In-depth: South Africa - The world’s biggest ARV Programme?
SOUTH AFRICA: Some are less equal than others
The ARV clinic at Johannesburg General, a large academic hospital, draws on a sizeable pool of medical expertise that rural clinics cannot hope to match
JOHANNESBURG, 14 September 2006 (IRIN In-Depth) - South Africa may have the largest number of people on ARV treatment in the world, but civil society organisations monitoring the rollout since its launch in April 2004 say access across South Africa's nine provinces is highly uneven.
Some provinces are better resourced; others are simply doing a better job of managing scare resources, but countrywide too few healthcare workers are battling to treat too many HIV-infected patients.
Gauteng Province, South Africa's economic heartland, is the smallest province but has the highest population - nine million, of which just over 1.4 million are HIV positive - and highest per capita gross domestic product (GDP).
HIV prevalence ranks second - 14.3 percent - but the province is providing ARVs to the highest number of people. It also has the second highest ratio of doctors to patients.
Johannesburg General, a large academic hospital in South Africa's biggest city, was one of the first sites in Gauteng to offer ARVs and is treating over 3,000 patients.
The ARV clinic, with 15 doctors and a number of appropriately trained nurses, benefits from a considerable pool of medical expertise and innovative strategies for managing the ever-increasing patient load. "We'll never be big enough," said clinic director Prof Jeff Wing. "We can't process more than 150 patients a day, so we've spread the load in terms of decentralisation."
Once patients have started treatment and their health has stabilised, they are referred to smaller clinics to make way for new patients, reducing waiting time to just one or two weeks.
Wing acknowledged the key role of non-governmental organisations (NGOs) in helping to staff the clinic: the Reproductive Health and HIV Research Unit (RHRU) of the University of Witwatersrand pays the salaries of one full-time doctor, two clerks and a part-time pharmacist; Community AIDS Response (CARE), a local NGO, supplies several counsellors. "Without that we'd be struggling," said Unit Manager Sister Ursula Malao, who added that they needed more staff nurses and counsellors and, most urgently, another pharmacist.
The Joint Civil Society Monitoring Forum, a coalition of academic, medical and private-sector organisations compiling progress reports on the rollout, noted in June that the shortage of all categories of properly trained healthcare workers threatened the future of the ARV programme but, "in particular, there is a dire shortage of pharmacists, even in provinces with resources, such as Gauteng".
Photo: Mujahid Safodien/PlusNews  |
| Despite a caseload of 3,000 patients, skilled staff management and a system of down-referral to satellite clinics has significantly reduced waiting times at Johannesburg General's ARV clinic |
Deanne Hazle, a graduate pharmacist working her community service requirement at Johannesburg General, is the only full-time pharmacist responsible for ordering, tracking and dispensing prescriptions for the ARV clinic and the maternity and paediatric wards. She is not surprised by the shortage of pharmacists in the public sector when salaries are compared to those in the private sector.
In a recent assessment of South Africa's ARV programme, Nicoli Nattrass, a researcher with the AIDS and Society Research Unit of the University of Cape Town, pointed out that less than 30 percent of the original target set in the government's Operational Plan were accessing treatment at public-sector outlets by the end of 2005, and this would be even lower without the considerable assistance of NGOs and international funding agencies.
Dr Nomonde Xundu, who heads the government's HIV/AIDS unit, responded that the Operational Plan targets relied on estimates that had considerably overestimated the need. She acknowledged the importance of external donors, but warned against the duplication of government and privately funded programmes that wasted resources.
Mpumalanga Province, in the largely rural northeast of the country, has the fourth highest HIV prevalence - 13.3 percent or just over 446,000 people - but per capita spending is 34 percent less than Gauteng's. In terms of treatment coverage, by the end of 2005 Mpumalanga ranked second last out of the nine provinces.
According to Dr Francois Venter, an HIV specialist with the University of Witwatersrand's RHRU, numbers tell only part of the story. Other provinces that are similarly or even more poorly resourced have achieved much higher treatment coverage.
North West Province, for example, has fewer doctors and nurses, and lower levels of health spending, but has achieved 24.5 percent coverage to Mpumalanga's 20.9 percent. The difference, said Venter, was "good, strong leadership".
The ARV clinic at Tintswalo Hospital, in the town of Acornhoek, Mpumalanga, is managed by the Rural AIDS Development Action Research Programme (RADAR), a collaboration between the University of the Witwatersrand's School of Public Health and the London School of Hygiene and Tropical Medicine.
Photo: Mujahid Safodien/PlusNews |
| Patients travel up to 100km to access the ARV clinic at Mapulaneng Hospital in rural Mpumalanga and often wait all day to see the clinic's one full-time doctor |
It opened in October 2005 with only two full-time doctors and seven nurses, but has enrolled 517 patients in just 10 months by adopting a similar model to Johannesburg General. RADAR trains nurses to play a central role, so that doctors need only support them. A local NGO follows up patients who do not fetch their prescriptions.
"At most hospitals, it would be the other way round," said Tintswalo Clinical Director Dr Mosa Moshabela. "We're able to see huge numbers of patients with this model."
Programme Coordinator Regina Mathumbu believes the main difference between Tintswalo and Johannesburg General is not the level of service, but the socioeconomic status of patients: Tintswalo services an extremely poor area with an unemployment rate of 70 percent and lower education levels; many people consult traditional healers until they are at an advanced stage of the disease and need more support, like nutritional supplements, treatment of opportunistic infections and adherence counselling, which puts additional demands on staff.
"For what we can manage, we have reached capacity," said Mathumbu, "but we can't turn patients away."
Mapulaneng Hospital in Bushbuckridge, the other site in the district, lies about 35km south of Tintswalo and started operating in September 2004. Despite having only one full-time doctor, the clinic now has about 900 patients on treatment.
Sparsely spread rural clinics risk being overwhelmed without the additional training and resources of RADAR. According to Xundu, the accreditation of rural sites depends on local infrastructure, such as roads, public transport and communication systems.
"Initially, the province promised they'd accredit more clinics," said Lizzy Maluleke, a nurse who has served as acting programme manager since the Mapulaneng clinic opened. "But some patients are still coming from over 100km away because their local hospital hasn't been accredited yet."
Photo: Mujahid Safodien/PlusNews |
| Nurses at the ARV clinic at Tintswalo Hospital in Mpumalanga, have been trained by the Rural AIDS Development Action Research Programme (RADAR) to treat patients, relieving pressure on doctors |
Tony Molapo, a doctor from Tintswalo who assists at the Mapulaneng clinic one day a week, said some patients do not survive the several months they have to wait to access ARVs.
Maluleke denied there was a waiting list, but admitted the facility lacked staff and space. On a typical day, patients arrive early in the morning and fill the clinic - most are in for a long wait.
UNAIDS estimates that 78 percent of those in need of ARVs in South Africa are not receiving them. Organisations like the Treatment Action Campaign (TAC), an AIDS lobby group, have attributed the slow, uneven pace of South Africa's rollout to a lack of government leadership and commitment at national level and in some provinces.
Xundu countered that the government was only midway through a five-year programme to achieve universal access, and said the Treasury was considering a request by the Health Department to increase funding for ARV treatment services.
Prof Wing suggested that the pace of the rollout has been determined by the limited skills base rather than lack of funding. "To move too fast would be to sacrifice quality for quantity - there is an optimal speed."
Moshabela agreed: "A certain degree of slowness is acceptable. We had no experience with ARVs; we had to see how patients responded. Now we can proceed more quickly."
Francois Venter is more cautious: "Those 140,000 who have come forward for treatment so far, they were the easy ones; the next 140,000 will be much more difficult."
He pointed out that South Africa may have the largest treatment programme in the world, but it also has the largest HIV caseload. "People must stop thinking we're on top of the problem," he said. "We're barely tackling the problem."