Where is the ARV rollout?

“Not very far”, says TAC

Government’s decision to roll out anti-retrovirals as part of a national plan on HIV/Aids prevention was greeted with joy when it was announced in November 2003. In July 2004, the Treatment Action Plan (TAC) held a summit to assess progress. The article below by the TAC reports on progress eight months into the Plan. Together with this article, we carry Minister Tshabalala Msimang’s response to the TAC report.

In November 2003 Cabinet approved a national plan on HIV/AIDS prevention, care and treatment. The Plan estimated that 53 000 people would be placed on anti-retroviral (ARV) treatment by the end of March 2004. In May 2004 the President shifted this target to the end of March 2005 – signalling a one year delay in reaching patient targets, and many lives that will now not be saved.

In the meantime urban and rural inequity in access to health care services in the public health sector has emerged as a major challenge to reaching these targets. To start a campaign to overcome these inequities, as well as the divide between the private and public sectors, TAC co-hosted a People’s Health Summit from July 2-4 in one of the poorest provinces in our country, Eastern Cape .

The summit brought together over 500 people representing about 66 organisations and included doctors, nurses, trade unionists, the faith based sector and people living with HIV/Aids.

At the summit, TAC’s first report on the status of the ARV rollout was released. It indicates that, after 8 months, less than 10 000 people are receiving ARV medicines through public hospitals nationally.

In provinces such as Gauteng , Western Cape , Northern Cape , Mpumalanga and the Free State , the report identifies positive developments.

While the Northern Cape, Mpumalanga and Free State each have less than 100 patients on ARV treatment, the provincial governments’ commitment and willingness to share information with civil society are steps in the right direction. With this level of commitment, their programmes should expand in the coming months.

Similarly both Gauteng and the Western Cape have also shown how politcal committment can result in hundreds of patients benefitting from ARV treatment. The Western Cape is treating about 3000 adults and children and Gauteng is treating about 2300 adults and children. Gauteng and the Western Cape have also operated transparently.

On the other hand the provincial health departments in the Eastern Cape , Limpopo and North West seem reluctant to share information. Despite signs of a tireless commitment of health care workers, very few patients are on treatment because of provincial bungling and the lack of national support.

In Limpopo , TAC has not been able to establish whether the ARV programme has even commenced. Repeated requests to the provincial department to make information available have been ignored.

In KZN, despite 20 hospitals and clinics being accredited, less than 200 patients are receiving ARV treatment.

Why the low numbers?

However, focusing on patient numbers exclusively (which tell a worrying tale) can be misleading. The report points to several factors that explain low patient numbers. These are primarily human resources, drug supplies and (the lack of) national political leadership.

Shortage of health care workers

SA is experiencing an acute shortage of skilled and trained health care workers in the public sector. At many treatment sites, new posts have not been advertsied or speedily filled. At these sites, the lack of doctors, nurses, pharmacists and counsellors is hampering the ability to offer treatment. The ARV rollout shows the need for an emergency human resources plan for the public sector “” to address the systemic issues that have led to the exodus of health care workers. A national strategy is needed to attract, train, recruit, retain and reward health care workers. As one nurse at the Summit commented, “It would be wonderful if government could committ the same level of energy and resources given to the soccer world cup bid to addressing the human resources crisis in the public health sector.”

Delay in supply of drugs

Secondly, many sites could not commence providing ARV treatment without the drugs. The national department must take the blame for the delays in drug supplies. The formal tender process may only deliver medicines in September! The Minister only approved an interim procurement mechanism in March — after TAC threatened legal action. Orders for interim supplies that were placed in April eventually enabled provinces to start or expand programmes without having to wait for the formal tender process to be completed. But there is still confusion and uncertainty around drug supplies.

Sadly, the department’s failures on the issue of drug procurement has resulted in many provinces citing drug shortages as the reason for the delay.

Lack of transparency from national department

This brings us to the third issue, political commitment and information sharing. Despite an injunction from the Constitutional Court on the importance of communicating health plans to all levels of the health service, information is not being shared by the national department.

Documents that were initially part of the Plan have never been released to the public. The Minister herself has refused to make information available on patient targets and timelines for the implementation of the Plan, despite informal and formal requests for her to do so. TAC hopes that, in coming weeks, it does not have to take the Minister to court to compel her to do so.

The secrecy and lack of transperency in the national department are not constitutionally legitimate. If this continues then it will be very difficult for civil society organisations who are concerned with saving lives, to help government to make the rollout a success.

Comparison of national targets Vs Actual number of patients receiving ARV medicines

Operational plan March 2004 target (Revised for 2005

Numbers on treatment (Adults and children)

10 000

2300 (Adults 1924) (Children 416)

North West
1 808

130 (Adults 130) (Children 0)

Northern Cape

51 (capacity July-September 600) (Adults 51) (Children) Possibly < 100

Eastern Cape

298 (Adults 287) [227 MSF, 60 Province](Children 11) [11 MSF]

Western Cape

May 2004 3059 (Adults 2256) [537 Province 1719 Donor] (Children 803) [304 Province 499 Donor] (Inc.MSF, ARK, Tshepeng Trust, donor funded) 20 July 2004 3750 patients

24 902

120 Possibly max. 250


Do not know Does not appear to have started dispensing ARVs


51 Possibly <100

Free State

Not > 50 (capacity next 2 months 90) [*SACBC 100 patients at 3 sites per year- pending]

54 004 (53 000)
<10 000 (close to 6000)
(This is an updated report of figures gathered after the release of the TAC report to the public and after the Minister of Health had responded to the TAC in ANC Today. See pages ??-??)

Fatima Hassan, Attorney, Law and Treatment Access Unit, Aids Law Project (ALP) and Treatment Action Campaign (TAC)

This article originally appeared in the Mail and Guardian on July 9 2004