Politics

Sixty-one Masvingo nurses were left stranded in Mozambique after they were swindled of over $10 million by a trickster who lied to them that he would facilitate employment for them in Maputo. It was not clear where exactly the nurses were employed in Masvingo, but one of the nurses said she had taken off days to survey what seemed to be a greener pasture. The nurse said she and others had paid $200 000 each two weeks ago after she learnt from other nurses that there was an employment agency looking for nurses to work in Maputo. She said the agent, whom they only knew as Makaure, had said he had been tasked by a certain hospital and the Health Ministry of Mozambique to look for nurses who would be paid in United States dollars. She said Makaure also said he wanted to sort out other administration issues in Rutenga and referred them to a certain Mr Vasili who he said owned lodges where they would temporarily stay. She said when they arrived at Mr Vasili's residence they were shocked by the state of the house which was dilapidated and did not appear like a lodge. The nurse said they all proceeded to the country's health ministry where they were told they never requested for any nurses from Zimbabwe. The hospital Makaure had mentioned was also non existent. Nurses went on strike two months ago demanding for a salary increase. The Government awarded them and other civil servants a 250 percent pay rise.(Source: Herald Reporter, Tuesday, 10 February 2004)

Introduction: This study aims to establish the costs and effectiveness of antiretroviral therapy (ART) for HIV positive adults in a resource-constrained public-sector setting. The research compares ART to the current status quo for HIV-positive adults who are dependent on the public sector for care in South Africa i.e the treatment of opportunistic and HIV- elated infections and events (e.g. wasting) in the absence of ART. This research is clearly important in the developing country context, where the HIV epidemic is expected to have a dramatic impact on life expectancy and to lead to early mortality for a large proportion of the population (Dorrington, Bourne et al. 2001). This study presents the first cost-effectiveness results derived from a public sector clinic-based treatment programme. Cost, effectiveness and quality of life data have been collected from a single cohort receiving care in three HIV-dedicated clinics in Khayelitsha, a township on the outskirts of Cape Town. This setting is similar to what will be encountered in the public sector ART rollout.

The draft medicine price regulations constitute the most fundamental shake-up of the private healthcare sector in decades - and threaten the super-profits traditionally earned by most corporates operating in this sector. Not only should they occasion an immediate reduction in the price of medicine, if introduced as envisaged on May 2, they should also curb annual increases in medicine prices and thereby help rein in medical inflation, which has raged at double digits throughout most of the 1990s. A pricing committee of 13 technical experts chaired by University of Cape Town health economics professor Di McIntyre developed the regulations. They are entirely consistent with what exists in most European Union countries and in Australia, fundamentally free-market economics. Discovery Health estimates that the regulations could cut a staggering R4bn (roughly 40%) off the medical schemes industry's annual drugs bill. If passed on to members, that would translate into an 8,5% reduction in annual contributions. Though the means to achieve this involve the state fixing the price of medicine and interfering in the free market to regulate profit-taking in the distribution chain, the advantages clearly outweigh the disadvantages. The pros are cheaper medicine and a transparent pricing system where the factory-exit price of a drug is known and the mark-ups added by middlemen are limited to a ceiling set by government. This will prevent undue profit-taking in the distribution chain; and because it will no longer be more profitable to sell higher-priced drugs, the market should shift as a whole towards cheaper generic drugs. The downside is that any discounting of the factory-exit price will not be allowed. This will eliminate volume-based discounting, a function of free markets the world over. Among the hardest hit will be New Clicks, Dis-Chem and other big pharmacy and hospital groups, which will no longer be able to use their size and buying capacity to negotiate better wholesale prices than their smaller competitors. However, the reality is that in the past bulk discounts have seldom been passed on to the consumer, allowing some players to make unreasonable profits on the sale of medicine, reportedly of up to 350%. The problem is that though savings on drugs of 40% are achievable, the various players in the industry who stand to lose out under the new system - private hospitals, pharmacists, dispensing doctors, wholesalers and drug manufacturers - are unlikely to give up a collective R4bn without a fight. It's the job of civil society, large medical aid administrators, the health department and the pricing committee to ensure that players don't buck the new system. For this to be credible and transparent, the future watchdog role of the pricing committee needs to be clarified. In terms of the regulations, its future role is limited to setting the annual amount by which drug manufacturers will be allowed to increase their factory-exit prices - and issuing public warnings if it feels a new drug is unfairly priced. This role should be adequate, provided the industry players work together to implement the new system in the interests of making private healthcare more affordable and sustainable. This goal is in every player's best interest. Whether the corporates can rise to the challenge remains to be seen. (Source: The Financial Mail, 23 January 2004)

The head of the trauma unit at Cape Town's Red Cross Children's Hospital and director of the Child Accident Prevention Foundation Dr Sebastian van As, director of the Medical Research Council's alcohol and drug abuse research group Dr Charles Parry, and director for social services in the department of finance Dr Mark Blecher have called on government to set up an alcohol injury fund, bankrolled by taxes on booze, for victims of alcohol-related injury. The fund could also be used for equipment for beleaguered trauma units, and to finance substance abuse treatment centres(South African Medical Journal - November 2003, Vol. 93 No. 11) However if (South African) government programmes to address this serious public health programme continue to lag behind, such calls for dedicated financing will become increasingly loud. The time has come for stronger government action on alcohol. They say that in stark contrast to the image liquor industry advertising portrays, South Africa suffers particularly heavily from negative consequences of alcohol use. For example in 1999, 67 percent of patients at trauma units in a Port Elizabeth hospital had breath alcohol concentrations of 0.05g per 100ml or more. Also a national study published in 2002 showed that 52 percent of people dying in transport-related accidents had elevated blood alcohol levels. They say levels of excise taxes on alcohol are approaching international levels.Our main concern, however, is that the level of social costs in South Africa, given extremely high levels of alcohol-related violent trauma and accidents, far exceeds that of most other countries.This suggests that our excise taxes need to be higher to achieve the correct balance between benefits and costs. They say increased taxes should be specifically allocated for prevention and treatment of problems caused by the misuse of alcohol. These could include counter-alcohol advertisements, alternatives liquor-industry funded sports sponsorships, and community-based prevention programmes. The fund could also compensate victims where the perpetrator had been under the influence of alcohol, by paying for health costs and other damages. This would also be in accordance with the point made in the draft national liquor policy that we should move towards a 'polluter pays' policy, Source: Sapa 10 November 2003).

Last month WHO declared the HIV/AIDS epidemic a global health emergency. Should governments go one step further and treat it as a disaster? Over the past 20 years, the public health community has learnt a tremendous amount about the HIV/AIDS epidemic. Yet, despite widespread discussion about the epidemic and some measurable progress, the overall response has been insufficient: globally 42 million people are already infected with HIV, prevalence continues to rise, and less than 5% of those affected have access to lifesaving medicines.1 In the face of this growing crisis, the World Health Organization has made scaling up treatment a key priority of the new administration.2 We argue that not only is the HIV/AIDS epidemic an emergency, but its devastating effects on societies may qualify it as one of the most serious disasters to have affected humankind. As such, this crisis warrants a full disaster management response. Why the HIV/AIDS epidemic should be formally treated as a disaster According to the United Nations, a disaster is any serious disruption of the functioning of a society, causing widespread human, material or environmental losses which exceed the ability of a society to cope using only its own resources.3 In just over two decades, the epidemic has already killed over 23 million people.4 Although other diseases may have cumulatively resulted in more deaths, HIV and AIDS are unique because they attack young adults in their peak productive years. These are the people who are essential to a society's current stability, potential economic growth, and functioning in the next generation.5 Unless more effort is put into saving lives and remedying the loss of human resource capacities in vulnerable countries with high prevalence or increasing incidence rates, the devastating effects may exceed these societies' ability to cope and could lead to their eventual disintegration. This potential can already be seen in some sub-Saharan countries.6 Using components of a formal disaster management framework There are three main components in a formal disaster response that could be beneficial in tackling the HIV/AIDS epidemic: firstly, officially recognising a disaster; secondly, enacting appropriate policy actions; and, thirdly, organising an appropriate management system to tackle the disaster. Official recognition as a disaster When faced with serious disasters, countries often declare a formal state of emergency. International law dictates that the nation itself has the primary responsibility for calling a state of emergency. Declaring a state of emergency in a country plagued by HIV and AIDS could help catalyse a response in several ways. The declaration signals to the country and international community that the nation is tackling a critical situation. It could also serve as the basis for an appeal to the international community for humanitarian aid. Internally, the declaration commits the government to take appropriate actions to resolve the crisis and has the potential to increase accountability. By declaring a state of emergency, the state also acquires the ability to over-ride legal, operational, and bureaucratic obstacles that often impede effective multisectoral responses. Such over-rides may help to overcome problems associated with the lack of trained health professionals in some countries and allow, for example, the military to help in the construction of clinics or guarding antiretroviral drugs. In addition, a formal declaration of a state of emergency allows countries to use provisions for public health emergencies that have been built into the Trade-Related Aspects of Intellectual Property Rights (TRIPS). Nations that declare a state of emergency would have indisputable grounds for applying for compulsory licences to manufacture and import, under certain circumstances, generic versions of anti-viral drugs and antibiotics required to treat patients with HIV and AIDS.7 Enacting risk based policy decisions Under a formal disaster management response, policy decisions are based on estimates of risk and vulnerability and on a utilitarian approach to saving lives. Vulnerability to the HIV/AIDS disaster could be approximated by incidence of HIV infection and female mortality (aged 15-45 years) reflecting susceptibility and excess effects (see bmj.com for full discussion). Often, policy guidelines are created by categorising the situation into disaster phases based on the risk of progression to a full blown disaster. Each phase is linked to concrete activities and objectives that could act as guidelines for setting priorities and allocating resources (table). Such a simplified decision making system could reduce the paralysis by analysis currently seen among policy makers struggling with formulating an appropriate response to the HIV/AIDS epidemic at the national level. This tool could also place positive political pressure on countries lagging in their response. In addition, it could provide donors with guidance for channelling aid to countries in the greatest need of assistance. Managing the HIV/AIDS epidemic as a disaster Disaster response teams typically adopt a streamlined and centralised management system known as an incident command system.8 Several components of this type of management system could have a beneficial effect on the HIV/AIDS epidemic. A key characteristic of the incident command system is that it minimally disturbs existing infrastructure but can draw on sectors and integrate all major stakeholders, as needed, to fulfill its task. The system provides clarity of purpose, ownership, defined responsibility and authority, and efficient use of resources. Core members of the incident command system are trained to respect a culture of commitment to a common goal; maintain respect for technical and managerial competence; be intolerant of petty infighting or incompetence; and show great flexibility. Presently, large numbers of qualified people have begun to work on HIV and AIDS and many countries are directing appreciable resources to combat the epidemic. An incident command system could help make best use of their talents and direct them to attain a common goal. In addition, this structure would allow for a more integrated response from other non-health sectors, including construction, military, education, and finance. Summary points HIV and AIDS threaten social survival in vulnerable countries Treating the HIV/AIDS epidemic as a disaster could speed up the response Declaring a state of emergency would overcome barriers to multisector cooperation and facilitate access to cheaper drugs Resources could be better coordinated, eliminating duplication and ensuring everyone is working to the same goal Governments should be encouraged and rewarded for adopting a disaster response to HIV and AIDS

Despite much optimism, the training and resource shortcomings of rural hospitals and clinics may stymie antiretroviral rollout, writes Kerry Cullinan. People living with HIV/AIDS around the country are anxiously waiting to see whether Cabinet will approve an operational plan to introduce antiretroviral drugs into the public health sector. The immediate priority is to prepare health facilities and provide training for health workers - the vast majority of whom have had absolutely no training in antiretroviral treatment. While the detail of the operational plan has been a tightly guarded secret, insiders close to the task team say it proposes that each health district in the country should have a service point to deliver antiretroviral drugs. This means that initially there will be 56 service points countrywide. These will be centred at hospitals, but may also include the clinics that the selected hospital serves. Metropolitan areas, which each count as a health district, are likely to be permitted to have more than one service point. Initially, the task team had proposed that provinces should identify their own sites. However, the Department of Health apparently rejected this idea in favour of the district-based model, fearing a more ad hoc approach would be inequitable. According to the current proposal, doctors will be in charge of the plan. They will assess patients, prescribe the antiretroviral drugs and check on patients every three months. However, patients will be expected to come to their service centre every month, where nurses will check their progress and drug adherence. Before patients get their drugs, they will be expected to attend three treatment training sessions. These will explain how the drugs work and the common side effects and help patients to work out a treatment plan that will ensure they take the drugs every day at the same time. Under-serviced rural hospitals pose a particularly tough challenge, as Dr Paul Pronyk, director of Wits University's Rural AIDS and Development Action Research Programme, based in rural Limpopo, knows only too well. He sees the chronic lack of health resources every day, and says, a systematic and cautious approach is necessary for the roll-out of antiretrovirals at Limpopo hospitals. The antiretroviral roll-out is not simply about administering drugs, says Pronyk. Hospital laboratories don't work. Health workers need to be trained. Proper patient registers need to be kept. Patients need counselling. The drug supply must be safe and secure, because there will be a public health disaster if they get into the black market. Nevertheless, Pronyk believes that universal access to antiretrovirals is possible - but only if there is full buy-in by government, which results in large-scale capacity building. He points out that there are massive funds available for the antiretroviral rollout, both from the South African government and international donors. One thing that has lightened the government's load in recent weeks has been the dramatic lowering of antiretroviral prices. Last week the Clinton Foundation announced that it had brokered a deal with generic manufacturers, including the Johannesburg-based company Aspen Pharmacare, that would reduce the price of triple therapy to about R81 per patient a month for public-sector buyers. This is less than half the previous best price available. The TAC has described this huge reduction as excellent progress, although it is concerned that some of the generic manufacturers have not been licensed by patent holders to produce generic versions of their drugs. This means that they could infringe patents if they do produce the drugs. In addition, the Medicines Control Council has not yet licensed some of the generic antiretrovirals that have been given the go-ahead by patent holders. It may take a little while to sort out these complications, but the massive price reduction makes antiretroviral intervention far more affordable as a life-long treatment option. But prevention is still the best medicine, and the Department of Health is concerned that the antiretroviral treatment rollout must go hand-in-hand with prevention. While there are no miracle cures, British medical journal the Lancet published a study a few weeks ago demonstrating that antiretroviral treatment could buy patients at least 10 more years of life. The thought of spending 10 more productive years with the people they love is a powerful message of hope for the 4.5-million South Africans living with HIV/AIDS. - Health-e News Service. (Source: Kerry Cullinan: The Sunday Times, 2 November 2003) Link //\// Determinants of survival following HIV-1 seroconversion after the introduction of HAART http://www.thelancet.com/journal/vol362/iss9392/full/llan.362.9392.origi...

Scientists have come up with a faster and cheaper HIV/AIDS monitoring technique which could make treatment more affordable in developing countries. A study conducted by researchers in Zambia's University Teaching Hospital and the University College in London, has found that spots of dried blood, filter paper and inexpensive commercially available chemicals, could be developed into a field-friendly alternative to the sophisticated technology required to carry out CD4 count testing. A CD4 count measures the strength of the immune system. Although ARVs are increasingly becoming available in African countries at reduced prices, the high cost of monitoring equipment remains one of the biggest obstacles. Researchers at the University Teaching Hospital took blood spots from 42 HIV-positive patients and put them on filter paper, which was allowed to dry. The test samples were then sent to a central clinic without refrigeration. The blood spots were analysed using a simple test involving antibodies that latched onto CD4 cells. The bound antibodies caused a colour change in a solution made from the dried blood: a deeper colour equaled a higher cell count. The report found that filter papers offered an attractive alternative to use of fresh whole blood. Once the samples have dried, the filter papers can be stored at room temperatures for long periods before being batched and sent to a central laboratory. The results compared very well to the [flow] cytometer - there were some very slight variations but these won't change the meaning of the result, Mwaba noted. Mwaba called for African scientists to take such work forward and come up with innovative ways to provide such technology. ( Source: IRIN, PLUSNEWS 4 November, 2003) Link //\// Use of dried whole blood spots to measure CD4+ lymphocyte counts in HIV-1-infected patients http://www.thelancet.com/journal/vol362/iss9394/full/llan.362.9394.origi...

NAIROBI, Kenya - Aid workers, pharmaceutical companies and donors have made drugs available to a small number of African AIDS patients, but as new programs take root, the lack of trained doctors and facilities are becoming the biggest barriers to care. A few years ago, activists protested the high price of antiretroviral drugs and demanded deep discounts from pharmaceutical companies, or access to generic equivalents in Africa. Both patented and generic drugs have become available in some countries at affordable prices, and aid agencies and pharmaceutical companies have set up trial programs to find the best way to treat the 30 million Africans with HIV. The availability of drugs has dramatically increased the demand for treatment in countries that have experimental programs, but the main problem now is a shortage of clinics, trained doctors and pharmacists, doctors at the conference said. In Tanzania, donors found the government was willing to begin treating AIDS patients, but the public health system in the impoverished country was a shambles. Hospitals served as warehouses for the sick and dying with few drugs or laboratory tests available. Most Tanzanian doctors, like the majority in Africa, know little about prescribing AIDS drugs, experts said. Medecins Sans Frontieres has taken a different approach in Kenya. Doctors have imported generic drugs from Brazil and have concentrated on streamlining anti-retroviral treatment to develop a methodology to treat as many patients as quickly as possible. The largest and oldest national anti-retroviral program in Africa is in Gaborone, Botswana, and is a partnership between the national government and Merck and Co. Inc., based in Whitehouse Station, N.J. As the co-director for infectious diseases at the national hospital in Gaborone, Dr. Tendane Gaolathe has more than 6,000 patients on anti-retroviral drugs. But only 21,000 of the 120,000 people who need the drugs in Botswana have prescriptions, she said. Both Gaolathe and Oman said there is no shortage of drugs so far. They also said that after the clinics opened - and people learned that drugs were available - the number of patients asking for treatment skyrocketed. Access is a pie, if you will, and one of the slices is pricing and drugs and the challenges of getting them there, Richardson said. But there are others: infrastructure, training... the success isn't that you get X number of pills there, but what happens once they are there. -- On the Net: Tanzania Care: http://www.tanzaniacare.org African Comprehensive HIV/AIDS Partnerships: http://www.achap.org Medecins Sans Frontieres: http://www.msf.org World Bank: http://worldbank.org/aids Global Fund: http://www.globalfundatm.org/ UNAIDS: http://www.unaids.org AFRONETS: http://www.afronets.org

Furious doctors are planning to march on parliament, and may even go on strike, over what they say is a crisis in South African medicine. They have: hit out at chronic under-funding by the government and the halving of budgets; claimed that the department of health is spending more on bureaucracy than patients; complained of appalling pay and working conditions; and, threatened to emigrate in their hundreds. The doctors' dissatisfaction has grown to such a degree that the SA Medical Association has become an affiliate of Cosatu. A weekend conference in Johannesburg to discuss strategies for doctors' survival was peppered with war talk. Dr Kgosi Letlape, head of the Medical Association, said although doctors were essential personnel and may not strike, this drastic action was still a possibility. But first we need to raise public awareness about our plight. Letlape said it was time for doctors to join forces and stand up and fight. We have been at the bottom of the food chain for too long. We are not going back. We will negotiate with the government. But if deafness ensues, we will resort to sign language, he warned. The doctors' anger was fuelled by the last-minute pull-out from the conference by the minister of public service and administration, Geraldine Fraser-Moleketi. She said she wasn't able to address the pay and working conditions of public sector doctors. Letlape said the association had tried desperately to create dialogue with the government but doors had been slammed in its face. If there is anyone out there with other remedies, herbal or otherwise, please try to help us, he said. Dr Mark Sonderup, chairman of the SA Registrars' Association, who works at Groote Schuur Hospital, said a sore point was the chasm between administrators and clinicians, as well as expensive top-heavy administrations. Groote Schuur, for example, had appointed a new chief executive officer and seven or eight medical superintendents since 1996, along with healthcare and nursing managers. There is a huge bureaucracy running a hospital that has lost half its beds in the past seven years. They seem to be spending less money on care and more money on administration systems, he said. The joint budget for Groote Schuur and Red Cross Children's hospitals was R1,1 billion in 1996. That had been halved to R525 million this year, but hospitals in the area were seeing one million more patients a year. Money is falling down the pyramid, allegedly to primary healthcare, but it's definitely not reaching those people who really need it. Is it going into administration and bloating the bureaucracy? Sonderup asked. Dr Timothy Berlyn, of the Junior Doctors' Association, said: As many as 60% to 70% of my friends in the medical sector plan to emigrate. Another 20% will stay to specialise and then they will leave. The majority of the rest of them will migrate internally - to the private sector. He said the migration was having an avalanche effect. As doctors left, those left behind picked up a bigger burden and became stressed. Then they left. It's a never-ending cycle. Professor Denise White, chair of the Medical Association's committee on public sector doctors, said she wasn't working in the public health sector for the money. We just want a fair deal to serve the people of this nation. White said the association had made many submissions to the department, but was stonewalled - something it would no longer tolerate. White said problems with working conditions included: understaffing, lack of essential medicine and equipment; inadequate support and supervision of junior doctors in rural areas; declining capacity for supervision and training of registrars; poor living conditions for community service doctors; lack of security at work; burgeoning patient loads; and the burden of diseases like HIV/AIDS and TB. (Di Caelers: The Cape Argus, 22 September 2003)

This report is the result of two inextricably linked processes at the Centre for Health Policy. In 1992, the Centre produced a proposal for financing a National Health Insurance Fund. In the context of this work, it became clear that among other things, there was an insufficient understanding of the cost of primary health care (PHC). The Centre began to develop a research protocol that aimed at studying the cost of PHC in different delivery models such as public clinics, private general practitioners (GPs) and in health maintenance organisations (HMOs), and feasibility of an essential package of PHC services that could be available to all. When this project began, few costing studies of primary health care facilities had been undertaken in South Africa, the notable exceptions being a comprehensive costing of Diepkloof Community Health Clinic in Soweto (1991) and a costing analysis of Alexandra Health Centre (1992). The cost of providing primary care (PC) either through public or private sector facilities had not been well researched, and yet the kinds of decisions that were required about the delivery of health care depended to a great extent on what care was affordable.