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Effects of Global Health Initiatives Funding for HIV on South African Health Systems

Author(s): T. Mathole*1, A. Parsons1, T. Bisika2, E. Buch3, D. Sanders1
Affiliation(s): 1School of Public Health, University of Western Cape, Cape Town, 2School of Public Health, 3School of Public health, University of Pretoria, Pretoria, South Africa
Keywords: Global Health, South Africa, Health Systems, Donor Funding, HIV/AIDS

This study reviews country level evidence about the impact of Global Health Initiatives (GHIs) on HIV/AIDS in South Africa. The study was initiated in response to increases in the amount of funding from GHIs, which have emerged as an alternative to traditional bilateral and multilateral health development funding. This study therefore seeks to understand how GHIs (like PEPFAR, GFATM) operate in South Africa and their effects on the health systems.


Data were generated using qualitative research methods including document analysis and individual interviews with 19 participants at national level. Participants were purposefully selected from among key staff involved in GHIs at government, donors and recipient NGOs. Data analysis was an ongoing process using interpretive description as described by Thorne and others.


The GHIs have among other things positively contributed to mobilisation of HIV funding, rapid scale up of HIV/AIDS programmes and rapid increase of people on ART. GHI funding has helped vastly expand access to life saving ARV treatment for thousands in South Africa. Of the total estimated number of people in need of treatment, 55% were enrolled in the ART programme by the end of 2007. However workers in the public sector are generally struggling with increased workloads. Competition for available labor by the public sector and the private sector, including GHIs and other donors, as well as by overseas recruitment agents, increases high mobility among more experienced, skilled labor in focal areas such as TB and HIV management. For example, six out of nine TB/HIV coordinators trained by the NDOH in 2006 were reported to have left the department by February 2009. Such turnover usually disrupts the management and implementation of projects, with additional time needed to orient and train new staff. Despite severe staff shortages and migration of skilled labour in the health sector, there is no available evidence of increased investment in overall human resources development from government, GHIs or other donors. Fragmented implementation, monitoring and evaluation of programmes both within Government Departments and among GHI/NGOs have resulted in production of many different uncoordinated reports. There is some level of competition amongst GHIs, which view themselves as primarily accountable to their head offices and funding structures. Each GHI therefore produces separate reports, often based on individual data collection by recipient organizations. HIV/AIDS is a challenge to South Africa, but well-meant interventions should not undermine both GHIs/Donors and government efforts. Effectively utilized, GHIs can increase health care coverage and improve access to health care in South Africa. Our data suggest that funding specific programmes without building overall capacity in the recipient country by improving the public health system is not ideal. It is necessary to have a well-functioning health care system, align funds with the state, and ensure commitment from all stakeholders.

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