BMJ  2004;328:241-242 (31 January), doi:10.1136/bmj.328.7434.241

Editorial

Access to antiretroviral treatment in Africa

New resources and sustainable health systems are needed

The demand for people living with HIV and AIDS in Africa to access treatment cannot be ignored. At the same time the challenges to meeting this demand are many. They include the shortfalls in health services and lack of knowledge about treatment, making decisions about newer regimens, and the risk of resistance to antiretrovirals highlighted in the paper by Stevens et al (p 280). ^{1 2} The challenges also include ensuring uninterrupted drug supplies, laboratory capacities for CD4 monitoring, accessible voluntary counselling and testing, trained healthcare workers, and effective monitoring of resistance to antiretroviral drugs.³ A series of papers produced in 2003 through the southern African regional network on equity in health raised further concerns about measures to ensure fairness in the rationing of scarce treatment resources and the diversion of scarce resources from strained public health services into vertical treatment programmes.^4-8

The reasons for these challenges are not a mystery. They stem from the chronic under-resourcing of health systems, the underdevelopment of strategic public health leadership, the attrition of health personnel, and the high prevalence of poverty, factors that already limit the delivery of many less complex primary healthcare services.^5-7 Given this context, how should resources best be allocated to ensure access to treatment for HIV/AIDS in Africa?

Existing initiatives provide some indications of what to do and what not to do. Making treatment accessible through private and non-government sectors or through redeployment of personnel without addressing the staffing, pay levels, and working conditions of health personnel in public health services can further increase attrition from essential services and aggravate uncoordinated health planning.⁷

Providing treatment on a "first come, first served" system favours urban, higher educated people who are not poor. It also unfairly delegates frontline healthcare workers to decide who does and does not access treatment, resulting in inconsistencies and even corruption.⁸

Providing treatment at central hospitals without strong links to community outreach or primary healthcare services weakens the link between prevention and care. It also limits the benefits that treatment brings in reducing stigma to the higher income users of these hospital services.^{5 7}

Vertical programmes established to achieve rapid delivery against unrealistic targets can divert scarce resources from strained public health services and bring undesirable opportunity costs and inefficiencies through the creation of parallel management and administrative systems.

In contrast, approaches to expand access to treatment can simultaneously strengthen health systems; build synergies between treatment, prevention, and primary healthcare services; and reach vulnerable groups. For example, when treatment is linked to prevention of parent to child transmission of HIV, provided through maternal health services, the likelihood of women having enhanced access to treatment, reduced social stigma around AIDS in women, and strengthening general maternal health services for all women is greater.

Criteria for selecting patients that explicitly target low income groups or particular subgroups of the population such as health workers and teachers (because their job promotes services for poor people), or that involve communities in decisions about selecting patients, can enhance equity and prevent the development of patronage or corrupt practices around treatment. Community health workers have had an important role in Africa in nutrition, immunisation, maternal health, child spacing, and many interventions that enhance health and treatment related literacy. Developing their role in access to treatment could strengthen primary health care and should be further explored.⁷

Such approaches to treatment access on a national scale will be possible only if the health system is properly organised, coordinated, and managed, and if it is adequately resourced. Organisationally, the principles of a district health system should remain paramount as a remedy to the destructive effects of uncoordinated, disease focused, vertical interventions. For such systems to be functional, we need to address the growing shortfalls and maldistribution of personnel and resources in African countries.^{8 9}

If effective, equitable, and sustainable approaches to treatment access are to be replicated, considerable new resources will need to be channelled to Africa's health systems, particularly for district level services. Such resources should come from national public budgets, overseas development aid, global funds, and from the cancellation of debt. The International Monetary Fund and World Bank medium term expenditure framework constraints currently limiting the uptake of increased resources in the public health sector also need to be revisited.

The global recognition of rights to treatment reflects a significant shift in mindset. Another shift is now needed to deliver on those aspirations. Health systems cannot be built from a patchwork of non-government, vertical, ad hoc services around a crumbling public sector core. For treatment access to become a reality for more than a minority, a further step needs to be taken towards an explicit global and national commitment to refinance Africa's public health sector and district health systems.

Training and Research Support Centre, (rene{at}tarsc.org)

EQUINET, 47 Van Praagh Avenue, Milton Park, Harare, Zimbabwe

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Education and debate p 280; Papers p 249

Competing interests: None declared.

References

1. Stevens W, Kaye S, Corrah T. Antiretroviral therapy in Africa. BMJ 2004;328: 280-2.[Free Full Text]
2. Yazdanpanah Y, Sissoko D, Egger M, Mouton Y, Zwahlen M, Chene G. Clinical efficacy of antiretroviral combination therapy based on protease inhibitors or non-nucleoside analogue reverse transcriptase inhibitors: indirect comparison of controlled trials. BMJ 2004;328: 249-52.[Abstract/Free Full Text]
3. Kumar S. India's treatment programme for AIDS is premature. BMJ 2004;328: 70.[Free Full Text]
4. McCoy D. HIV care and treatment in southern Africa: addressing equity. Harare: EQUINET and OXFAM GB, 2003. (EQUINET discussion paper No 10.)
5. Ray S, Kureya T. Zimbabwe's challenge: equity in health sector responses to HIV/AIDS in Zimbabwe. Harare: EQUINET and OXFAM GB, 2003. (EQUINET discussion paper No 9.)
6. Ntuli A, Ijumba P, McCoy D, Padarath A, Berthiaume L. HIV/AIDS and health sector responses in South Africa. Treatment access and equity: balancing the act. Harare: EQUINET and OXFAM GB, 2003. (EQUINET discussion paper No 7.)
7. Kemp. J, Aitken JM, LeGrand S, Mwale B. Equity in health sector responses to HIV/AIDS in Malawi. (EQUINET discussion paper No 6.)
8. EQUINET Steering Committee. Equity in health in southern Africa: turning values into practice. Harare: EQUINET, 2000. (Policy series No 7.)
9. Aitken JM, Kemp J. HIV/AIDS, equity and health sector personnel in southern Africa. Harare: EQUINET and OXFAM GB, 2003. (EQUINET discussion paper No 12.)

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