Abstract
BackgroundSouth Africa’s antiretroviral programme is governed by defined national plans, establishing treatment targets and providing funding through ring-fenced conditional grants. However, in terms of the country’s quasi-federal constitution, provincial governments bear the main responsibility for provision of health care, and have a certain amount of autonomy and therefore choice in the way their HIV/AIDS programmes are implemented.MethodsThe paper is a comparative case study of the early management of ART scale up in three South African provincial governments – Western Cape, Gauteng and Free State – focusing on both operational and strategic dimensions. Drawing on surveys of models of ART care and analyses of the policy process conducted in the three provinces between 2005 and 2007, as well as a considerable body of grey and indexed literature on ART scale up in South Africa, it draws links between implementation processes and variations in provincial ART coverage (low, medium and high) achieved in the three provinces.ResultsWhile they adopted similar chronic disease care approaches, the provinces differed with respect to political and managerial leadership of the programme, programme design, the balance between central standardisation and local flexibility, the effectiveness of monitoring and evaluation systems, and the nature and extent of external support and programme partnerships.ConclusionsThis case study points to the importance of sub-national programme processes and the influence of factors other than financing or human resource capacity, in understanding intervention scale up.
Highlights
South Africa’s antiretroviral programme is governed by defined national plans, establishing treatment targets and providing funding through ring-fenced conditional grants
antiretroviral therapy (ART) was provided through the private sector and local initiatives in a few dozen sites in the public health system, the most celebrated of which was the MédicinsSans-Frontières (MSF) supported Khayelitsha programme in the Western Cape Province
This was succeeded by the 2007 National Strategic Plan (NSP) which established universal access targets over five years
Summary
South Africa’s antiretroviral programme is governed by defined national plans, establishing treatment targets and providing funding through ring-fenced conditional grants. Scale up was initially guided by a national framework, the Comprehensive Care Management and Treatment (CCMT) Plan (2003), which proposed a progressive expansion in access over five years. This was succeeded by the 2007 National Strategic Plan (NSP) which established universal access targets (defined as the annual enrolment of 80% of those newly eligible onto ART) over five years. On the basis of the CCMT Plan, initial funding for implementation of the policy was mobilised from the national budget through conditional grants, standardized first and second line drug regimens were defined, and treatment guidelines developed. Drugs were sourced through national tenders, and a centralized accreditation process for the establishment of “CCMT” sites was instituted
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