Based on the principle that social accountability is enabled through participation by an empowered civil society that demands efficiency and transparency, the three-year journey of a South African Budget Monitoring and Expenditure Tracking (BMET) project demonstrates that citizen involvement in economic governance is both possible and progressing.
Conducted by the Centre for Economic Governance and AIDS in Africa (CEGAA) in partnership with the Treatment Action Campaign, the BMET project is funded by the Open Society Institute - New York (OSI-NY), Open Society Foundation for South Africa (OSF-SA) and International Budget Partnership (IBP).
Aimed at improving the delivery, accessibility and affordability of treatment for people living with HIV/AIDS and TB, the model is designed to enhance health budget management at local level by building the capacity of citizens, communities and health workers to monitor health care services, engage with budget processes, and unite for strategic advocacy to elevate the quality of service delivery.
The passage of the project
The project began in 2009, with a pilot study entitled ‘Giving Power to the Community: Community Monitoring of HIV/AIDS and TB Spending in Two Districts in South Africa’, that developed the skills of community-based fieldworkers to document experiences of patients’ access to and health workers’ provision of HIV/AIDS and TB services at public hospitals and clinics in two South African provinces: the uMgungundlovu District in KwaZulu-Natal, and the Lusikisiki Sub-district of the O R Tambo District in the Eastern Cape.
Building on the challenges and achievements that were identified in the study findings, the project team analysed related policy and budgets, and trained community members in health budget monitoring and expenditure tracking (BMET) to advance their awareness of the critical linkages between appropriate investment in health services and the human right to health.
In 2010, and again in 2012, the results of this work were shared in each district with a coalition of civil society networks and government stakeholders in public hearings. These fora were facilitated by the project partners to assemble ordinary citizens and representatives of district and local health structures, in order to strengthen the advocacy voice from the ground, foster relationships between State and society representatives, and enable government officials to respond to the concerns raised on the basis of sound evidence. Community members used an open platform to give their testimonies, and initiate dialogue around the next steps towards ensuring that efforts to improve health, HIV/AIDS and TB services in the districts were strengthened and sustained.
At the 2010 public hearings, Action Teams were formed and tasked with maintaining momentum towards improved health service delivery through regular updates and feedback on progress made and resolution of problems. These teams include both governmental and non-governmental stakeholders to promote accountability and compel responsibility for implementing change, and have succeeded in addressing numerous challenges to quality health care for HIV/AIDS and TB patients.
For follow-up, one-on-one and forum advocacy meetings ensure that senior government officials and allied stakeholders are kept abreast of prevailing concerns, ideas for solutions and also calls for action.
Over the past three years, the project has achieved many objectives designed to support district clinics in dealing with issues such as HIV and TB drug stock-outs, long waiting lists and patient queues, laboratory test delivery logistics, and information dissemination to communities on the reasons for inadequate health care provision. These efforts have highlighted that a lack of human resource capacity is the main challenge, as most health facility problems identified have a direct or indirect relationship with serious shortages of health workers, particularly of specialist staff such as doctors, professional nurses and pharmacists.
In the second phase of the project, implemented during 2011 and 2012, the CEGAA BMET staff provided ongoing capacity development and technical support for in-depth budget analysis to the Treatment Action Campaign (TAC) Community Mobilisers, so that they could use the information for daily follow-up monitoring of health service provision in their communities. The TAC monitoring team has achieved credibility among the various role-players through routine engagement with health facility staff, consistently positive consultations with local leadership, and a heightened knowledge of health budget processes which they are now able to impart to clinic managers.
Impact and inspiration
The BMET project interventions have reached a range of targeted beneficiaries and achieved a positive impact in four key aspects:
- Community engagement has stimulated community members’ interest in budget issues relating to health care provision and mobilising for improvements;
- Health workers have a better understanding of their own and their client-community needs towards enhancing facility systems;
- Citizens are empowered with skills to research and track the quality of HIV/AIDS and TB services in their community and demand answers;
- With citizens, organisations and health authorities having a shared, relational understanding of both the barriers to and the opportunities for change, collaboration on resolving longstanding and complex health service delivery problems has been enhanced.
Moreover, the national TAC structures - with technical support from CEGAA - have expanded the initial BMET project model to four additional districts in other provinces: Ekurhuleni in Gauteng, Gert Sibande in Mpumalanga, Khayelitsha in the Western Cape, and Mopani in Limpopo - a replication phase which demonstrates its efficacy and sustainability.
Onward: BMET and the NHI
The achievement of better health outcomes in South Africa – specifically by reducingthe impact of HIV/AIDS and TB – is undoubtedly dependant on whether the National Health Insurance (NHI) scheme is successfully implemented over the next 10 years. Among NGOs, government, donors and taxpayers, there is deep interest in the implementation of the Conditional Grant to finance the NHI in its pilot districts.
The National Treasury has allocated a Conditional Grant to cover the testing of innovations needed for implementing the NHI, to undertake health system strengthening initiatives, and to support the NHI pilot districts in implementing identified service delivery interventions. In particular, the Department of Health has committed to prioritising improved health infrastructure to absorb patient numbers, increasing health staff complements, and strengthening the resource management of selected central hospitals.
The NHI pilot phase has been allocated a total of R150 million for the 2012/13 financial year, in order to strengthen the systems for better health care delivery. The total NHI grant for all pilot sites will increase to R350 million in 2013/14, and further to R500 million in 2015/16.
In the Medium-term Budget Policy statement issued by the Finance Minister in October 2012, funding for HIV/AIDS and TB programmes was to be increased in next year’s budget, with the provision that, given the constrained fiscal environment, the health sector had to seek greater efficiency and improve financial management.
The NHI is a critical undertaking in South Africa’s health system development, and as such, requires expertise around budget analysis, solid evidence of health resource allocation and expenditure, and citizen-driven advocacy for related service delivery.
Such expertise is available through the BMET project’s ongoing research and capacity-building in this field, incorporating the knowledge gained by communities in theirinformed monitoring of HIV/AIDS and TB services at clinics.
In advancing the collaborative energy and agency of an empowered, active citizenry and a responsive, capable State, this work will add unique value to the efforts ofall role-players in supporting the effective roll-out of the NHI, and ensuring that money for health-services is well-spent.
For more information, refer to www.cegaa.org/projects/budget_monitoring_and_expenditure_tracking.htm.
Senior Programmes Manager
Tel: 033 3940845
Mobile: 073 1987219
Tel: 033 3940845
Mobile: 078 0590309
- Judith King is communications and advocacy manager at CEGAA.