Providing anti-retroviral drugs and preventing mother-to-child transmission of HIV are not always feasible with South Africa’s health-care infrastructure
David McCoy
Now that we’ve celebrated a victory over multi- national pharmaceutical companies for access to cheaper medicines, what are we going to do about preventing mother-to-child transmission of Aids and access to anti-retroviral drugs?
While activist groups are calling for the immediate implementation of access to anti-retroviral medication, the case for this needs to be examined.
A programme for prevention of mother-to-child-transmission is firstly a relatively complex health care intervention that requires good health care infrastructure.
Everybody agrees with this, but it has remained a peripheral issue due to the attention on drug pricing.
“Health care infrastructure” needs to be understood in terms of physical infrastructure. This includes clinics having adequate space, electricity and running water; hospitals with enough beds and working equipment; roads and vehicles to allow access to health care; and a laboratory service for conducting basic investigations.
Secondly, there is the human infrastructure of appropriate staffing levels, a basic standard of clinical and public health competency and a level of morale, motivation and commitment to the job. Nothing stresses the importance of the human factor in health care as much as HIV testing and counselling for pregnant women.
Thirdly, there is organisational infrastructure that ensures, for example, good working relationships between clinics and hospitals, between nurses and doctors, between provincial and local government and, for prevention of mother-to-child transmission in particular, between maternal health programmes and HIV programmes.
Good health care infrastructure also means a health system that allows multi-disciplinary front-line health workers to work as an integrated team to address the specific health needs of a particular area. And it includes a system capable of ensuring that the basic logistics of a health service, such as medicine supply and distribution, are in place.
So, does South Africa have a basic health care infrastructure? Unfortunately, in many parts of the country that pioneered heart transplantation, the answer is a clear no. This situation may even be getting worse in some respects. Space does not allow a full description of this view, but consider the following facts.
While the doctor:population ratio is about 1:650 in the Western Cape, it is 1:30 000 in the Mount Frere health district of the Eastern Cape. For every 100 babies born alive in South Africa, four die in their first year. In Region E of the Eastern Cape, where 1,2-million people live, the figure is one in 10.
In 1998 only 63,4% of all children were fully immunised. In two provinces immunisation was as low as 49,5% and 52,6%. Last year a study showed that 43% of a sample of clinicians could not give the correct treatment for genital ulcer disease (a contributing factor to HIV transmission).
Tshungwana clinic, which serves 14 000, has no telephone, running water or electricity. Work at night is done by candle-light and the full range of primary health care services are often expected to be delivered with only one professional nurse on duty at any time. There is no visiting doctor. Patient transport is non- existent, so patients requiring hospital attention may have to hire private transport at a cost of R200. The arrangements for laboratory tests and regular medicine supplies fall well below acceptable standards.
There is no reason why areas providing a sub-standard level of basic health care should be any more successful with a mother-to-child-transmission programme.
This is especially the case when hundreds of front-line health workers in poor and isolated working conditions are stressed, undervalued and burdened by excessive demands and expectations.
In addition, there are potential harmful effects from the implementation of mother-to-child transmission programmes. For a start, it could lead to resources being drained from other more, or equally important, areas of health care. We could see some babies saved from HIV but other children dying from deterioration in the quality of other services.
If government is put under pressure to rapidly implement a nation-wide programme, there will also be a temptation to set up centralised “vertical” delivery systems that will ultimately cost more, compound the problem of diverting resources from other areas of health care and disrupt the development of effective local health management structures.
In some areas, a poorly planned mother-to-child-transmission prevention programme could even result in direct harm if accompanied by confusing and inappropriate messages about breast-feeding.
We have already seen calls for the introduction of breast-milk substitutes without adequate consideration of the childhood disease and mortality that could result from this.
Despite the reminder of the cholera epidemic, huge assumptions are still made about the safety and feasibility of feeding with breast-milk substitutes.
Therefore, even though nevirapine and HIV testing may be affordable in budgetary terms, the Department of Health is correct in cautioning that in some areas a programme for prevention of mother-to-child transmission may be inappropriate.
However, this is not an excuse for government to avoid prevention of mother-to-child transmission, or to trumpet a counter-position to activist groups calling for immediate implementation. While the Department of Health argument is valid, it is made from the unflattering position of government not having got the basics right in large parts of the health-care system.
For all the progressive intentions of promoting equity in health and a better life for all, too little has been done to translate this into concrete and sustainable development. Too little has been done to establish a process of affirmative action to rapidly improve each of three dimensions of health care infrastructure in the under-developed areas of the country.
It is hard to understand why, but one does get the impression of a state of denial about South Africa’s Third World realities and a fixation with its First World capacity.
In the meantime, the Directorate: HIV/Aids is left with a dilemma. Does it implement a policy of prevention of mother-to-child transmission across the country knowing that this could disrupt priority-based health care planning in some areas and worsen inequity between those with and without access to good health care? Or does it say no until all areas in the country have an acceptable level of basic health care infrastructure?
What can be taken out of the equation is the issue of afford- ability. At a country level, we can surely afford the direct costs of preventing mother-to-child transmission if we prioritise government spending more appropriately.
Even with the current public sector health budget it might be affordable. However, an affordable intervention does not mean that it would be feasible or cost-effective.
A starting point, therefore, would be a more explicit recognition that we are dealing with a wide spectrum of scenarios. These range from situations where a mother-to-child-transmission programme is both feasible and cost-effective, to situations where it is feasible but inappropriate, to where it is inappropriate and generally unfeasible.
This in turn implies the need to move from one-size-fits-all policies and plans to more appropriately targeted planning and upliftment of health care from the bottom up, rather than a top-down imposition of development.
We also need to raise the technical level of debate through better analysis and understanding of resource allocation and the relative costs and benefits of different interventions within the health care system.
Two weeks ago the Mail & Guardian implied that prevention of mother-to-child-transmission was cost-effective throughout the country, based on research at the University of Cape Town. While it is not possible to go into the detail of this research, it is vital to recognise that cost-effectiveness analyses are complex calculations based on a range of assumptions that can lead to wrong conclusions. They depend on sev- eral variables that may be specific to a particular area. So what may be relatively cost-effective in urban South Africa may not be so in rural, impoverished South Africa.
Furthermore, the quoted research only compared the cost-effectiveness of different types of mother-to-child-transmission intervention.
It did not compare these with the cost-effectiveness of tuberculosis control, other HIV-related health intervention, improved nutrition, child health care or basic health infrastructure development.
More research and understanding of cost-effectiveness is needed to build a bigger bank of knowledge and information for informing health policy and planning, and the 18 pilot sites for prevention of mother-to-child transmission are critical for that.
On the issue of anti-retroviral drugs for people with Aids, the argument is more clear-cut. At present prices (even for generics), public-sector health budgets are inadequate. Even if providing anti-retroviral drugs is cost-effective, it may still be unaffordable.
Unless the public-sector health budget is increased to a level that would pay for basic health care infrastructure and relatively expensive treatment, the call for anti- retroviral drugs is like asking a person to buy a house rather than a new car, when that person has only R5 000.
But once again, there is a danger of reducing the debate to just one of rands and cents. Throwing money inappropriately at a health-care system with inadequate health-care infrastructure can make things worse, not better. Finally, this whole debate needs to incorporate the fact that the health system’s response to HIV includes more than just anti-retroviral drugs.
There are many preventative strategies and vital treatment requirements for HIV patients, and good basic primary health care is in itself good for our HIV health sector programme.
Nothing better illustrates this than tuberculosis control and sexually transmitted disease care. Tuberculosis is not only an opportunistic condition of HIV but one of the most potent accelerators of the progression from infection to full-blown Aids, while sexually transmitted diseases are considered to be a potent co-factor for HIV transmission. And yet on neither front can we say that the health-care system is performing adequately.
So what about the Department of Health’s dilemma? It seems that we should be striving towards the general implementation of mother-to-child-transmission prevention. But it must be done in a way that will ensure rapid and continued health infrastructure development, keep equity high on the agenda and not inadvertently cause more harm than good.
Dr David McCoy is director for technical support at Health Systems Trust