The purpose of monitoring and evaluation (M&E) is to produce reliable and timely health information and use it to evaluate policy, set priorities, plan, and monitor the effectiveness and impacts of interventions [1, 2]. In recent years, many low- and middle-income countries have established dedicated (or vertical) M&E systems for their HIV programmes [3, 4]. The anticipated aims of such M&E systems have however not been realised in many countries due to low financial investment in M&E infrastructure, weak or ill-defined systems for collection, analysis, and dissemination of HIV data, inadequately trained data collectors, and insufficient technical capacity to transform HIV data into usable indicators [3, 4]. The non-integration of HIV M&E systems with overall health information systems is another important factor. Vertical M&E systems are often coordinated as separate parallel systems, often in a bid to improve the availability of quality HIV information for decision-makers. However, this intended benefit is often not realised [3–7].
South Africa has established a vertical HIV M&E system to monitor its national HIV programme . In South Africa's decentralised health sector, the district (sub-national) level of the health system is well-placed to use information generated by this HIV M&E system to monitor the HIV programme. However, it has not been documented if and how the HIV M&E system interacts with the district health information system (DHIS) designed to monitor overall health system performance at district level, or whether it affects the availability of HIV programme information at district level. This paper addresses this gap.
Disease-specific programmes and health systems
The emergence of global health initiatives (GHI)-notably the Global Fund for AIDS, TB and Malaria (GFATM) and the Presidential Emergency Plan for AIDS Relief (PEPFAR)-as major funders of HIV/AIDS interventions in low- and middle-income countries-has raised questions about the sustainability of disease-specific (vertical or targeted) programmes [9, 10]. GHIs increase HIV funding and services , but also fragment coordination by establishing parallel planning, coordination and monitoring systems within recipient countries, and worsen already weak health systems by diverting resources from general health services [12, 13]. This has prompted calls to strengthen health systems and find ways of maximising positive synergies between disease-specific programmes and health systems [9, 14].
Integration of disease-specific programmes into health systems is one way of strengthening health systems and maximising programme-system synergies . Integration is largely understood in relation to the service delivery function of health systems: e.g. combining two or more disease-specific services at one delivery point, incorporating disease-specific services into general care, continuity of care over time or across levels, or working across government sectors [16–19]. Health system impacts of service integration are however inconclusive due to poor evidence because of weak or incomparable evaluation methodologies [18–20]. There is even less evidence on how targeted programmes interact with health system functions other than service delivery, such as financing, M&E, or governance [13, 18]. In practice programmes lie along a continuum from integrated to fully vertical, and depending on the context, integrate with different health system functions to varying extents [10, 13]. In the absence of conclusive evidence on effects of integration, it is advised that countries adopt organisational arrangements that optimise benefits for both programmes and systems in their context-specific settings .
The high cost of maintaining parallel disease-specific programmes, and the potential benefits of integrated services with unified finance, management and M&E processes provide compelling reasons to adopt organisational arrangements that optimise programme integration, particularly in weak health system contexts . Some even suggest there are very few instances when integration should not be the norm . Countries however need guidance on when and how to integrate disease-specific programmes to strengthen health systems. For example, in South Africa health system strengthening is a stated HIV programme goal [22, 23] but how to achieve this is unclear. Documenting how the HIV programme interacts with and affects health system functions is a step towards clarity.
HIV programme and the health system in South Africa
South Africa's post-apartheid HIV programme was established in 1994, initially emphasising prevention. Public sector antiretroviral therapy (ART) services were introduced in 2004 with earmarked funding following the Operational Plan for Comprehensive HIV/AIDS Care Management and Treatment (comprehensive plan) [22, 24]. An HIV M&E system was established to monitor the comprehensive plan [8, 22], and after adoption of the multi-sectoral HIV & AIDS and STI Strategic Plan 2007-2011 (NSP), the M&E framework was expanded to include other sectors .
Health services in South Africa are largely funded through the National Treasury. External funding constitutes less than 1% of the National Department of Health (NDOH) budget [25–27]. However, South Africa does receive GHI funding (largely from GFATM [dispersed to Government] and PEPFAR [dispersed to non-governmental agencies]), the bulk of which goes to HIV/AIDS. As such, external aid constitutes 26% of the government's HIV/AIDS budget .
The National Treasury funds health largely through an annual unconditional block grant named the 'equitable share' (based on population numbers and needs) which is allocated to provincial governments, who then distribute this between various departments including health. In addition, the National Treasury allocates to each provincial government dedicated funding for HIV-this is termed the conditional grant for HIV and AIDS . Reporting on expenditure for conditional grants is different to that required for equitable share funding. The Division of Revenue Act (DORA) provides the legislative and accountability framework for the HIV and AIDS conditional grant, requiring provinces to submit HIV data as well as narrative and financial reports to the National Treasury .
Health system decentralisation has also been a national priority since 1994. As such, responsibility for managing health service delivery is decentralised to the district (sub-national) level [29, 30]. A district health information system (DHIS) has been established to support district health management teams (DHMT) in this role [31, 32]. The DHIS-a critical component of the national health information system-collects public sector facility data to produce a set of district health service indicators. Ideally, the disease-specific HIV M&E system should be a sub-component of a system-wide information system like the DHIS . As such, DHMTs would be well-placed to integrate HIV information into overall district health system management.
A national study however reports that programme information generated through disease-specific M&E systems is not necessarily made available to district managers . Though that report did not specify the HIV M&E system, it highlights the need to understand how the HIV M&E interacts with the health system M&E function (the DHIS) to determine whether any negative synergies between them affect the availability and use of HIV information for district management. This paper thus uses a district in South Africa as a case study to determine the extent to which the HIV M&E is integrated with the DHIS, and assess effects of the HIV M&E on availability of HIV information at district level. The paper also discusses factors influencing HIV M&E integration, and proposes ideas for maximising HIV programme-system synergies.