Equity and the Expansion of Access to Treatment and Care for HIV/AIDS in Southern Africa: Report of a workshop at ICASA | Hiv/Aids | Health

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The Regional Network for Equity in Health in Southern Africa (EQUINET) and Oxfam GB with government and civil society partners have since early 2003 initiated a programme of research and analysis in support of policy and advocacy focusing on HIV/AIDS and equity in health sector responses. The programme has held and reported on an expert review panel, has initiated country research in four southern African countries on equity in health sector responses (Zimbabwe, Malawi, Tanzania and South Africa), and with support from DfID regional analyses of specific health equity concerns related to HIV/AIDS, covering issues such as health personnel, nutritional interventions, and gender equity in health sector responses(see www.equinetafrica.org). A, EQUINET/Oxfam GB workshop was held at the ICASA conference with support from UNAIDS and DfID giving feedback on the work done in the programme. It presented evidence gathered from country case studies from Malawi, Zimbabwe and South Africa and from the SADC region from work on nutrition and HIV/AIDS. It used this evidence to explore options for safeguarding equity AND improving access to treatment and for strengthening equity in health sector responses to AIDS from global to national level. The workshop was facilitated by D McCoy for EQUINET/Oxfam GB. This report summarises the proceedings of the workshop. It was prepared by D McCoy and edited by the EQUINET secretariat at TARSC.
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   Southern African Regional Network on Equity in Health (EQUINET) and OXFAM (GB) Report of a Workshop at ICASA on Equity and the Expansion of Access to Treatment and Care for HIV/AIDS in Southern Africa Satellite Session at the 13 th  ICASA Conference Nairobi, 23 September 2003   With support from UNAIDS and DfID Report produced by D McCoy and TARSC    Report of a Workshop at ICASA on Equity and the Expansion of Access to Treatment and Care for HIV/AIDS in Southern Africa EQUINET, Oxfam GB with UNAIDS and DfID Nairobi September 23 2003 1. Background HIV/AIDS has had a deep impact on health and health equity issues in Southern  Africa. Health care systems have been stressed by increased demand for care, while themselves suffering HIV/AIDS related losses in health personnel. Household and community caring have complemented and sometimes substituted health care inputs. Where these lack adequate support they increase burdens on already poor households. As HIV/AIDS related mortality rates have fallen with new treatments available in high income countries, treatment access has become a central issue, with campaigns on this in South Africa recently widening through the Pan African HIV/AIDS Treatment Access Movement. The Global Health Fund (GHF) has added raised attention about international obligations around resourcing responses to health risks such as HIV/AIDS, and the challenges to the TRIPS agreement has focused attention on the areas of conflict between trade agreements and access to treatment, including to ARVs. Funds available from the GHF and other sources make ARVs potentially more accessible to some people in southern Africa, but there are issues to be addressed of who, on what basis, and how? The Regional Network for Equity in Health in Southern Africa (EQUINET)   and Oxfam GB with government and civil society partners have since early 2003 initiated a programme of research and analysis in support of policy and advocacy focusing on HIV/AIDS and equity in health sector responses. The programme has held and reported on an expert review panel, has initiated country research in four southern  African countries on equity in health sector responses (Zimbabwe, Malawi, Tanzania and South Africa), and with support from DfID regional analyses of specific health equity concerns related to HIV/AIDS, covering issues such as health personnel, nutritional interventions, and gender equity in health sector responses(see www.equinetafrica.org).  A, EQUINET/Oxfam GB workshop was held at the ICASA conference with support from UNAIDS and DfID giving feedback on the work done in the programme. It presented evidence gathered from country case studies from Malawi, Zimbabwe and South Africa and from the SADC region from work on nutrition and HIV/AIDS. It used this evidence to explore options for safeguarding equity AND improving access to treatment and for strengthening equity in health sector responses to AIDS from global to national level. The workshop was facilitated by D McCoy for EQUINET/Oxfam GB. This report summarises the proceedings of the workshop. It was prepared by D McCoy and edited by the EQUINET secretariat at TARSC. 2   2. Report of the workshop proceedings “The theme of the conference, “ACESS TO CARE AND CHALLENGES”   captured the large challenges faced by us all in the struggle to provide care to the huge numbers of persons affected by HIV/AIDS”. Closing remarks at the conference Dr. Malaki Dundu Owili, Conference Chair The EQUINET/ Oxfam GB satellite session took place at for 6 pm till 8 pm on 23 rd  September 2003, at the end of a long day of the 13 th  International Conference on  AIDS and Sexually Transmitted Infections in Africa (ICASA). There were five other satellite sessions taking place at the same time. As such, it was gratifying that there was a reasonable turn-out to the satellite session, with between 50 – 60 people attending. Notable attendees included Julian Fleet, from the UNAIDS head office in Geneva who is responsible for coordinating UNAIDS policy issues on HIV/AIDS care; and Vinand Nantulya, special advisor to Richard Feachem from the Global Fund. Sian Long, the HIV advisor for Save the Children Fund Southern Africa was also present. The session was chaired by Catherine Sozi, and all the case study presenters made presentations that clearly explained the equity challenges related to the expansion of care and treatment. Each case study also precipitated several interesting and contributory comments from the floor. The study reports are separately reported.  After the case presentations there were about 30 minutes dedicated to further comments from the floor. Many of these comments reinforced the questions, conclusions and recommendations that were emanating from the EQUINET / Oxfam commissioned papers. Key issues arising There seemed to be general recognition and acceptance that the issue of access to care and treatment could not be divorced from much broader issues related to the political economy of health at both the global and national level. The absolute lack of resources to meet the full package of developmental needs in southern Africa was also emphasized, and the nutrition case study illustrated this. The phenomenon of the global health personnel brain drain was raised in this regard, illustrating the tensions that exist in a polarized world. While shortfalls in personnel were identified as a critical constraint to treatment access, as one delegate from the floor said, it would not be right to limit the aspirations of an African doctor to achieve a lifestyle enjoyed by doctors in the United Kingdom. There was interest expressed by some delegates that many developed countries seem to be deliberately under-investing in the local production of health workers because it is cheaper to recruit them from aboard. Many of the presentations described how the underlying health system was already inequitable. In some, such as in Malawi and Zimbabwe, there was insufficient resources to deliver the basic package of basic PHC services. The addition of a new set of requirements for the delivery of health care would therefore entail some form of opportunity cost. 3 Furthermore, all three country case studies pointed out that rapid expansion and full coverage of access to treatment while a right and a goal, was not possible in the  immediate with current resources. Rationing or limited access was the inevitable de facto situation. Julian Fleet echoed this and said that UNAIDS were interested in helping to develop criteria and guidelines on the targeting or rationing of ART through public sector and not-for-profit programmes. The limiting factor of human resource capacity was again raised at national level. Even with the additional funding provided by the global fund, the inability to translate additional financial resources into human resources would mean that the ambitious targets and plans that have been set would either fail to be achieved, or would be reached at the expense of other health services. It was therefore felt that the Global Fund, together with the other donor agencies, needed to pay greater attention to the issue of human resource capacity and the strengthening of the overall health system, particularly of the public sector. There was also concern that the expansion of treatment and care could push the public sector into a spiral of self-depletion. In order to reach the targets set and because of the comparative advantage the NGOs have over the public sector bureaucracy in terms of responding quickly to the development of project plans, there could be a proliferation of NGO-managed ART projects which would recruit personnel from the public sector, and thereby further weaken human resource capacity in this sector. There was therefore a general call from the presenters and the floor for plans and budgets to be set through a much more coordinated process, with attention paid to the strategic objectives of health systems development in general. In response to this, Vinand Natulya indicated that the Global Fund was much more sympathetic to the inclusion in Global Fund proposals of line items that would support the development and strengthening of the broader health care infra-structure.  Another pertinent comment from the floor was the reminder that as public health professionals, one of our primary responsibilities is to do no harm. It was mentioned that poor systems for increasing access to treatment that resulted in the development of resistance could make things much worse in the long run for the poor. In such a situation it was argued that the provision of ART could cause more harm than benefit. Hence unless there was parallel investment in health systems and health personnel the dedicated and well-intentioned efforts of expanding access to treatment could have unintended harmful consequences, and even possibly result in an overall deterioration of care. It is important for countries to develop a research and evaluation strategy that would pro-actively monitor the possibility of unwanted outcomes. The session ended with the conclusion that there were more questions than answers. The complexity of ensuring equitable and sustainable access to treatment in the context of other widespread developmental and health needs involves a variety of resource allocation and policy trade-offs. However, it is only by asking the right questions and being prepared to address them that programmes for expanding treatment access can be designed to be cost-effective, sustainable and equitable. 4  
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