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This brief draws from a longer research paper entitled "Responding to the HIV/AIDS pandemic in the Department of Social Development." The paper is one of series of four papers just released on Funding the Fight Against HIV/AIDS in the health, education and social development sectors. or more information, contact Jolene Adams [email protected]

SUMMARY

The National Integrated Plan for Children and Youth Infected and Affected by HIV/AIDS (NIP) is the government's key strategy for managing the spread and impact of the disease. Within the NIP programmes, the Department of Social Development (DSD) and the Department of Health (DoH) are assigned the role of establishing Home and Community Based Care support programmes and providing income and food support via the poverty relief programme. The objective of this Budget Brief is therefore to examine the allocations to these two programmes and the initial problems experienced during the implementation phase of the National Integrated Plan from a Social Development perspective. Following is a summary of the findings:

HIV/Aids Grant: Cabinet voted an amount of R450 million to be made available for the implementation of the National Integrated Plan over a period of three years. An amount of R13 million was allocated to HCBC to the Departments of Health and Social Development in the financial year 2000/2001; R28 million for 2001/2002/2003; and R68 million in the financial year 2002/2003 (DSD, 2001).

HCBC allocation: In 2001/2002/2003, R12.5 million is allocated to provincial DSD to implement the home and community based support programme. Provincial DSDs will each receive an amount of R1.5 million (except Gauteng and Western Cape which will each receive R500 000 less). In 2000/2001 Gauteng, Western Cape and KwaZulu-Natal did not receive a share of the HIV/AIDS conditional grant for the HCBC support programme.

Poverty Relief allocation: In the 2001 budget the Poverty Relief Programme (PRP) is allocated R50.4 million, with a projected allocation of R228 million over the medium term (R106.6 million in 2002/2003 and R71 million in 2003/2004). As one component of the PRP, the HIV/AIDS allocation over the medium term is R5 million (2001/2002/2003), increases to R12.5 million in 2002/2003, and decreases to R7.5 million in 2003/2004. Furthermore through the establishment of food production clusters (see table 3) an additional R5.4 million for 2001/2002/2003; R12.2 million for 2002/2003; R6.8 million for 2003/2004 will be added.

Limited priority given to HCBC: The primary focus of the NIP remains prevention. The low priority given to home and community based care (10%) is evident in the small allocation compared to the other two programmes.

Targeting for HIV/AIDS programmes: Targeting in the case of HIV/AIDS is made difficult because of stigma associated with the disease. Infected and affected people were unwilling to make use of services in cases because of fear of stigmitisation and isolation from the community. It is difficult to establish whether the target group actually benefits.

Problems with the funding mechanisms at local level: In both cases conditional grants (HCBC) and special allocations (PRP) were introduced as the preferred funding mechanism, however, both programmes were plagued by under-spending problems related to capacity at national and provincial level. In 2000/01, in the case of the Department of Health, none of the funds set aside for HCBC were released.

HOME AND COMMUNITY BASED CARE PROGRAMME

In response to the HIV/AIDS crisis, the DSD, in conjunction with the Departments of Health and Education, designed the HIV/AIDS/STD Strategic Plan for South Africa 2000-2005 (Government of South Africa, 2000 b). The strategy consists of four major components: prevention; care and support; research, monitoring and evaluation; and human and legal rights.

The HCBC support programme combines the care of infected people with support to those affected by the disease. The NIP aimed to establish 40 HCBC support programmes in the financial year 2001/2002/2003 (Departments of Health and DSD-workshop on HCBC in April 2001). In February 2001 Cabinet approved the HCBC policy document tabled in parliament which includes five models for HCBC (Departments of Health and Social Development, 2001). Using estimates drawn from a population-based approach, the HCBC policy document estimated that at least 200 HCBC teams must be operating nationally by March 2002 in order to cater for those infected and affected by the disease. This is a far cry from the initial figure of 40 HCBC teams for which funds were allocated.

In 2000/01, R 6.8 million of R13 million allocated to the DSD for the implementation of HCBC. Of this amount, R 5.6 million was allocated to six provinces to pilot the implementation of the HCBC programmes (see table 1). The aim was to pilot the HCBC support programme in one area in the six provinces. The national DSD retained the rest of the funds R 1.18 million in 2001 and distributed R1.123 million of that amount to existing projects in KwaZulu-Natal, Gauteng, Eastern Cape and Western Cape in order to strengthen them. The rest of the funds, R57, 700, were spent on administration and travelling costs.

In the 2001/2002/2003 financial year provincial DSDs received a combined amount of R12.5 million and national will receive R900 000 (see table 1). Each provincial DSD will receive R1.5 million, except for Gauteng and the Western Cape which each receive R500 000 less. The initial aim was to roll out the HCBC to three other sites within each province, identifying infected and affected children and adults and strengthening existing HCBC support programmes. At the HCBC workshop in April 2001, it was decided that each province should have at least 20 HCBC support programmes in order to reach the 200 target by March 2002. As a result, the R1.5 million per province now has to cover an additional seventeen sites, in the absence of additional funding.

Table 1: HIV/Aids Share of Conditional Grant allocated to provincial DSD 2000/2001 2001/2002/2003 Province Conditional grant Allocation from national DSD Eastern Cape 950,000 138,250 1,500,000 Free State 910,000 1,500,000 Gauteng 200,000 1,000,000 Kwazulu-Natal 230,000 1,500,000 Mpumalanga 960,000 1 500 000 Northern Cape 1,000,000 1,500,000 Northern Province 800,000 1,500,000 North West 1,000,000 1,500,000 Western Cape 404,000 1,000,000 Amount distributed to provinces 5,620,000 12,500,000 Amount retained by National DSD 1,180,000 900,000 Total for HCBCS 6,800,000 13,400,000 Source: National Treasury 2001

The Health and Social Development departments undertook a costing study which found that the departments will have to spend R120 million or R125 million in the current financial year to operationalise the HCBC programmes (see table 2). This cost estimate assumes a R500 stipend for volunteers in the HBC teams, and either the need-based or population approach (the calculation excludes the cost of food parcels, school fees and uniforms etc). It is unclear whether provinces have budgeted adequately for the expansion of the HCBC support programme.

Table 2: Total Costs - All Scenarios (Millions of Rands) Needs Based R500 Needs Based R1000 Population R500 Population R1000 2001/02 120 125 120 125 2002/03 351 370 351 370 2003/04 574 612 694 737 2004/05 706 760 1,027 1,099 2005/06 815 880 1,361 1,462 2006/07 896 970 1,335 1,450 2007/08 980 1,060 1,335 1,450 2008/09 1,045 1,132 1,335 1,450 2009/10 1,088 1,180 1,335 1,450 2010/11 1,129 1,225 1,335 1,450 Source: Department of Health and Social Development 2001/2002/2003.

The next section looks at the poverty relief programme allocations specifically targeted to HIV/AIDS projects.

POVERTY RELIEF AND HIV/AIDS

The Department of Social Development has embarked on a dynamic anti-poverty strategy "that will provide financial and human resources support to identified targets of poor communities especially in the rural areas and where women, children, the disabled and the youth are most vulnerable." The PRP strategy is currently in its second three year funding cycle, and for the first time HIV/AIDS has been identified as part of the main objectives and implementation plans.
A number of priorities have been identified as key objectives for the next three years: food security, food shortage and low income levels, unemployment and underemployment, social crime and HIV/AIDS, the limitations of existing social assistance, the reduced asset base, and no access to credit in communities. HIV/AIDS ranks high amongst these priority areas, as it is featured a number of times in these objectives.
The programme links the reduction in poverty with the ability of communities to participate in the National Integrated Plan educational and awareness programmes aimed at controlling the spread of the disease. The rationale is that the NIP, HCBC and Life Skills programmes are more effective if poverty is addressed concurrently.
The broad national objectives as set out in the PRP business plan for 2001-2003:

Food security
This focuses on households affected by HIV/AIDS and will be realised through the establishment of food production clusters in communities.

Social support structures
The provision and maintenance of social support structures in communities where HIV/AIDS is high.

Urban regeneration strategy
This seeks to broaden skills and employment opportunities to reduce youth criminality while encouraging recreational alternatives.

Income generating opportunities for rural women
Intended to improve the economic viability of rural households.

Community-based child care initiatives
The Department hopes to capitalise on the social and economic capability of the aged.

Targeted economic and employment opportunities
The enhancement and integration of the productive capacity of people with disabilities.

Social finance capacity
Address poverty through facilitating, implementing and institutionalising beneficial social networks at a grass roots level.

Table 3: Expected outputs Objective Expected Output Food Security 144 food production clusters Social support structures 100 HIV/AIDS community-based support structures in partnership with local role players Urban regeneration strategy 18 pilot skills development centres Income generating opportunities for rural women 100 income generating initiatives for rural women together with 10 000 employment opportunities Community-based child care initiatives 100 dual purpose centres for the aged, together with 500 production opportunities and child care facilities for 2500 children Economic & employment opportunities At least 2% of all projects will capitalise on the capacities of the disabled Social finance capacity At least 60% of projects will be linked to the Social Finance programme

Figure 1 below illustrates the provincial allocations reserved for HIV/AIDS programmes for the current financial year (2001-2002). Provincial allocations are calculated on the basis of poverty and HIV/AIDS rates, population size, and prevalence of the seven objectives. It is therefore not surprising that the Free State, KwaZulu-Natal and Mpumalanga received an amount of R1 million respectively, followed by the Eastern Cape, Gauteng and North West who each received R500, 000. The Western Cape and Northern Cape, who have the lowest prevalence of HIV/AIDS and poverty in South Africa, received the smallest allocation of R150,000 each.

Figure 1: Provincial HIV/AIDS allocations for 2001/2002/2003 Table 3 below, shows the distribution of HIV/AIDS funding over the medium term (2001 - 2004). An amount of R50 million is budgeted for PRP in 2001/2002/2003; R106.6 million in 2002/2003; and R71 million in 2003/2004. Of this amount R5 million is set aside for HIV/AIDs in the current financial year; R12.5 million in the second year; and R7.5 million in the third year. Furthermore through the establishment of food production clusters (see table 3) an additional R5.4 million for 2001/2002/2003; R12.2 million for 2002/2003; R6.8 million for 2003/2004 will be added.

For 2002-2004 a similar picture, as illustrated in figure 1, can be seen in terms of the HIV/AIDS allocations across provinces. The Free State, KwaZulu-Natal and Mpumalanga are still the recipients of the bulk of HIV/AIDS funds. The Western Cape and Northern Cape receive the least.

Table 4: Provincial HIV/AIDS allocations over MTEF, for PRP Province 2001/2002/2003 2002/2003 2003/2004 Eastern Cape HIV/AIDS allocation 500,000 1,250,000 750,000 As percent of provincial PRP funds 7% 7% 6% Free State HIV/AIDS allocation 1,000,000 2,500,000 1,500,000 As percent of provincial PRP funds 20% 22% 21% Gauteng HIV/AIDS allocation 500,000 1,250,000 750,000 As percent of provincial PRP funds 20% 26% 22% Kwazulu-Natal HIV/AIDS allocation 1,000,000 2,500,000 1,500,000 As percent of provincial PRP funds 12% 13% 12% Mpumalanga HIV/AIDS allocation 1,000,000 2,500,000 1,500,000 As percent of provincial PRP funds 20% 22% 20% Northern Cape HIV/AIDS allocation 150,000 375,000 225,000 As percent of provincial PRP funds 6% 7% 6% Northern Province HIV/AIDS 200,000 500,000 300,000 As percent of provincial PRP funds 3% 3% 3% North West HIV/AIDS 500,000 1,250,000 750,000 As percent of provincial PRP funds 11% 13% 11% Western Cape HIV/AIDS allocations 150,000 375,000 225,000 As percent of provincial PRP funds 7% 9% 8% Source: Department of Social Development, Poverty Relief programme: Business Plan 2001/2003.

POINTS OF CONCERN AROUND THE IMPLEMENTATION OF THE NIP
Limited priority given to HCBC
Budgetary allocations are the clearest and most unambiguous statement of the priorities of a government. The primary focus of the NIP remains prevention. The low priority given to home and community based care (10%) is evident in the small allocation compared to the other two NIP programmes.
The initial NIP objective was to pilot HCBC in six provinces in the first year, and roll it out to 3 more sites the following year. The aim was to improve the programme before embarking on a nation wide effort.
Due to great existing need, the projects had to expand earlier than planned. The NIP's targeted number for HCBC in 2000/2001 is 40, although the model options accepted by parliament in February 2001 show the revised target number of 200 HCBC teams for the current financial year. The implementation of HCBC would therefore require substantial additional funding for provincial Health and DSD departments. In the current financial year Departments of Health and Welfare have a combined budget of R28 million for HCBC programmes in conditional grants only. The costing study estimated that it would cost R120-125 million to reach the target of 200 HCBC programmes by March 2001/2002/2003.

Improving funding mechanisms at local level
Conditional grant funds for the HCBC programme flow to provinces via both the DoH and DSD. The lack of an adequate interdepartmental funding mechanism was highlighted as another problem (Departments of Health and DSD, 2001). Provincial coordinators often mentioned the lack of a common budget for the two departments as a major stumbling block for implementation, as well as the different criteria used for grant approval by each department.
According to DSD, the central problem in the successful delivery of HBCB at a local level is "how to transfer funds to communities with minimum bureaucracy and maximum flexibility whilst ensuring proper accountability." (Departments of Health and DSD, 2001 p.17)
Conditional grants were introduced to ensure that earmarked funds are spent for intended purposes, however the health allocations were not spent. The Department attributed this to the lack of capacity at provincial level-while provinces identified difficult processes and late advertisement of the grant by National Health as the main obstacle.
The PRP has been plagued by under-spending and rollovers since its inception in 1997/98. Funding for the programme is in the form of special allocations to provinces from the national DSD. The projected poverty relief allocation for 2001/02 was R203 million in Budget 2000; this changed to R50 million for 2001/02 and reflects a decrease of R153 million for the current financial year.
Both HCBC and PRP introduced conditional grants and special allocations as the preferred funding mechanism, in both cases the programmes were plagued by under-spending problems related to capacity at national and provincial level.

Integrated Approach by DSD and DOH
The geographical districts of the two departments do not correspond even though they are expected to follow a district approach and combine their services.
They have different intradepartmental procedures for accessing and distributing funds.
No effective intra and inter departmental referral system exists as yet. The PRP programme does not have adequate capacity to refer people to PRP projects in their communities and as yet no system exists for referring patients dismissed from hospital to HCBC support programmes.
Targeting for HIV/AIDS programmes

Without correct targeting, programmes cannot do more than spread income (Everatt and Zulu, 2001). Accurate targeting in the case of HIV/AIDS is made difficult because of stigma associated with the disease. Provincial DSDs have identified the unwillingness of infected and affected persons to make use of services because of fear of reprisal and isolation from the community.

To avoid individuals being stigmatised for participating, the PRP based their projects in geographical locations with high infection rates.

At present the PRP is unable to deal with the child-headed household phenomenon. However they do plan to deal with the phenomenon through the establishment of food production clusters (see table 3) in future.

The child support grant is restricted to children younger than seven years, while the foster care grant involves a judicial process which can take up to two years. Many families headed by children could therefore be without any financial support.

CONCLUSION
The policy of the DSD and DoH is to move away from institutionalised care and said dependency, towards community responsibility and self-reliance. The introduction of the PRP and HCBC illustrates this shift. The NIP calls for cooperation and integration between government departments and communities. However the HCBC and PRP interventions will have a limited impact unless particular attention is paid to human resource capacity, lack of adequate funds, the destigmitisation of HIV/AIDS infected and affected people, and the problems related to child-headed households. We have to commend the Departments of Health and Social Developments for their well-intended objectives and programmes.
Sources
Department of Social Development, Poverty Relief Porgramme: Operations and Procedures Manual (Draft 1), 2001.
Department of Social Development Business Plan 2001-2003, Poverty Relief Programme. 15 May 2001.
Everatt, D and Zulu, S (2001) "Analysing rural development programmes in South Africa 1994-2000". Development Update. Quarterly Journal of the South African National NGO Coalition and INTERFUND. The learning curve: A review of government and voluntary sector development delivery from 1994. Vol.3 (4) pp.1-38.
National Departments of Social Development, Health and Education (2000) "National Integrated Plan for Children Infected and Affected by HIV/AIDS".
National Departments of Health and Social Development, (2001) Integrated Home/Community Based Care Model Options including Annexure A: Paper Distributed at a Workshop held to fast-track implementation of the HCBCS Programme in Provinces, Kopanong Hotel, Johannesburg, 17-19 June.
Pieterse, E (2001). In praise of transgression: Notes on institutional synergy and poverty reduction. Development Update. Quarterly Journal of the South African National NGO Coalition and INTERFUND. The learning curve: A review of government and voluntary sector development delivery from 1994. Vol.3(4) pp.39-70.

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