Health sector responses to HIV/AIDS treatment in southern Africa

”Disparity is a shocking reality that we cannot hide from. This is a global injustice. It is a travesty of human rights on a global scale.” (Nelson Mandela on the lack of access to antiretroviral drugs at the International AIDS Society Conference in Paris, July 2003)

An equity lens seeks not just to look at improving access to care and treatment for the millions of people who currently lack it, but rather seeks to reduce the gap in access to health resources between different population groups. Underlying this view is an explicit argument that the current inequities in access to treatment are related to differentials in power and political influence between different population groups over the manner in which resources for accessing care and treatment are distributed. An equity-oriented approach is necessary not only from a moral and humanitarian perspective but also for public health reasons. Unless attention is paid to the redistribution of available resources and to the relative and absolute levels of disempowerment amongst individuals, communities and countries, we run the risk of failing to achieve the Millennium Development Goals and the targets that have been set for increasing access to ART.

All people with HIV/AIDS should have equal opportunity to access effective and appropriate treatment. Access to treatment is, however, only beneficial if it is translated into improved health outcomes. In the context of existing social and health inequities, widespread poverty, high rates of new HIV infections, famine and budgetary constraints, increasing access to HIV care and treatment must be organised in a manner that balances HIV prevention and treatment efforts; HIV interventions and the broader strengthening of the health system as a whole; and HIV care and treatment with other public health and social needs.

Equity in access to HIV care and treatment needs to be assessed across groups (particularly gender, socio-economic status, age and race) and at various levels, including the household, community, country, regional and global levels.

The HIV/AIDS epidemic in southern Africa is undermining the broader state of socio-economic development in the region. The epidemic is patterned on a range of underlying social and economic inequities, and results in a further deepening of those same inequities. Unless interventions are deliberately set to break this vicious cycle, HIV/AIDS worsens aggregate socio-economic and health indicators and unfair and unacceptable disparities. This requires more than just a pro-poor approach to development and treatment initiatives, but an approach that intervenes in these socio-economic and health disparities.

Current levels of health expenditure in many countries are insufficient to meet basic public healthcare (PHC) needs, let alone complex and relatively expensive treatment programmes. The push to increase treatment coverage cannot be planned in isolation of broader socio-economic reform, including of the global trade and investment regimes that currently act to keep poor countries poor. Inadequate levels of official development assistance and slow progress towards debt relief are markers of a lack of global commitment towards addressing poverty and the HIV epidemic, and represent issues around which the global public health community should rally. African governments face extreme difficulties in allocating scarce resources across multiple priority health and social needs. Concerns are raised about the possible over-medicalisation of HIV/AIDS interventions to the cost of the underlying economic and food security needs of the poor, particularly as the latter are necessary for them to realise the benefits of clinical and behavioural interventions.

Pricing of medicines need to be looked at from an equity perspective. Although cheap medicines will not automatically result in effective treatment, especially for the poor who lack access to effective, accessible and affordable health services, the issue of drug pricing has taken on an important symbolic function. Efforts to exempt poor countries from patent regulations and differential pricing policies are only partial solutions to making medicines more affordable. Beyond this are issues of how society manages patents and intellectual property, how research and development of new medicines and vaccines is funded, and how fair and sustainable pricing is ensured. The current intellectual property regime and market structure is inefficient, acts as a barrier to scientific cooperation and undermines equity.

The organisation and management of the health system matter in regard to expanding access to care and treatment for HIV/AIDS. Without adequately skilled health personnel, regular supplies of medicines, community-based support and laboratory services, effective, efficient and sustainable treatment programmes are not possible. Although it will be possible to create ‘islands’ of effective treatment through dedicated ‘special’ projects, even in the most under-resourced setting, any hope of achieving sustainable and widespread coverage requires a health system that is functional at the country level.

Much needs to be done to develop appropriate and equitably organised health systems. There needs to be an explicit commitment to equity and to expanding HIV/AIDS treatment as part of a broader set of health system priorities. The focus on expanding access to HIV/AIDS treatment could either take the route of least resistance and implement treatment interventions that are built on the current pattern of inequities; or it could consciously set out to use the impetus around expanding HIV care and treatment to reduce inequities, preferentially target the poor and systematically uplift the healthcare infrastructure of the most under-resourced areas in a country. The latter requires a broad-vision approach to the expansion of HIV/AIDS treatment, which includes a sustained engagement with various health systems policy questions. These include the way the health system is financed and organised; how health resources (government, donor and private) are distributed; how ministries of health fulfil their governance and stewardship functions; how the public and private sectors interface with each other; and how concepts of equity, redistribution and rights to health are accepted and reflected within the health system.

Within this context, the policy and operational considerations of treatment programmes themselves need to be discussed, including the need to:

• balance the rapid expansion of access to treatment with the need to develop basic healthcare infrastructure
• optimise the balance between HIV treatment and other healthcare services
• optimise the balance between HIV prevention and treatment
• ensure that the burden of care and treatment is equitably shared between the commercial, for-profit sector and the public and not-for-profit NGO sector
• ensure that criteria for rationing care and treatment are optimal, transparent and equitable
• promote a policy and regulatory environment at a country level that balances the need for minimum standards of care and treatment with increasing access.

Unless treatment programmes are carefully and appropriately planned and organised, they may worsen inequities and result in inefficiencies and unwanted outcomes. More could be done to carefully develop context-specific plans for the expansion of treatment in a way that will not aggravate inequities or result in the inappropriate withdrawal of resources from other health interventions or from other parts of the health system.

Doing things in a way that will promote integration, sustainability and long-term local capacity development will require much more coordinated strategic planning and strong public health leadership. Donors also have an obligation to ensure that their plans are sustainable and are part of an appropriate long-term strategy to improve healthcare for all. It is critical, therefore, that appropriate and realistic targets are set for the expansion of treatment and that treatment is expanded only in a way that strengthens the health system’s capacity to provide ART and comprehensive PHC in the long run. The danger that quick-fix, vertical and multiple top-down approaches will fragment the already fragile health systems of southern Africa and lead to a worse outcome in the long-run should not be discounted lightly.

* Executive Summary of the Equinet Discussion Paper 10: Health Sector Responses to HIV/AIDS and treatment access in southern Africa: Addressing equity. By David McCoy, Health Systems Trust, EQUINET. Web: www.equinetafrica.org/bibl/docs/discussionpaper10.pdf; Contact: David.McCoy@lshtm.ac.uk. Other Equinet Discussion Papers on HIV/AIDS can be found on the Equinet website: www.equinetafrica.org. The Regional Network on Equity in Health in Southern Africa is a network of professionals, civil society members, policy makers, state officials and others within the region who have come together as an equity catalyst, to promote and realise shared values of equity and social justice in health.