Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa

Abstract

^#Supplement Editor Sharon Fonn has not participated in the review and decision process for this paper.

Background : In light of an increasing global focus on health system strengthening and integration of vertical programmes within health systems, methods and tools are required to examine whether general health service managers exercise administrative authority over vertical programmes.

Objective : To measure the extent to which general health service (horizontal) managers, exercise authority over the HIV programme's monitoring and evaluation (M&E) function, and to explore factors that may influence this exercise of authority.

Methods : This cross-sectional survey involved interviews with 51 managers. We drew ideas from the concept of ‘exercised decision-space’ – traditionally used to measure local level managers’ exercise of authority over health system functions following decentralisation. Our main outcome measure was the degree of exercised authority – classified as ‘low’, ‘medium’ or ‘high’ – over four M&E domains (HIV data collection, collation, analysis, and use). We applied ordinal logistic regression to assess whether actor type (horizontal or vertical) was predictive of a higher degree of exercised authority, independent of management capacity (training and experience), and M&E knowledge.

Results : Relative to vertical managers, horizontal managers had lower HIV M&E knowledge, were more likely to exercise a higher degree of authority over HIV data collation (OR 7.26; CI: 1.9, 27.4), and less likely to do so over HIV data use (OR 0.19; CI: 0.05, 0.84). A higher HIV M&E knowledge score was predictive of a higher exercised authority over HIV data use (OR 1.22; CI: 0.99, 1.49). There was no association between management capacity and degree of authority.

Conclusions : This study demonstrates a HIV M&E model that is neither fully vertical nor integrated. The HIV M&E is characterised by horizontal managers producing HIV information while vertical managers use it. This may undermine policies to strengthen integrated health system planning and management under the leadership of horizontal managers.

• integration
• vertical programme
• disease-specific intervention
• health system strengthening
• monitoring and evaluation
• district health system
• South Africa

Acknowledgements

We thank the University of the Witwatersrand Carnegie Transformation Programme for their generous research grant. We also thank the health authorities as well as staff and managers of participating health facilities in both our study sites as well as all our research participants.

Notes

^#Supplement Editor Sharon Fonn has not participated in the review and decision process for this paper.