Roll-out no walkover
The case for providing anti-retrovirals (ARVs) is clear and compelling. The sheer magnitude of the problem and its consequences form the most serious public health problem ever to face South Africa.
Over the next 10 to 15 years more than five million HIV-positive South Africans will die from the consequences of the infection unless treated.
This is our very own holocaust. However, providing ARVs for this number of people is a daunting prospect.
Our aim must not only be to introduce ARVs, but to make the initiative work, to attend to the factors that will support or undermine it. If we do not do so, the intervention could do more harm than good.
I believe that if we introduce an ARV programme for these five million people in the same way that we have approached the introduction of the termination of pregnancy, the cervical screening, the voluntary counselling and testing, and the prevention of mother-to-child transmission programmes, then certainly we will do harm.
There is a substantial risk that the overall performance of the primary care service in this country will be compromised without, in any substantial way, improving the health care of the five million.
There are many risks to scaling-up an ARV programme. Primary care services make up about 15% of the public sector health budget. In the Inter-governmental Fiscal Review of 2003 the projections of expenditure indicate that this proportion is likely to remain constant over the next three years.
This 15% slice is insufficient for the current needs of primary care facilities, and so adding an ARV programme will exponentially increase the under-funding of primary care.
Currently there are widespread inequities in the resources provided for primary care. These range from about R30 per capita in the worst-resourced districts to about R300 in the best-resourced districts. Paradoxically there is an inverse relationship between health needs and resources provided.
It is likely that ARVs will be introduced selectively, based on the capacity to run programmes, and those districts with the best services and the most resources will be given extra resources to run ARVs. This will not only increase inequity directly, but also indirectly by attracting scarce human resources.
Even if ARVs are introduced everywhere, the likelihood is that there will be good care in some areas and inadequate and sub-standard care in poorer areas.
Currently, the resources available to primary care are insufficient to cope with both the volume of patients and the comprehensive basket of services in the primary care package.
Rationing thus occurs in a number of ways. Some services are not offered (for example, cervical screening), others are offered on a selective basis (antenatal care on certain days of the week only), patients are turned away and told to come back on another day (quota system), patient waiting times are extraordinarily long (four or more hours), and clinics are closed at certain times (for example, Friday afternoons). Introducing ARVs will increase this rationing due to the human resources and time commitments required to run this programme.
With the introduction of a universal free care service, clinics have experienced increased numbers of patients requiring curative care.
This curative care often takes place at the expense of programmes focused on preventive care, such as immunisation and health promotion. The introduction of a high-profile ARV programme is likely to enhance this trend, as it is dependent on highly technical clinical monitoring and management.
Currently, most of the key targets set by the national Department of Health around primary care programmes, such as immunisation coverage and tuberculosis cure rate, are not being met. The competition for prioritisation set by an ARV programme will distract attention from other important public health programmes that are more cost-effective. There is also the danger that individuals who receive ARVs with sub-optimal care will be at risk of toxicity and drug resistance.
The inadequate provision of human resources is probably the greatest risk facing the introduction of an ARV programme. There is an absolute shortage of skilled personnel in the public-health sector and this is worst in areas that need it the most — the rural and disadvantaged urban areas. These are also the areas with the highest HIV prevalence rates.
To expect a huge ARV programme to be run by already overworked staff is wishful thinking, and additional doctors, nurses and other health-care workers will have to be added to the system. Where will they come from?
There is no strategic plan on the table to increase the graduation of key staff and even if the decision to increase production were taken today it would take four to seven years before they start coming out of training institutions. Also, recent research by the Human Sciences Research Council suggests that over the next 10 years there will be a shortage of 20 000 nurses.
All personnel involved in ARV programmes will require significant in-service training to cope with the requirements. Previous experience around training for sexually transmitted infections and tuberculosis has highlighted the complexities of providing this in-service training that is not a once-off event and requires constant follow-up.
Experiences in many ARV pilots suggest that dedicated staff will be required to run this programme.
A national ARV programme will require monitoring and evaluation at a number of levels. Currently, supervisors of primary care and managers do not have the skills and capacity to do this. Without adequate information systems there is every likelihood that an ARV programme will not achieve what it is meant to.
This has been seen in relation to the TB control programme and the prevention of mother-to-child transmission programme, where goals and objectives have not been met.
Because of the unique features of South Africa, such as its diversity and heterogeneity, as well as its burden of disease profile, the decentralised district health system is considered by many public health experts to be essential to improving health. The health system is in a crucial and complex stage in the establishment of a department of health services, with a health Bill awaiting the legislative process.
As governance and managerial issues have more relevance to the individual lives of managers, because of career development and uncertainty of job security, it is likely that their attention will be focused on structural issues rather than ARV quality of care issues.
There are many facilities without the infrastructure or back-up systems necessary to provide quality primary care, let alone more complex ARV therapy. This basic infrastructure includes water, sanitation, electricity, communication and consultation rooms. Back-up includes transport, drug supply and laboratory support. Without these infrastructural and systemic improvements it will be difficult to provide an adequate ARV programme.
Having highlighted the risks, what then should be done? To rush in and introduce ARVs on a large scale could be foolhardy and more negligent than doing nothing. To introduce a programme that uses scarce resources and does not achieve its aims does more harm than good. In economic terms this is known as the “opportunity cost”, whereby spending resources on one programme reduces the opportunity of spending resources on another.
What is required is action. A comprehensive plan from the highest levels of decision-making to radically restructure primary care services through the provision of more human and financial resources needs to be made. This plan needs to incorporate relevant innovations from countries such as Brazil and Botswana, where there has been harnessing of resources from all sectors of society.
An ARV treatment programme that is not located within a comprehensive plan to strengthen the health-care system, its human infra-structure and its public health management and leadership will increase inequity and lead to unacceptable opportunity costs that may include an overall deterioration in health care. Implementing an ARV programme with inadequate capacity will also lead to poor treatment adherence and a black-market in ARV drugs in Southern Africa, which in turn will lead to the development of ARV resistance.
This is not an argument against the provision of ARVs. Nor is it a denial of the fact that without an ARV programme we will see a deterioration of the South African public health sector and economy. We have to have a national ARV programme, but we have to do it the right way and with the right level of commitment and capacity.
Peter Barron is a director of the unit for sub-district support of the Health Systems Trust.