From policy to implementation: a needs-based budget program for implementing the cervical cancer screening policy in South Africa

Robertson, Jamela Ellen
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Background In South Africa cervical cancer has an age standardised incidence rate of 23 per 100 000 in women below the age of 35 and 76 per 100 000 amongst women over 35. The National Department of Health (NDoH) introduced the national cervical cancer screening policy guidelines in 2000, with the aim to screen 70% of women aged between 30 and 59 over a 10-year period. Health managers at provincial and district level were expected to implement this policy at their respective levels. Research has shown that implementing national health policies is often challenging due to management weaknesses, including the lack of guidelines or tools on how managers should plan and allocate budget for services. Aim The aim of this study is to develop and test an approach to planning and budgeting that would assist health managers to follow a rational process to plan and estimate budget requirements for implementing the cervical cancer screening policy at subnational level. Method This study was conducted in three districts in South Africa. The study was conducted in four phases. A situational analysis of budgeting practices was conducted in the first phase, to describe existing planning and budget allocation practices for cervical cancer screening programmes in the study sites and identify any existing gaps. The process requirements for implementing a cervical cancer screening programme were then identified prospectively in the second phase. Informed by the situation analysis and the process requirements, a computer-based planning and budget estimation program was developed in the third phase and tested through interviews with key informants in the fourth phase of the study. Results The situational analysis revealed a lack of involvement of interviewed programme managers at all the levels, in planning and budgeting for implementing cervical cancer screening programmes. The participants’ descriptions of budget allocation processes indicated that there was no defined process for allocating budget to services and the allocations were not specifically informed by assessed programme needs in their respective areas of jurisdiction. Process requirements for cervical screening were identified and documented for the following aspects of a cervical screening programme: calculating target population to inform planning for service provision, staff and equipment audits, equipment and supplies, material required for systems functioning (e.g., tools, forms, guidelines), transport and communication systems, community information education and communication (IEC) strategies, staff training, laboratory services and services for the treatment of High grade Squamous Intraepithelial Lesions (HSIL). A computerbased planning and budget estimation program, which could enable managers to define and quantify resources needed to implement a cervical screening programme was developed, informed by the documented process requirements. The testing of the computerised planning and budget estimation program indicated that the program could improve planning and help managers to estimate budget requirements for implementing cervical screening. Respondents indicated that the program was relatively easy to use and also felt that it could potentially be useful for programme planning as follows: a) it could serve as a tool for programme needs assessment, b) it could facilitate rational budget estimations, c) managers could use it as a bottom-up tool to motivate for resources, and d) managers could use it to refute inadequate budget allocations where possible. Conclusion The findings of the situational analysis support existing literature in revealing very little if any change in relation to inherent challenges in implementing cervical cancer screening services in South Africa. The findings of this study are relevant for public health programme planning and budgeting beyond cervical screening. Since managers at sub-national level are delegated to implement policy, it is imperative that they are provided with tools that may guide them to plan and budget for services on the basis of needs in their areas of jurisdiction. This study provides one such tool.
A Dissertation submitted to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, to fulfil the requirement to acquire a degree of Master of Science in Medicine Johannesburg 30 September 2014