process Not much progress made in Function group in this area Only significant proposal was to top-slice R200m from HIG and HRG for nursing college upgrading Some potential within goods and services area (procurement, arv prices, fraud, collusion leading to higher prices, improved controls, protocols); inefficiencies in capital projects More reprioritisation is required given fiscal position, personnel pressures, cuts exercise and improving efficiency Each province will need to look at this in finalising budget for 2012/13 19 Budget bids – NHI Pilots • Various aspects of NHI need to be tested and piloted • PHC reforms: 1. Family health teams: ward based teams set up to improve primary health care delivery 2. District specialist support teams: Aims to strengthen district health services 3. School health services: Package of health services (e.g. testing, prevention, deworming) offered at schools • Contracting with private providers: review legal aspects of contracting with private GPs, determine how these contracts can be designed, measured and monitored, and experimentation with reimbursement mechanisms (e.g. capitation) • Costing still in progress: Initial rec xxx 1 Non-discretionary areas Certain pressures are effectively non-discretionary – ICS (6.8% vs 5.5% carry-through) – ARV uptake increases (approximately 400 000 pa) – Possibly rising PHC visits (4-5m pa average over past decade) 21 HIV and AIDS • ART Programme: new cd4 350 threshold generalised – Need to make provision for at least 400 000 growth pa – Unit cost R4300-R4900 per capita – Analysis suggests baselines largely sufficient (R1.8b growth pa) except outer year – Recommendation xxx • New NSP development – implications for other sectors 22 Primary health care and volume adjustment: Rising PHC visits • • • • PHC visits rising by 4 mil pa Possible volume adjustment for outer year as non-discretionary baseline adjustment Transfer as part of new NHI conditional grant Links to PHC policies of family health teams, ward based community teams, district support teams and school health services Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape Grand Total 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 14,339,786 14,383,889 13,746,488 14,503,175 15,312,880 14,618,214 16,589,065 16,606,276 17,796,107 18,647,433 5,069,882 5,446,065 5,725,472 5,972,199 6,031,495 5,912,089 5,932,312 5,903,854 6,460,991 6,536,325 10,649,014 11,094,574 12,012,319 12,396,325 13,059,604 14,162,418 14,961,820 16,261,089 19,372,439 19,636,757 15,315,661 16,908,055 18,000,507 18,948,993 19,428,937 19,789,376 18,703,020 22,309,763 24,498,906 26,088,177 10,984,360 11,748,869 13,680,318 14,381,591 15,253,259 14,862,213 14,063,129 13,684,125 14,784,386 15,145,254 3,953,523 5,100,122 5,399,366 6,063,243 6,193,706 6,792,927 6,923,114 7,388,645 7,923,291 7,959,887 1,931,154 2,010,410 2,124,661 2,420,212 2,332,201 2,175,354 2,267,522 2,828,567 3,511,999 3,434,203 8,237,237 9,039,665 8,892,998 8,768,182 9,668,768 9,822,014 8,029,057 7,804,490 8,574,971 8,321,827 11,426,477 11,839,414 12,856,051 12,877,078 13,593,636 13,623,772 13,126,182 13,291,336 14,979,546 15,792,199 81,907,093 87,571,063 92,438,180 96,330,998 100,874,486 101,758,377 100,595,221 106,078,145 117,902,636 121,562,061 23 Policy priorities • • • • • NHI pilots Nursing college upgrading Office of Standards compliance Planning large PPPs and infrastructure support HR strategy 24 NHI • Key theme for Budget 2012/13 • Release of Green paper, public announcements by Ministers, wide media coverage and public interest • Need to chart practical way forward • DG Health requested NHI pilots as key priority for Budget 2012/13 • Need to accept that NHI will entail greater national control over sectoral funding • Need to establish functioning interim mechanism prior to NHI Fund • Probable establishment of new transitional NHI grant – need to finalise funding mechanism • Two other cgs (NTSG, HIV) potential slight renaming to indicate longer term shift into NHI 25 Infrastructure • Ministers driving new approach to health infrastructure with larger direct role for National Department and DBSA • Nursing colleges upgrading and recapitalisation is immediate focus – • Large PPPs in planning (but feasibility studies not yet complete) • New Schedule 7 (in-kind) grant is proposed as option / test case on nursing colleges upgrading • Preconditions: i) Provincial sign-off ii) Signed agreements • Reprioritisation: Nursing college upgrading to be funded initially through top-slicing of HIG/HRP • DBSA and CSIR IUSS support interventions • Efficiency of infrastructure delivery: AG Report and Scopa hearing 26 HR Strategy and ICS for health • • • • • • • Development and implementation of the new HR strategy for health 100 page document, draft policy and models released Large focus on filling posts and increasing supply Partly via NHI pilots ICS increase 1.3% estimated to cost R800m pa Over-spending on health personnel >R1bil pa for several years Over-spending projection on personnel going forward 27 Provincial Health budget baselines 28 HIV conditional grant health baseline Rmil 04/05 ec fs gt kz lm mp nc nw wc tot 05/06 99 70 134 186 77 54 32 71 58 782 161 96 207 240 94 90 58 105 93 1,144 06/07 218 142 253 344 176 107 69 142 116 1,567 07/08 233 154 400 467 201 121 74 156 201 2,006 08/09 301 190 577 757 233 187 91 246 266 2,849 09/10 426 298 890 1,036 402 236 110 370 376 4,143 10/11 691 434 1,278 1,499 515 384 182 476 554 6,012 11/12 864 530 1,621 1,889 625 490 213 599 661 7,493 12/13 13/14 1,014 1,222 622 751 1,934 2,294 2,246 2,675 734 884 578 694 247 302 706 849 743 935 8,825 10,607 29 HIV/AIDS subprogramme Health (Health) R million Eastern Cape Free State Gauteng KwaZulu Natal Limpopo Mpumalanga Northern Cape North West Western Cape Total 05/06 182 109 368 528 103 106 53 120 172 1,741 06/07 310 152 429 704 207 134 74 197 249 2,456 07/08 357 170 580 1,059 205 195 81 244 240 3,130 08/09 396 214 707 1,239 257 225 113 332 269 3,753 09/10 479 326 1,037 1,535 414 347 149 479 384 5,149 10/11 789 484 1,517 1,611 526 409 221 602 555 6,714 11/12 884 581 1,912 1,925 625 505 247 696 661 8,035 12/13 13/14 1,112 1,314 682 813 2,418 2,910 2,330 2,774 734 884 626 745 283 340 807 852 743 935 9,735 11,568 30 Provincial IYM Sept 11 (6 months of 11/12) Projection Available Province budget EC 14,237,249 14,485,025 FS 6,820,708 6,944,216 GT 22,837,577 24,156,622 KZN 24,507,254 24,685,811 LIM 11,587,901 12,014,843 MPU 7,365,135 7,213,896 NC 2,946,839 3,072,265 NW 6,322,945 6,650,467 WC 13,395,060 13,393,628 Tot 110,020,668 112,616,773 Spending % spend Deficit by September 7,484,979 52.6% -247,776 3,219,779 47.2% -123,508 11,310,740 49.5% -1,319,045 11,728,040 47.9% -178,557 5,894,931 50.9% -426,942 3,291,162 44.7% 151,239 1,411,654 47.9% -125,426 3,005,416 47.5% -327,522 6,268,554 46.8% 1,432 53,615,255 48.7% -2,596,105 31 Estimate of national HIV spend Rand million National DOH Total DOH core DOH conditional grants Provincial own dedicated Education grant Social services Sub-total Treatment of opportunistic infections Donor Total 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 1,107 1,512 2,026 2,474 3,078 4,868 6,621 7,975 9,344 11,154 372 362 410 467 493 492 569 482 520 547 735 1,150 1,616 2,006 2,585 4,376 6,052 7,493 8,825 10,607 412 542 762 911 1,124 772 663 542 911 961 134 136 144 158 168 177 188 199 209 221 128 223 339 452 607 678 795 843 894 938 1,781 2,413 3,271 3,995 4,977 6,496 8,267 9,559 11,358 13,274 4,477 4,701 4,936 5,183 5,442 5,714 6,000 6,300 6,615 6,946 3,731 3,918 4,114 4,319 4,535 4,762 5,000 5,250 5,513 5,788 9,990 11,032 12,320 13,497 14,954 16,972 19,267 21,109 23,485 26,008 32 NASA draft: Total Funding & Sources for HIV/AIDS/TB in SA (2007/08-2009/10) (incl % of the Child Support Grant) 33 Conclusion • Budget 2012/13 is being formulated in very tough fiscal climate • Budgets going forward will not be as strong as growth over past three years • Very small number of additional allocations from contingency reserve • NHI pilots will be important going forward and plans will need to become very practical in year ahead • Need to finalise whether will or will not have two new conditional grants – NHI – S7 nursing colleges grant • Provinces will need to focus substantially on reprioritisation • Control of personnel spending will be nb noting projected shortfall • Increasing efficiency and delivery on capital expenditure 34 NASA draft: Total SA HIV/AIDS Spending Activities (2007/08-2009/10) . 35