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South Africa: AIDS Treatment Update

AfricaFocus Bulletin
Aug 9, 2004 (040809)
(Reposted from sources cited below)

Editor's Note

"Not more than 10,000 people are receiving anti-retroviral treatment in South Africa at public health facilities. Of these, many are funded by donor agencies. At this rate, the Plan will fall far short of the target announced by President Mbeki of 53,000 people on treatment by March 31, 2005. a target that is already more than 100,000 people less than that proposed in the Plan." - Treatment Action Campaign

Almost nine months after the South African Cabinet adopted a long-delayed plan for urgent rollout of anti-retroviral treatment (see http://www.africafocus.org/docs03/tac0311.php), the Treatment Action Campaign reports, substantial efforts are being made to implement the plan in several provinces and many districts. Overall, however, the effort still suffers from ambivalent national leadership and lack of human resources for implementation.

This AfricaFocus Bulletin contains brief excerpts from two documents. One is the report from the Treatment Action Campaign on implementation of the government's plan for AIDS treatment, with estimates by province comparing the targets and the number of people now being treated. The other is a reflective analysis of the current status of the issue, by Mandisa Mbali, a researcher at the Centre for Civil Society in Natal who is also a TAC activist. The full versions of both documents and much additional information are available on the websites of TAC (http://www.tac.org.za) and CCS (http://www.ukzn.ac.za/ccs).

For earlier AfricaFocus Bulletins on related subjects, see http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

"Our People Are Suffering, We Need Treatment" (Health Care Worker in the Eastern Cape)

Treatment Action Campaign (TAC) & AIDS Law Project (ALP)

Updated First Report on the Implementation of the Operational Plan for Comprehensive HIV/AIDS Care, Management and Treatment for South Africa (Operational Plan)

July 2004

[Excerpts: full report available at:
http://www.tac.org.za/Documents/ARVRollout/FinalFirstARVRolloutReport.pdf ]

... The purpose of this report is not to attack the commitment of health care workers who are trying to make the ARV programme a success; instead the report is a necessary tool to monitor the efficacy of the programme, to share information and to make government accountable to the people who will most benefit from the Operational Plan. Of course, the process of information gathering is on going. ...If you or your organisation would like to add to or correct information in this report please contact: Ayanda Bekwa (011 717 8600 or bekwaa@law.wits.ac.za) Fatima Hassan (083 279 9962 or fatima@tac.org.za)

Compiled by Fatima Hassan

Law & Treatment Access Unit, AIDS Law Project.

With contributions from TAC provincial offices, health-care workers and several provincial health departments.

Executive Summary

This report shows that substantial effort is being directed at implementing the Operational plan at district and provincial level. However, this effort is not being matched with the degree of prioritisation and political commitment to this service that is necessary at a national level. This is making it more difficult for provinces to overcome many of the difficulties that they encounter in speedily implementing the Operational Plan.

Communication about and popularisation of the plan is also extremely weak in most provinces. ...While lists of some accredited sites are made available to internet users and the media, the list and contact details of actual sites that are providing treatment are not being made available to ordinary people who have some access to radio, television and/or newspapers. Provinces such as Gauteng, KZN, FS and the WC are examples of how public media should be used, but the same level of information dissemination is also needed in other provinces. ,,,

The failure to provide national leadership is widening the gap between resourced and underresourced provinces . in particular assistance and instruction is needed in provinces such as the Eastern Cape and Limpopo. ... One particular concern is that although hospitals and clinics are coming under pressure to start to provide a treatment service, they are not getting the additional capital or human resources that the plan promises. ... Waiting lists at Johannesburg's hospitals already run into 2005 - many patients will die waiting for an appointment. ...

Finally, there are clear problems with drug supplies. Accredited sites that have capacity are holding back because they cannot guarantee drugs to patients. This too is a management and monitoring issue.

The updated report estimates reflect that not more than 10,000 people (the figure is closer to 6,000) are receiving ARV treatment in SA at public health facilities. Of these, many are funded by donor agencies. At this rate, the Plan will fall far short of the target announced by President Mbeki of 53,000 people on treatment by March 31, 2005 - a target that is already more than 100,000 people less than that proposed in the Plan.

So, despite the best efforts of health care workers, political prevarication and weak management continue to deny many people access to health services that would save their lives. Despite the attack by the Minister regarding TAC's ability to report objectively about the rollout, and despite some provinces accusing TAC of misleading the public, we are satisfied that the updated report confirms that not even 10 000 patients are receiving ARV treatment in public facilities across South Africa.

Below is a table that summarises the comparison between national targets as they appear in the Operational Plan and estimates of patients on ARV treatment as at 20 July 2004.

B. Comparison of National Targets V Actual Number of Patients Receiving Arv Medicines

Province Operational Plan
March 2004 target
(Revised for 2005)
Numbers on treatment (Adults and children)
Gauteng 10,000 2,300 (Adults 1924) (Children 416)
North West 1,808 130 (Adults 130) (Children -)
Northern Cape 790 (capacity July-September 600) (Adults 51) (Children -) Possibly < 100
Eastern Cape 2,750 298 (Adults 287) [227 MSF, 60 Province] (Children 11) [11 MSF]
Western Cape 2728 May 2004 3059 (Adults 2256) [537 Province 1719 Donor] (Children 803) [304 Province 499 Donor] (Inc.MSF, ARK, Tshepeng Trust, donor funded) 20 July 2004 3750 patients
KZN 24,902 120 Possibly max. 250
Limpopo 6965 Do not know Does not appear to have started dispensing ARVs
Mpumalanga 1934 51 Possibly <100
Free State Target: 2127 Current: Not > 50 (capacity next 2 months 90) [*SACBC 100 patients at 3 sites per year- pending]
TOTAL Target: 54,004 (53 000) Current: <10 000 (close to 6000)


"Iphi i-treatment? Where is the Treatment?": Reflections on the Treatment Action Campaign (TAC) People's Health Summit

by Mandisa Mbali

Mandisa Mbali is a Research Fellow at the Centre for Civil Society, University of KwaZulu-Natal. She has written this piece in her personal capacity.

[Excerpts: full report available at:
http://www.ukzn.ac.za/ccs/default.asp?2,40,5,435]

Introduction: Where is TAC headed?

In late 2003, largely as a result of pressure exerted by TAC, the government formally committed itself to rolling out HIV treatment. This policy shift has posed several questions related to TAC's interim and long term political future, given the reality of the roll-out. Will the 'centre fail to hold' as factions emerged in the politically 'broad umbrella' social movement that is TAC? Will it simply become a service-delivery focused NGO working for the Department of Health? Will the government's commitment to HIV treatment policy reform lead to TAC's co-option? Will it render itself obsolete through its own success lobbying for wider HIV treatment access?

Now that the roll-out is a reality, one cannot fail to be struck by the immensity of the challenges it poses: thousands of health workers need to be trained in managing patients with anti-retrovirals; communities and patients need to be informed about and mobilised around the issue of adherence to HIV treatment; a consistent drug supply needs to be secured; systems have to be set in place to get blood samples to laboratories and results back to roll-out sites on time. Even if one recognises these challenges, it hard not to feel increasingly frustrated with the roll-out's pace and the seeming lack of political leadership and transparency on its progress exhibited by national and provincial governments.

The reality is that in KZN, where hundreds of thousands of patients are in desperate need of treatment, only two hundred patients are receiving treatment as a part of the public sector roll-out. Even Gauteng, where five times the number of patients are receiving treatment as a part of the roll-out, has public sector roll-out sites where waiting lists for treatment extend into 2005. However, measuring the success of the roll-out is not merely a numbers game, as there appears to be a lack of political will to ensure the success of the roll-out at the highest levels of national government.

In the context of the roll-out's slow progress, I attended TAC's People's Health Summit in East London from 2-4 July, as a representative of the University of KwaZulu-Natal's TAC branch. This paper contains my reflections on that summit and what political future TAC may have, given the government's commitment to roll out HIV treatment.

There are three main impressions I gained from the summit as a researcher of TAC and a member of the organisation.

  1. Firstly, the summit marked a subtle, but strategic, shift in TAC's emphasis: it positioned itself as a movement advocating for wider HIV treatment access as a part of a broader campaign for the strengthening of the public health system. In reality, TAC never really was the 'single issue movement' which some critics have claimed it was: lobbying for wider HIV treatment access has always implied a bigger vision of claiming the right to access to health for all, at very least this has been the case since the period of the Consitutional Court challenge on the Prevention of Mother to Child Transmission (PMTCT):
  2. Secondly, TAC has never been stronger politically: it has more branches than before, all of whom seem to be deeply committed to the organisation's aim of campaigning for wider HIV treatment access. TAC encompasses activists from a variety of civil society organisations, classes, genders and sexual orientations and activists from across the left-wing ideological spectrum. However, a unifying factor remains, which is the overarching aim of ensuring the success of the roll-out by holding government to commitments it has made.
  3. Thirdly as discussed above, the antiretroviral roll-out has been woefully slow, in a large part, due to the lack of political commitment to the roll-out from the highest levels of the government. This has generated anger and frustration among ordinary TAC members who find that far too little is being done to alleviate the status quo of needless deaths of members of their support groups, family members and communities.

TAC has a treatment project which provides treatment for hundreds of its members and collaborative projects with MSF providing treatment to hundreds of community members in Khayalitsha and Lusikisiki (an area facing grinding poverty in the rural Eastern Cape). This has clearly shown ordinary TAC members across the country the benefits of HIV treatment. In the summit some of these members proudly carried their pill boxes around and were happy to discuss in plenary sessions their personal experiences of treatment's benefits such as: dramatic weight gain, added energy and surges in their CD 4 counts (a type of immune cell that HIV attacks, which can be measured to show whether someone needs AIDS treatment). Their personal experiences of the startling benefits of HIV treatment have only heightened their frustration that the government is not providing HIV treatment to everyone else who needs it.

...

Before discussing each of these three key impressions I gained from the summit on future trends in TAC it may be worth providing a brief overview of the history of TAC.

A brief history of TAC

TAC was founded in 1998 to push for wider HIV treatment access and in memoriam of anti-apartheid, gay rights and AIDS activist Simon Nkoli. One of TAC's major strategies has been to urge people living with HIV/AIDS to be open about their status in order to push for access to HIV treatment. The movement has always battled against two major foes: the pharmaceutical industry's abuse of patent monopolies on anti-retroviral drugs and government AIDS denialism.

TAC has had several major successes in its brief history. In 2001 it forced multinational pharmaceutical companies to drop their case against the government's Medicines Act which allowed for production and importation of cheaper generic antiretroviral drugs. TAC's pressure for generics has led to a major reduction in the price of HIV treatment: combination anti-retroviral therapy cost over four thousand rand a month when TAC began its campaign, whereas today such combinations begin at three to six hundred rand per month.

In the same year, it forced the government to expand provision of the drug Nevirapine (which can cut the risk of mother to child transmission by half) to all antenatal sites in South Africa, by obtaining a Constitutional court ruling. This ruling has been international celebrated as it confirmed the right to access to Health care enshrined in South Africa's Bill of Rights. (2)

In 2002, it tried to obtain an agreement on a comprehensive plan for HIV treatment and prevention at the National Economic Development and Labour Council (NEDLAC). When these negotiations collapsed in early 2003, due to government intransigence (linked to government denialism), TAC embarked on a civil disobedience campaign.

Finally in August 2003, following the first South African National AIDS Conference held in Durban, Cabinet instructed the ministry of Health to develop a comprehensive HIV/AIDS treatment and prevention plan. As a result of pressure from TAC, the Department of Health produced Operational Plan for Comprehensive HIV and Aids Care, Management and Treatment for South Africa (hereafter referred to as the 'roll-out plan'). The South African government finally committed itself to rolling out comprehensive HIV treatment. Since the government committed itself to rolling out HIV treatment, it has been interesting to reflect on what TAC's role in the roll-out would be and what it would mean for the future of movement. It is clear that TAC organised the summit to begin the work of figuring out its future political directions following the roll-out.

Building a house on sand: The need for public health reform and the roll-out

The summit was not only convened to discuss the shortcomings of the roll-out in a narrow sense. As Olive Shisana argued in a plenary address, the roll-out must be used to strengthen the public health system. Similary, the health system must be strengthened in order to ensure the long-term success of the roll-out. AIDS simultaneously deepens and draws attention to the crisis in the public health sector. To paraphrase the parable, you can't build the house of a sustainable and successful roll-out on the quick sand of a public health system in crisis.

Achmat gave an eloquent address in the opening session, which outlined the legacy of apartheid's production of racial inequalities in access to health care and health status. The crisis in the health system can be largely explained in terms of the following statistic 50% of health spending in South Africa is in the private sector largely serving the 16% of the population privileged to have medical aid, whereas over 80% rely on the public health sector. This statistic was represented in the poster advertising the summit which showed photographs of a packed waiting room in a run down public sector facility and an almost empty, luxurious hotel-like, private sector facility's waiting room. The overarching call was to reduce the inequalities between the public and private sectors and for there to be a reallocation of resources from the private to the public sector. On the other hand, as I have mentioned above, there was a diversity of opinions on how to address this crisis. ...

Many other, related problems facing the public health sector were also highlighted in an explosive report on the state of public sector health service delivery in the Eastern Cape formulated by the Public Service Accountability Monitor. Delegates heard research claiming that the provincial department of health had not properly accounted for hundreds of millions of rands of its health and AIDS budgets. The PSAM cited government reports alleging mismanaged, unhygienic mortuaries and ambulances which arrived hours late, some of which had been privatised. This resonated with ordinary activists' experiences of staff shortages in rural clinics, so severe that in some cases only one nurse single-handedly ran a whole clinic. This lead to lengthy queues and occasionally, at times when the few staff went on leave, a total interruption of clinics' services.

The Eastern Cape MEC for Health, (Monwabisi Goqwana) who was invited to address the opening session of the Summit, eventually only arrived on the final day. When he arrived a fascinating debate ensued between him and Colm Allen (of the PSAM). The MEC denounced the PSAM research as a 'pack of lies' and celebrated the 'achievements' of the Eastern Cape government in delivering health care including purchasing two helicopters to medically evacuate patients when required. At the end of his speech TAC activists spontaneously burst into song and began toyi-toyi-ing asking the Minister Iphi i-treatment (where's the treatment).

Indeed, TAC spokesperson Sipho Mthathi expressed the sentiments of many TAC activists when she asked the MEC to devote an equal amount to implementing the rollout as he has to implementing legislation to ensure safe male circumcision (a practice common among Xhosa-speaking people in the Eastern Cape). His pet project of purchasing two helicopters was out of touch when there was inadequate basic ambulance coverage of most of the province. Mthathi also asked the MEC to apologise for telling people in Lusikisiki "Not to listen to white people" who promoted 'toxic' drugs. ...

Deadly delays and 'business as usual' in the roll-out

TAC is even stronger since the roll-out, which was not necessarily a given in August 2003. Reform can either co-opt opposition, or, if it is cosmetic or half-baked, it can show the power of resistance and make people even more militant in pushing for the realisation of all of their demands. TAC's review of the roll-out presented at the summit argued that government was not treating the roll-out as an emergency. ...

Indeed, in the case of the roll-out, I would argue the second scenario of incomplete reform increasing resistance may be materialising. As TAC's reports on the roll-out show, government is far from on track with reaching its own target to treat fifty thousand people by the end of March 2004, TAC estimates that it was only treating ten thousand people by the end of June 2004 (including just over one thousand people on HIV treatment at the TAC/MSF clinics). President Mbeki recently announced that there will be a one year delay in meeting initial targets. This is a deadly delay, which has resulted in the waiting list extending into 2005 at some Gauteng roll-out sites. One wonders how long desperately ill patients will have to wait in other provinces such as KwaZulu-Natal. TAC estimates that only two hundred people are being treated of just under twenty five thousand stated in the KwaZulu-Natal provincial government's targets. The deadly wait may be even longer in provinces such as Limpopo, where TAC has received no evidence that anyone has begun treatment.

Another delay earlier this year happened when TAC had to threaten court action to push the government to procure drugs for the rollout. TAC's review also argued that a Helpline set up to answer questions about the roll-out was not giving accurate information and government was not using mass media to its full potential to publicise the roll-out and promote treatment literacy.

The most damning aspect of TAC's critique was that there had been a lack of visible, unambiguous political leadership for the roll-out from the highest levels of national government. ...


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at africafocus@igc.org. Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see http://www.africafocus.org


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