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Universal Access to ARVs Requires Stronger Health Systems

January-March 2006

When the United Nations General Assembly met in June to review progress in tackling the AIDS epidemic it was reminded by civil society globally of the commitment made to ensure universal access to treatment for AIDS by 2010. This commitment has greatest resonance in sub-Saharan Africa where AIDS-related mortality is highest.

Two years ago, in June 2004 the regional EQUINET conference of civil society, state, academic and parliamentary delegates resolved that the health challenges in east and southern Africa demanded health systems that are universal, comprehensive, equitable, participatory and publicly funded. This also has urgency in a region where poverty is undermining progress in meeting the most basic Millennium Development Goals.

How do these two sets of imperatives relate to each other? Do they reinforce each other or are they competing for policy attention and resources? Does giving urgency to addressing the right to treatment for AIDS boost or weaken efforts to rebuild fragile health systems? This was the focus of debate at a meeting in Cape Town in early May 2006 that gathered international AIDS activists, people living with HIV and AIDS (PLWHA), and health activists. The meeting was organized by Gay Men's Health Crisis (GMHC) with support from the Rockefeller Foundation, and focused on "Identifying public policies for scaling up antiretroviral therapy (ART) and strengthening health systems in developing countries."

The gathering of AIDS and health systems activists itself signals a widening social debate on health and health systems, raising the social, economic and political profile of health after decades of market reforms that have undermined equity and solidarity in health and that have weakened public health systems. It builds on new and increased resources that AIDS brings to health systems, and a growth in social movements for health that can strengthen relationships between health services and communities.

Delegates recognized that access to treatment for AIDS is a right, and so too is access to essential health care. An advocacy and public policy agenda that recognizes both of these rights of necessity calls for health -- systems friendly, people (especially PLWHA) -- driven approaches to the establishment, scale-up and long-term sustainability of AIDS treatment programs. There has been past debate on whether the speed of responding to treatment rights compromises this goal of building sustainable systems. The AIDS epidemic is an emergency and the level of avoidable infection and death calls for measures to bring HIV prevention and AIDS treatment services rapidly to community levels. At the same time it is a chronic long-term issue that calls for sustainable systems and measures beyond emergency responses.

How can this be achieved? The meeting reinforced the more general call within the region for people-centered health systems. The role people play in decision making in the health sector is important, and often weakly recognized. Specific measures were called for to remedy this.

For example, it was proposed that decision-making structures and processes include the active participation of PLWHAs, their communities, health care workers and other stakeholders from civil society. However, the governance of the health sector is weak in many countries and the acceptance of the role of civil society is contentious for many governments, thus making real participation a challenge in most settings. In order to pave the way for greater involvement, this participation needs to be backed by regulatory frameworks, guidelines, clear policy messages from governments and effective mechanisms and processes to manage this engagement, including for transparently managing conflicts in the interests and priorities of different groups.

Delegates agreed that involvement in decision making and delivery raises a corresponding obligation of PLWHAs and communities to be literate on both HIV prevention and AIDS treatment and on how health systems work. Building on community-based AIDS treatment literacy, health systems literacy is needed to build community knowledge on public health, and the health systems through which prevention and treatment are delivered. Just as AIDS treatment literacy has become a vehicle for mobilizing communities around rights of access to ART, so health systems literacy should be a tool to mobilize communities around their collective rights to health and health care.

The desire to move at "AIDS speed" has led to vertical programming to meet short-term demands, and delegates at the meeting agreed that some verticality is needed in the short term in response to the epidemic. However vertical programs can only sustain the long-term, lifetime delivery of ART if they are integrated within the wider health system.

The issue of vertical programming and the integration in health systems is not unique to AIDS, and affects many other disease-based programs. The resources flowing to AIDS programs gives it specific prominence, however, as the positive and negative systems effects can be pronounced. This issue naturally arose in the dialogue: delegates at the meeting recommended that plans for AIDS treatment programs need to assess which components can be immediately integrated into general health systems and which require vertical implementation in the short- to medium-term. Delegates also raised the need for plans to be set up front for how all vertical components will be integrated into the health system in the medium- and long-term. Whether initial decisions are made to vertically implement certain components of AIDS treatment programs or to immediately integrate these components into general health systems, delegates raised the need to recognize, monitor and address problems that might arise from whatever approach is adopted.

As the meeting noted, this calls for national information systems and research that is able to identify these effects. It also calls for policy processes that are responsive to this information and flexible enough to rapidly correct problems.

EQUINET has raised that fair financing and valuing of health workers is central to rebuilding national health systems in the region. These issues were also central in the dialogue at the meeting.

The absolute shortage of trained health care workers, at crisis levels in some African countries, is now a major impediment to treatment access, and needs short-term action linked to long-term measures. Health systems and AIDS activists agreed on this. Efforts by some governments in east and southern Africa to tackle this issue were noted, and need to be supported, spread, and backed by consultation with health workers. This calls for targets for training and employing health workers, new resources to employ and pay incentives to retain health workers and removal of any international finance institution conditions or fiscal restraints that undermine the application of these measures. The meeting delegates expressed frustration at the slow pace of global discussions and measures to cancel debt, mobilize aid and lift fiscal restraints to support these health system measures, relative to the speed with which these resources are needed.

The meeting agreed that a point of synthesis of all these points is that of support for bottom-up district level planning as this brings communities and health service providers together around priority health needs, including AIDS treatment. A number of key features were raised, for example:

  • bottom-up level district planning that involves communities in a substantive way;

  • respect for district planning by governments, international agencies, non government organizations and donors;

  • ensuring free access to AIDS treatment (and primary health care services) at point of service and addressing other barriers to accessing care, such as transport to health services;

  • resource allocation systems that are responsive to district planning.

To this we may add ensuring that health workers at district and primary health care levels are adequate, valued and retained, including ensuring their own access to AIDS treatment, strengthening district-level health information and planning systems and revitalizing and resourcing the community health worker and primary health care approaches that strengthened the interface between communities and health services.

Finally, the stewardship of global public health, AIDS programs and health systems, needs independent and rigorous external monitoring.

The promises made at the 2001 UNGASS were largely promises broken and the new promises made at the 2006 UNGASS in New York need to be held open to greater scrutiny in the years ahead. Stronger mechanisms for monitoring of good practices and stewardship in health at the global, regional and country level must be established and led by institutions from developing countries.

The dialogue at the meeting in Cape Town provided a useful opportunity to identify shared goals and paths to strengthening health systems and ensuring universal access to AIDS treatment. It now provides a useful "watching brief" for health systems activists and AIDS activists to see how far the dialogue at UNGASS addresses our shared expectations.

From EQUINET June newsletter. EQUINET, the Regional Network on Equity in Health in Southern Africa, is a network of professionals, civil society members, policy makers, state officials and others within the region who have come together as an equity catalyst, to promote and realize shared values of equity and social justice in health.

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This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.