All people with HIV/AIDS should have equal opportunity to access effective and appropriate treatment. However, 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.

The HIV prevalence and mortality rates in southern Africa read like a horror story. The SADC countries, with a combined population of only 3.5 % of the world’s population (approximately 207 million people), account for approximately 35 % of people living with HIV/AIDS and about a half of all infections in Africa. In several countries, HIV adult prevalence is over 30 % (Botswana; Lesotho; Swaziland; and Zimbabwe.

Research commissioned by Equinet and Oxfam GB highlights the inadequate levels of health expenditure in many Southern African countries, and argues that 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 further 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.

While drug-pricing is an important issue, the researchers argue for a more fundamental re-think about how society views and manages patents and intellectual property and how research and development of new medicines and vaccines is funded. It argues that contrary to popular opinion, the market-based structure of pharmaceutical research and development, based on the principle of intellectual property, is neither efficient nor effective.

The organisation and management of the health system is also highlighted as being important when it comes 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. This includes the policy and operational considerations of treatment programmes, including the need to:

• balance the rapid expansion of access to treatment with the need to develop basic health care infrastructure
• optimise the balance between HIV treatment and other health care services
• optimise the balance between HIV prevention and treatment
• strengthen public sector health management capacity relative to the non-government sectors
• 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.

This demands coordinated strategic planning and strong public health leadership. It places an obligation on donors to ensure that their plans are sustainable and integrated within long-term strategies to improve health systems. 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

Source(s):
‘Health Sector Responses to HIV/AIDS and treatment access in southern Africa: Addressing equity’, Equinet Discussion Paper No. 10, by D. McCoy, October 2003 Full document.

Funded by: UK Department for International Development (DFID); International Development Research Centre, Canada (IDRC)

id21 Research Highlight: 27 August 2004

Further Information:
David McCoy
Health Systems Trust
PO Box 808
Durban 4000
South Africa

Contact the contributor: davidmccoy@xyx.demon.co.uk

Equinet, the Regional Network on Equity in Health in Southern Africa

Oxfam GB

Other related links:
'DOTS on the spot - lessons for access to HIV care'

'Global or local: what factors most affect health policy in South Africa?'

'Prevention or care? What works best in the fight against AIDS?'

'Counting the cost of HIV in Southern Africa'

'Economies of scale-up? The cost of expanding access'

'Insights Health Editorial: Delivering the goods - HIV treatment for the poor'

See id21's collection of links relevant to HIV/AIDS.