Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa.
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.
Gauteng Health Department, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa, mary.kawonga@wits.ac.za
Mary
M
Kawonga
Sharon
S
Fonn
Duane
D
Blaauw
D000288:Administrative Personnel / Q000458:organization & administration* / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D013019:South Africa
South Africa; disease-specific intervention; district health system; health system strengthening; integration; monitoring and evaluation; vertical programme