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While South Africa has some experience in various forms of health technology assessment (HTA), it is currently fragmented across numerous players. Additionally, there is a lack of systematic and consistently applied HTA processes that inform priority-setting and budget allocations. To address this, the country is journeying toward more institutionalized use of HTA. This will begin with the establishment of a Ministerial Advisory Committee on HTA for National Health Insurance (NHI) and will gradually embed HTA processes in decision-making. The goal is to create an independent HTA agency. Although these reforms will be intrinsically linked to the wider health financing reforms envisaged under NHI, such as formulating the benefits package, they will also assist in strengthening South Africa’s health system. As a country facing a highly constrained fiscal environment, with limited space for additional funding for the health sector, evidence-based priority-setting will be critical to ensure that value for money is achieved in the government’s investments in health care services in NHI.

In recent decades, external financing of health systems in low- and middle-income countries has helped achieve remarkable improvements across the world. However, these successes have not come without problems. There are a growing number of areas where external assistance can cause harm and even undermine the development of national health systems. Recent decades have seen a surge of knowledge on investing in health systems. We propose the setting up of investment standards for external assistance that aim to incentivize a more efficient evidence-based investment in a country’s health system, led by decision-makers in country. Using a more standardized process would lead to a better use of precious external assistance resources. The long-term goal would be fully functioning health systems with all the necessary essential public health functions in all countries.

South Africa’s effort to eliminate malaria is significantly challenged by a large number of imported malaria cases, especially from neighbouring Mozambique. The country has a funding gap to achieve its malaria elimination goals (prior to 2019) and is ineligible to receive a national allocation from the Global Fund. The findings of an IC were utilised to successfully mobilise resources for malaria elimination in South Africa in 2018. A five-step resource mobilisation strategy was implemented to highlight financing challenges and leverage the economic evidence from an IC for malaria elimination in South Africa. South Africa’s malaria programme implements control and elimination activities in three malaria-endemic provinces (KwaZulu Natal, Limpopo, and Mpumalanga). Driven by the IC findings, the South African government took an unprecedented step and increased total domestic malaria financing by approximately 36%, from the 2018/19 to the 2019/20 financial years through the creation of a new conditional grant for malaria. The IC findings predicted that malaria control in southern Mozambique is a prerequisite to eliminate malaria in South Africa. Based on this, the South African government also allocated funding towards a co-financing mechanism to support malaria control efforts in southern Mozambique. The IC findings assisted the South African National Department of Health to make a convincing case to key government decision-makers to invest in national malaria elimination and maximise economic returns in the long run. The South African government is the first in Southern Africa to mobilise a significant increase in domestic malaria financing to address the financial sustainability of both national and regional malaria elimination efforts. Continued surveillance activities will be required to prevent the re-establishment of malaria transmission even after malaria elimination is achieved in South Africa. Information sharing and close collaboration with provincial and national government officials were key to the successful outcome.

Objective Previous research suggests a significant relationship between intimate partner violence (IPV) and HIV infection in women and that the risk of IPV is heightened in women with disabilities. Women with disabilities, particularly those residing in low-income and middle-income countries, may experience additional burdens that increase their vulnerability to IPV. We aimed to examine the association between having disability and HIV infection and the risk of IPV among women in South Africa.Design Using the 2016 South Africa Demographic and Health Survey, we calculated the prevalence of IPV and conducted modified Poisson regressions to estimate the unadjusted and adjusted risk ratios of experiencing IPV by disability and HIV status.Participants Our final analytical sample included 1269 ever-partnered women aged 18–49 years, who responded to the IPV module and received HIV testing.Results The prevalence of IPV was twice as high in women with disabilities with HIV infection compared with women without disabilities without HIV infection (21.2% vs 50.1%). Our unadjusted regression analysis showed that compared with women without disabilities without HIV infection, women with disabilities with HIV infection had almost four times higher odds (OR 3.72, 95% CI 1.27 to 10.9, p

COVID-19 disease models have aided policymakers in low-and middle-income countries (LMICs) with many critical decisions. Many challenges remain surrounding their use, from inappropriate model selection and adoption, inadequate and untimely reporting of evidence, to the lack of iterative stakeholder engagement in policy formulation and deliberation. These issues can contribute to the misuse of models and hinder effective policy implementation. Without guidance on how to address such challenges, the true potential of such models may not be realised. The COVID-19 Multi-Model Comparison Collaboration (CMCC) was formed to address this gap. CMCC is a global collaboration between decision-makers from LMICs, modellers and researchers, and development partners. To understand the limitations of existing COVID-19 disease models (primarily from high income countries) and how they could be adequately support decision-making in LMICs, a desk review of modelling experience during the COVID-19 and past disease outbreaks, two online surveys, and regular online consultations were held among the collaborators. Three key recommendations from CMCC include: A ‘fitness-for-purpose’ flowchart, a tool that concurrently walks policymakers (or their advisors) and modellers through a model selection and development process. The flowchart is organised around the following: policy aims, modelling feasibility, model implementation, model reporting commitment. Holmdahl and Buckee (2020) A ‘reporting standards trajectory’, which includes three gradually increasing standard of reports, ‘minimum’, ‘acceptable’, and ‘ideal’, and seeks collaboration from funders, modellers, and decision-makers to enhance the quality of reports over time and accountability of researchers. Malla et al. (2018) A framework for “collaborative modelling for effective policy implementation and evaluation” which extends the definition of stakeholders to funders, ground-level implementers, public, and other researchers, and outlines how each can contribute to modelling. We advocate for standardisation of modelling processes and adoption of country-owned model through iterative stakeholder participation and discuss how they can enhance trust, accountability, and public ownership to decisions.

BackgroundPrevious research on the association between maternal HIV status and child mortality in sub-Saharan Africa was published between 2005-2011. Findings from these studies showed a higher child mortality risk among children born to HIV-positive mothers. While the population of women with disabilities is growing in developing countries, we found no research that examined the association between maternal disability in HIV-positive mothers, and child mortality in sub-Saharan Africa. This study examined the potential compounding effect of maternal disability and HIV status on child mortality in South Africa.MethodsWe analyzed data for women age 15-49 years from South Africa, using the nationally representative 2016 South Africa Demographic and Health Survey. We estimated unadjusted and adjusted risk ratios of child mortality indicators by maternal disability and maternal HIV using modified Poisson regressions.ResultsChildren born to disabled mothers compared to their peers born to non-disabled mothers were at a higher risk for neonatal mortality (RR = 1.80, 95% CI:1.31-2.49), infant mortality (RR = 1.69, 95% CI:1.19-2.41), and under-five mortality (RR = 1.78, 95% CI:1.05-3.01). The joint risk of maternal disability and HIV-positive status on the selected child mortality indicators is compounded such that it is more than the sum of the risks from maternal disability or maternal HIV-positive status alone (RR = 3.97 vs. joint RR = 3.67 for neonatal mortality; RR = 3.57 vs. joint RR = 3.25 for infant mortality; RR = 6.44 vs. joint RR = 3.75 for under-five mortality).ConclusionsThe findings suggest that children born to HIV-positive women with disabilities are at an exceptionally high risk of premature mortality. Established inequalities faced by women with disabilities may account for this increased risk. Given that maternal HIV and disability amplify each other's impact on child mortality, addressing disabled women's HIV-related needs and understanding the pathways and mechanisms contributing to these disparities is crucial.

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage. This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.

We were tasked by the South African Department of Health to assess the cost implications to the largest ART programme in the world of adopting sets of ART guidelines issued by the World Health Organization between 2010 and 2016.Using data from large South African ART clinics (n = 24,244 patients), projections of patients in need of ART, and cost data from bottom-up cost analyses, we constructed a population-level health-state transition model with 6-monthly transitions between health states depending on patients' age, CD4 cell count/ percentage, and, for adult first-line ART, time on treatment.For each set of guidelines, the modelled increase in patient numbers as a result of prevalence and uptake was substantially more than the increase resulting from additional eligibility. Under each set of guidelines, the number of people on ART was projected to increase by 31-133% over the next seven years, and cost by 84-175%, while increased eligibility led to 1-26% more patients, and 1-17% higher cost. The projected increases in treatment cost due to the 2010 and the 2015 WHO guidelines could be offset in their entirety by the introduction of cost-saving measures such as opening the drug tenders for international competition and task-shifting. Under universal treatment, annual costs of the treatment programme will decrease for the first time from 2024 onwards.Annual budgetary requirements for ART will continue to increase in South Africa until universal treatment is taken to full scale. Model results were instrumental in changing South African ART guidelines, more than tripling the population on treatment between 2009 and 2017, and reducing the per-patient cost of treatment by 64%.