In November 2003 the Cabinet approved a national plan for HIV/ Aids prevention, care and treatment. The plan estimated that 53 000 people would be placed on anti-retroviral (ARV) treatment by the end of March this year. In May President Thabo Mbeki shifted this target to the end of March 2005 — signalling a one year delay in reaching patient targets.
Meanwhile, urban and rural inequity in access to public health-care services has emerged as a major challenge to reaching these targets. To start a campaign to overcome these inequities, as well as the divide between the private and public sectors, the Treatment Action Campaign (TAC) co-hosted a People’s Health Summit recently in the Eastern Cape. The summit brought together more than 500 people representing about 66 organisations and included doctors, nurses, trade unionists, the faith-based sector and people living with HIV/Aids.
At the summit the TAC’s first report on the status of the ARV roll-out was released. It indicates that, after eight months, fewer than 10 000 people are receiving ARV medicines through public hospitals nationally.
In provinces such as Gauteng, Western Cape, Northern Cape, Mpumalanga and the Free State the report identifies positive developments. While the Northern Cape, Mpumalanga and Free State each have less than 100 patients on ARV treatment the provincial governments’ commitment and willingness to share information with civil society are steps in the right direction.
Similarly, both Gauteng and the Western Cape have also shown how political commitment can result in hundreds of patients benefiting from ARV treatment. The Western Cape is treating about 3 000 adults and children and Gauteng is treating about 2 300 adults and children. Gauteng and the Western Cape have also operated transparently.
On the other hand the health departments in the Eastern Cape, Limpopo and North West seem reluctant to share information. Despite signs of a tireless commitment by health-care workers very few patients are on treatment — because of provincial bungling and the lack of national support.
In Limpopo the TAC has not been able to establish whether the ARV programme has even commenced. Repeated requests to the department for information have been ignored.
In KwaZulu-Natal, despite 20 hospitals and clinics being accredited, fewer than 200 patients are receiving ARVs.
However, focusing on patient numbers exclusively can be misleading. The report points to several factors that explain these figures. These are primarily human resources, drug supplies and (the lack of) national political leadership.
Firstly, South Africa is experiencing an acute shortage of skilled and trained health-care workers in the public sector. At many treatment sites, new posts have not been advertised or speedily filled. At these sites, the lack of doctors, nurses, pharmacists and counsellors is hampering the ability to offer treatment.
The ARV roll-out shows the need for an emergency human resources plan for the public sector — to address the issues that have led to the exodus of health-care workers. A national strategy is needed to attract, train and retain health-care workers. As one nurse at the summit commented: “It would be wonderful if government could commit the same level of energy and resources given to the soccer World Cup bid to addressing the human resources crisis in the public health sector.”
Secondly, many sites could not start ARV treatment without the drugs. The national department must take the blame for the delays in drug supplies. The formal tender process may only deliver medicines in September. The Minister of Health Manto Tshabalala-Msimang only approved an interim procurement mechanism in March — after the TAC threatened legal action. Orders for interim supplies that were placed in April eventually enabled provinces to start or expand programmes without having to wait for the completion of the tender process.
Sadly, the department’s failures on procurement has resulted in many provinces citing drug shortages as the reason for the delay.
This brings us to the issue of political commitment and information sharing. Despite an injunction from the Constitutional Court on the importance of communicating plans to all levels of the health service, information is not being shared by the national department.
Documents that were initially part of the plan have never been released. The minister herself has refused to make information available on patient targets and timelines for the implementation of the plan despite informal and formal requests for her to do so.
The secrecy and lack of transparency in the national department are not constitutionally legitimate. If this continues it will be very difficult for civil society organisations concerned with saving lives to help the government to make the roll-out a success.
Fatima Hassan is an attorney with the Aids Law Project