The challenge of rolling out antiretrovirals

Peter Barron, HST

South Africa is on the brink of introducing anti-retroviral (ARV) medication in the public health sector. One of the major challenges is how to improve the health service infrastructure to ensure adequate delivery of these drugs. Dr Peter Barron, who is the Director of the Initiative for Sub District Support (ISDS) of the Health Systems Trust, recently addressed a symposium at Wits University on the topic of scaling up ARVs. While he argues that we must have a national ARV programme, he cautions that we have to do it right.

SCALING UP THE USE OF ANTIRETROVIRALS IN THE PUBLIC SECTOR: WHAT ARE THE CHALLENGES? 

The case for providing ARVs is clear and compelling. The sheer magnitude of the problem and its consequences form the most serious public health problem to have ever faced South Africa. Over the next 10 -15 years more than 5 million HIV+ South Africans will die from the consequences of the infection unless treated. This is our very own holocaust on our doorstep.

However providing ARVs for anything approaching this number of people is a daunting prospect. The main focus of this presentation is that if we are to succeed in this task then it cannot be business as usual. 

The first principle of medicine is Do no harm. This principle applies equally to dealing with the health of an individual or with the health of a community or population. Our aim must not only be to introduce ARV's but to 'make it work', to attend to the factors that will support or undermine this initiative. If we do not do so, the intervention could do more harm than good.

I believe that if we introduce an ARV programme for these 5 million in the same way that we have approached the introduction of the Termination of Pregnancy programme, the Cervical Screening programme, the Voluntary Counseling and Testing programme and the prevention of Mother to Child Transmission Programme, then we will certainly do harm. There is a substantial risk that the overall performance of the whole primary care service in this country will be compromised without in any substantial way improving the health care of the 5 million.

Some of the risks facing scaling up of an ARV programme include:

AN INCREASE IN THE UNDERFUNDING OF PRIMARY CARE

Primary care services make up about 15% of the total public sector health budget. In the inter-governmental Fiscal Review of 2003 the projections of expenditure indicate that this proportion is likely to be constant over the next 3 years. None of the experts I have spoken to can give a rational explanation for the basis for this small slice of the total cake going to primary care and it is probably based on the historical hospi-centric health care model in the country. This 15% slice is insufficient for the current needs and virtually every primary facility has unmet primary care needs. Adding on an ARV programme, without addressing the current under funding, will exponentially increase the under funding on primary care. 

INCREASING INEQUITY

Currently there are widespread inequities in the resources provided for primary care. These range from around R30 per capita in the worst resourced districts to around R300 in the best resourced districts. Paradoxically there is generally an inverse relationship between health need and resources provided. In other words the districts with the greatest social, economic and health problems have the poorest infrastructure and the lowest level of resource provision. It is likely that ARVs will be introduced in a selective way based on the capacity to run programmes and those districts with the best services and the most resources will be given extra resources to run ARVs. This will not only increase inequity directly but also indirectly by attracting scarce human resources. Even if ARVs are introduced everywhere, the likelihood is that there will be good care in some areas and inadequate and sub-standard care in the poorer areas.

INCREASED RATIONING OF PRIMARY CARE

Currently the resources available to primary care are insufficient to cope with both the volume of patients and the comprehensive basket of services in the primary care package. Rationing thus occurs in a number of unplanned ways. Some services are not offered (e.g. cervical screening); others are offered on a selective basis (antenatal care on certain days of the week only); patients are turned away and told to come back on another day (quota system); patient waiting times are extraordinarily long (4+ hours); clinics are closed at certain times (e.g. Friday afternoons). Introducing ARVs will increase this rationing due to the human resource and time commitments required to run this programme.

CURATIVE CARE WILL TAKE PRECEDENCE OVER PREVENTION

With the introduction of a universal free care service, clinics have experienced increased numbers of patients requiring curative care. This curative care often takes place at the expense of programmes focused on preventive care such as immunization and health promotion. The introduction of a high profile ARV programme is likely to enhance this trend, as it is very dependent on highly technical clinical monitoring and management. While it has been argued that ART will promote HIV prevention this thesis is unproven. Even if true, improvement will be dependent on a good quality service able to not only provide ART but also VCT and post-test support and counseling to patients who are HIV positive.

DECREASED QUALITY OF CARE

Currently most of the key targets set by the national DOH around primary care programmes such as immunization coverage, TB cure rate and VCT provision are not being met. The competition for prioritisation set by an ARV programme will distract attention from other important public health programmes, which are more cost-effective. There is also the danger that individuals who receive ARVs with sub-optimal care will be at risk for toxicity as well as increasing drug resistance.

INADEQUATE PROVISION OF HUMAN RESOURCES WILL WORSEN

This is probably the single greatest risk facing the introduction of an ARV programme. Currently there is an absolute shortage of skilled personnel in the public health sector and the shortage is worst in the areas that need it the most; rural and disadvantaged urban areas. These are also the areas with the highest HIV + prevalence rates. The shortage is increased by high profile academic hospital projects such as Inkosi Albert Luthuli and Nelson Mandela that suck staff from less prestigious primary care to fill their staff establishments.

To expect a huge ARV programme to be run by already overworked staff is wishful thinking and additional doctors, nurses and other health care workers will have to be added to the system. Where will they come from? There is no strategic plan on the table to increase production and even if the decision to increase production was taken today it would take 4-7 years before they started coming out of training institutions. Also recent research by the HSRC suggests that over the next 10 years there will be a shortage of 20000 nurses.

All personnel involved in ARV programmes will require significant in-service training to cope with the requirements. Previous experience around training for STIs and TB has highlighted the complexities of providing this in-service training that is not a once-off event and requires constant follow-up.

Experiences in many ARV pilots suggest that dedicated staff will be required to run this programme.          

INCREASED NEED FOR MONITORING AND EVALUATION

A national ARV programme will require monitoring and evaluation at a number of levels, starting at the facility level. Currently supervisors of primary care and managers do not have the skills and capacity to do this. Without adequate information systems and use of information from these systems there is every likelihood that an ARV programme will not achieve what it is meant to do. This has been seen in relation to the TB control programme and the PMTCT programme where goals and objectives have not been met. This is partially due to the inadequate attention given to the monitoring and evaluation of these programmes.

DECENTRALISATION, DISTRICT HEALTH SYSTEM AND LOCAL GOVERNMENT.

The vision for primary health care in South Africa is based on a decentralized district health system. Because of the unique features of South Africa such as its diversity and heterogeneity, as well as its burden of disease profile, the DHS is considered by many public health experts to be essential to improving health. The health system is in a crucial and complex stage in the establishment of a DHS with a health bill awaiting the legislative process. It is likely that it will take the next 3 years for the governance and managerial structures of the DHS to be sorted out. As these issues have more relevance to the individual lives of managers, because of career development and uncertainty of job security, it is likely that their attention will be focused on structural issues rather than ARV quality of care issues.

INADEQUATE INFRASTRUCTURE AND SUPPORT SYSTEMS

There are many facilities without the necessary infrastructure or back-up systems to provide good quality primary care, let alone more complex ARV therapy. This basic infrastructure includes water, sanitation, electricity, communication and consultation rooms. The back up systems include transport, drugs supply and laboratory support. Without these infrastructural and systemic improvements it will be extremely difficult to provide an adequate ARV programme. Drug shortages, in particular, could have serious consequences for effectiveness of therapy.

Having highlighted the risks, what then should be done? To rush in and introduce ARVs on a large scale could be foolhardy and more negligent than doing nothing. To introduce a programme that uses scarce resources and does not achieve its aims does more harm than good. In economic terms this is known as the 'opportunity cost', whereby spending resources on one programme reduces the opportunity of spending these resources on another.

What is required is ACTION with a capital A. A comprehensive plan from the highest levels of decision making to radically restructure primary care services through the provision of much more human and financial resources needs to be made. This plan needs to incorporate relevant innovations from countries such as Brazil and Botswana where there has been harnessing of resources from all sectors of society.

An ARV treatment programme that is NOT located within a comprehensive plan to strengthen the health care system, its human infra-structure and its public health management and leadership will increase inequity and will lead to unacceptable opportunity costs which may include an overall deterioration in health care. Implementing an ARV programme with inadequate capacity will also lead to poor treatment adherence and a black-market in ARV drugs in southern Africa, which in turn will lead to the development of ARV resistance.

This is not an argument against the provision of ARVs. Nor is it a denial of the fact that without an ARV programme we will see a deterioration of the South African public health sector and economy. We have to have a national ARV programme, but we have to do it the right way and with the right level of commitment and capacity. (Source: this article appeared on Health-e, 08-08-2003, http://www.health-e.org.za/view.php3?id=20030811)