Equity and the Expansion of Access to Treatment and Care in Southern Africa

1. Equity and the Expansion of Access to Treatment and Care in Southern Africa Based on case studies commissioned by Equinet and Oxfam GB With active support from UNAIDS and SADC Health Desk

2. Presentations and case study powerpoints from the EQUINET/Oxfam GB workshop at the 13th ICASA Conference With support from UNAIDS and DfID

3. Defining equity • Equity is concerned with • Disparities that are considered unfair and avoidable • Distribution and share of available resources • Focus on wealthy and powerful as much as on the poor and marginalised • Value-based – linked to human rights an social justice discourse (not charity or aid)

4. Defining the parameters of equity • Comparison between socially defined groups • Socio-economic • Geographic • Gender • Racial • Patient groups • Compared across different levels • From the global to the local • Looking at the underlying determinants of health and access to health care and treatment

5. Why be concerned with equity? • Resource constraints mean that difficult decisions have to be made • Widening disparities increasingly unacceptable and undesirable • Necessary to address poverty

6. Why be concerned with equity? • Redistribution and social solidarity under attack • Marginalised voices need to be amplified • Public health principles of maximising cost-effectiveness

7. Why Southern Africa?

8. The global context

9. Programme • Case Studies • Malawi • South Africa • Zimbabwe • Nutrition • Framework of equity challenges for accessing care and treatment • Discussion : Safeguarding equity and improving access to treatment

10. Programme (cont) • Recommendations to: • Southern African governments and heath policy makers • Global health institutions and donors • Wrap-up

11. Framing the Equity Challenges of Increasing Access to Treatment Equitably • The broader development agenda • The broader health systems context • Financing and resource allocation • Culture and ethos • Health care infra-structure

12. Framing the Equity Challenges of Increasing Access to Treatment Equitably • Prevention - Treatment • Sharing the burden between the commercial and public sectors • Regulation / Standards - Access • Patient selection

13. “Equity in ART? But the whole health system is inequitable” Equity in Health Sector Responses to HIV/AIDS in Malawi Presented by Dr Andrina Mwansambo National AIDS Commission, Malawi Paper commissioned by Southern African Regional Network on Equity in Health (EQUINET) in co-operation with OXFAM (GB)

14. Overview of presentation • Situation analysis – HIV/AIDS epidemic in the context of Malawi • Impact of HIV/AIDS on the health sector • Equity in access to ART and health sector responses to HIV/AIDS • Summary

15. 1. Situation analysis The situation of poverty in Malawi is ‘widespread, deep and severe’ • 65% of the population is poor • 1/5 children die before the age of 5 years • Maternal mortality ratio 1,120/100,000 The HIV/AIDS epidemic undermines efforts to reduce poverty • National prevalence 8.4% • Prevalence highest in south, urban areas and in younger age groups • Vulnerability to HIV/AIDS is influenced by • Gender relations – sexual norms, violence • Poverty • Age

16. 1. Situation analysis Malawi’s health system – a plurality of providers with, on paper, ‘reasonable’ coverage • 54% of rural population has access to a health facility within 5km But ‘the poor wait longer, receive fewer drugs and ‘pay’ more in comparison to the wealthy’ • Severe staffing shortages, especially in rural areas – overall 50% posts unfilled • 50% doctors work in the four central hospitals • 1.9 nurses per health facility – many have only one • User perception of poor quality – poor staff attitudes, long waiting times, lack of confidentiality, & limited accountability to service users

17. 2. Impact of HIV/AIDS on the health sector HIV has created an increasing and changing pattern of demand for health services…. • Little information on demand for out-patient services (as a proxy, TB notification rates have increased five fold over last twenty years) • 40% of all admissions, or 70% of admissions to medical wards are HIV-related …..against a background of decreasing capacity to supply those services • Context of declining resources • 2% annual attrition of health care workers due to death 2% • Chronic absenteeism – illness, caring for family members, funerals • Increased workload for an understaffed & demoralised health service

18. 3. Equity in health sector responses to HIV/AIDS Continuum of care for HIV/AIDS? • Most policies in place or well advanced • Couple of areas where response is well established nationwide- public, CHAM & private sector • TB control • STI management • Others? • Depend on specific donor inputs – • Patchy coverage with islands of excellence Anti-retroviral therapy (including Prevention of Mother to Child Transmission) Voluntary Counselling and Testing Home-Based Care & Palliative care Opportunistic infections prophylaxis Nutrition support Behaviour Change Communication Sexually Transmitted Infections Management TB Treatment Other opportunistic infections treatment Infection management

19. 3. Equity in health sector responses to HIV/AIDS Inequities in access to continuum of care? • Limited geographical coverage, based at district centre or limited service implementation E.g. PMTCT in 9 hospitals - 95% of mothers have ante-natal care, but only 35% deliver at health facilities, few at hospitals • Social barriers to access E.g. VCT - evidence of gender differences in access, especially at stand-alone sites - fear of knowing HIV status? • Even within a comprehensive national response – barriers to access remain E.g. TB - costs urban poor 6 times available monthly income for TB diagnosis - people drop-out of diagnosis - social stigma

20. 3. Equity in health sector responses to HIV/AIDS Access to anti-retroviral therapy (ART) • Guidelines for ART in place – delivery in district system using a ‘public health’ approach • Standardised regimens • Clinical criteria for entry (not laboratory testing) • Monitoring on clinical criteria • AIDS Policy – ‘access to eligible persons of ‘affordable’ ART’ • Three systems for ART delivery currently in place • GOM/MOHP – at cost, Lilongwe & Blantyre • MSF-led provision, free of charge in Chiradzulu and Thyolo districts • Private providers • Performance of programmes – information limited • ? Drug interruptions in 21% cases, 4% of cases severe toxicity

21. 3. Equity in health sector responses to HIV/AIDS Equity in access to anti-retroviral therapy (ART)? • Need estimated at 200,000, 1370 beneficiaries in 2002 • Under GFATM, scale up is imminent for 25,000 + people • Most likely to be on first-come, first served basis, if people meet clinical criteria But, initial beneficiaries likely to be less vulnerable: • People already accessing the ‘at cost’ system operated by GOM/MOHP (higher socio-economic status) • High awareness of ART (high education level) • Able to afford the direct and opportunity costs of care seeking, and repeated visits for therapy (proximity to district centre ) • Able overcome social barriers to knowing HIV status and access VCT

22. 3. Equity in health sector responses to HIV/AIDS Responses to Human Resource crisis? • Emergency training plan & Health Services Commission • No workplace policy for HIV/AIDS - although now mandate for 2% budget allocation • Moves to improve waste management and infection control, but current situation poor • Amongst health workers giving vaccinations or curative injections, 49% and 57% respectively reported suffering at least one needle-stick injury during the last twelve months. • In 44% of a sample of 29 health facilities, injection safety boxes were stored in a manner that was not safe

23. 4. Summary Can provision of continuum of care be equitable ? • Equity is promoted through availability of quality care at the periphery • Current inequities relate to general health services - understaffing and weak infrastructure & management • New Essential Health Package should address inequities • BUT under resourced – finances and staff • 90% of health facilities currently cannot deliver EHP • Need for outputs for Global Fund will require rapid ‘project’ approach • HIV epidemic and response will cause depletion of staff unless – • Work as much as possible with current staffing levels • Use non-clinically qualified staff as far as possible e.g. VCT • Infection protection measures in place • Access to ART for staff • Performance-related incentives

24. 4. Summary Can provision of anti-retrovirals be equitable ? • Needs to be delivered through mechanisms that do not exclude poor/vulnerable • Feasible – but limited impact immediately • Guidelines point to whole service ‘public health approach’ • More specific targeting required? • Needs to be in context of comprehensive response – continuum of care • Continuum response patchy & slower in implementation • Needs to be delivered so as not to take away resources from essential health services • ‘Additional’ services require heavy staff load • Project based approach for funding under GFATM • Parallel drug procurement and distribution (initially)

25. 4. Summary ‘Equity’ in access to ART – who benefits? • If consider access to the treatment alone, then ART will be inequitable in the short and medium term • Explicit measures are needed to ensure equity in longer term – a ‘road map’ • In the Malawi situation of limited resources, question of equity should consider what will be the equity in access to benefits of the investment of ART provision • ‘how’ ART is rolled-out will have the greatest impact on equity in access to care (for HIV/AIDS and all other care) • Potential to deplete or support resources for the Essential Health Package

26. Acknowledgements • Authors of the technical paper • Dr Julia Kemp • Jean-Marion Aitken • Sarah LeGrand • Dr Biziwick Mwale • All those who have taken part in stakeholder interviews or who have contributed materials for the analysis

27. Zimbabwe’s challenge:Ensuring Equity in the Health Sector’s Response to Treatment Access for HIV and AIDS.byTendayi Kureya, and Sunanda Ray Review Commissioned by Southern African Regional Network on Equity in Health (EQUINET) in co-operation with OXFAM (GB) with support from DRC, DfID

28. Structure of the review • Part 1: Preparing the study • Part 2: Framing the context for treatment in Zimbabwe • Part 3: Current situation regarding treatment • Part 4: Conclusions and recommendations

29. Part 2: Framing the Context for Treatment in Zimbabwe • The burden of HIV in Zimbabwe is huge. • High HIV prevalence, nearly 800,000 OVCs and high incidence in the youth. Most felt at the family level as the health care system fails to cope. • Some economic sectors are severely affected: A case study with a bus company revealed that 54% of absenteeism is associated with attending funerals, followed by HIV-related illnesses at 35%. • Current socio-economic problems worsen the plight of remote health centres. Many hospitals are unable to supply even basic medications. • Stigma still shroud HIV and AIDS. • High inflation rates reduce the true value of public spending on health.

30. On equity and health service delivery • 90% of population rely on public service health delivery systems. • Only 1million are on medical AID. • 70% of population is rural. • 49% of population is serviced by mission hospitals. • In 1996, health sector had 1020 doctors, 50% of them in private practice, and some 50,000 traditional healers. • 50% of inpatients are HIV positive. • Size of population needing treatment is huge: estimated between 200,000 to 600,000

31. Part 3: Current situation regarding treatment • Government’s response to HIV and AIDS began as early as 1985 • Set up NAC and its structures and policy framework in 2000. Declared state of emergency in 2002 • Medicines Control Authority Of Zimbabwe has registered 6 patented and two generic ARVs, including one for local production. • Guidelines for Implementing ART have been developed by MoHCW. There is no regulation of doctors that can prescribe ARVs. • Pharmacies are already stocking ARVs with price ranges of US$30-400 Local production at around US$15 equivalent in Z$ is planned • There is limited Access to information on treatment options available in the country. Activism is still low.

32. ART programmes • 155 Hospitals participating in PTCT programmes and some are participating in the fluconazole initiative. Only one hospital, Luisa Guidotti Mission has an expanded ARV programme • Some NGOsand funding organisations are involved in various programmes: CDC, ZACH on the CHAPPL prog. The Centre already has people on ART. • Some Corporations are providing ART, e.g. Delta Corporation, De Beers, apart from prevention programmes. • CIMAS and PSMAS Medical AID schemes now cover ART.

33. Part 4: Conclusions and recommendations • Major Conclusions • There is considerable momentums to establish ART programmes, especially from the NGO sector. An equitable national programme, however, should mobilize through the public health sector to reach all the people who need treatment • National efforts still fall short because there is no sufficient will, funding and activism. • Generic versions of drugs make ART a potential reality for all in Zimbabwe, but require significant external financial input

34. Areas needing urgent focus include: • commitment to ensuring that services are provided on the basis of need rather than ability to pay. E.g: There is a proposal to place ccentres of excellence away from areas of greatest need. • Sharing Information on, and Coordination of national ART programmes • The national HIV policy and strategic framework is silent in advocating for ART.If resistance to first line ARV medications develops, more expenditure will be required using second line drugs for fewer people. • monitoring and evaluation on expenditure of resources allocated and activities done. • Funding:the funds currently available are not sufficient for equitable provision of treatment. • GIPA: Limited involvement of people infected or affected by HIV or AIDS. Community education and mobilisation is not fully planned for as an integral part of the treatment package. • END

35. HIV/AIDS TREATMENT ACCESS AND EQUITYSouth African Case Study Paper Commissioned by Southern African Regional Network on Equity in Health (EQUINET) in co-operation with OXFAM (GB) with support from IDRC, DfID

36. HIV/AIDS TREATMENT ACCESS AND EQUITYSouth African Case Study Antoinette Ntuli, Petrida Ijumba, Ashnie Padarath, Lee Berthiaume HST Presented at ICASA Conference – Nairobi Kenya, 21 - 26 September 2003

37. Socio-economic inequities • GDP per capita approx. $ 3 000 masks the inequities • 50% of the population receive 11% of country’s income • 7% of the population receive> 40% of the total income • > 19 million trapped in poverty living on or below $55 per month per person • Female H/H have 50% higher poverty than male H/H • 72% of the poor live in rural areas – have little access to land or employment

38. Inequitable income and employment opportunities

39. Inequitable access to basic facilities

40. Public Consumes < 40% of healthcare financing About $110 per capita > 80% of the population Employ 33% of specialists Over-used and under-resourced Private Consumes > 60% of health care financing About $ 800 per capita < 20% of the population Employ 77% of specialists Over- serviced Public – private divide

41. 94 93 100 90 76 75 73 80 70 59 60 50 41 40 27 25 24 30 20 7 6 10 0 Nurses Dentists Specialists Pharmacists Psychologists General Practitioners Publlic Sector Private Sector Inequitable distribution of health personnel between private and public sector

42. Inequities within the public health sector • Wealthier provinces have 8-9 health workers per 1000 people, the poorer provinces have 4 • There is a wide gap in per capita spending across provinces • There is a wide gap in per capita spending across districts in the same province • Only 15% of the health budget is spent on PHC (i.e. the most equitable level of care)

43. Inequities within the public health sector (cont….) • Poorer provinces • lack leadership, management and supervisory capacity, resulting in poor planning and use of resources • Have poor performance (e.g. in PMTCT) • Only 10-25% have access to VCT • In at least 5 provinces the PMCTC programme has not been expanded beyond the pilot sites • About 50% of public facilities have access to nevirapine but many lack human resources

44. Reforming the private sector • Government has regulated the private sector through for example : • mandatory open enrolment • Prescribed Minimum Benefits • Despite these efforts there is : • Shrinkage in number of beneficiaries • No decrease in total expenditure • Worsening of private – public inequities • Fee for service reimbursement system and high administration costs are used to guarantee profits

45. Of the estimated 4.8 million South Africans who are HIV + 500,000 need ARVs now. Over 4 million dependent on the public healthsector 100,000 miners are HIV + 525,000 belong to medical schemes and are HIV positive Less than 20,000 have access to ARVs Who has access to ARVs?

46. South Africa’s capacity to roll out ARVs • South Africa : • Is relatively a wealthy country-( e.g. its GDP is 5 times that of Malawi) • Has gross inequities - key blockage to expansion of access to treatment and care • Has inconsistent political leadership • Has a high burden of disease

47. South Africa’s capacity to roll out ARVs (cont…) • Health systems challenges to expanding treatment equitably are: • The locking up of resources in the private sector • Uneven health systems capacity • Lack of adequate human resources • Lack of functional PHC in some parts of the country • Implementing a complex labour intensive programme while the health system is undergoing massive structural transformation

48. Way forward • South Africa can afford to roll-out ARVs • In principle the government has given the go ahead • The roll out must complement other public health concerns ( e.g. MCH,TB, STI, nutrition) • Therefore a clear roadmap is needed of how to: • maintain a committed and consistent leadership • persuade the private sector to invest in the ARVs • guard against ARV roll out deepening existing inequities • use ARV roll out as a catalyst to restructure the health system and become more equitable system