Over the past decade, international health policy debates have been dominated by efficiency considerations. There has been a recent resurgence of interest in health equity, including consideration of the notions of vertical equity and procedural justice. This paper explores the possible application of these notions within the context of South Africa, a country in which inequities in income and social service distribution between ‘racial’ groups were systematically promoted and entrenched during four decades of minority rule, guided by apartheid and related policies. The South African experience since 1994 provides useful insights into factors which may facilitate or constrain health equity progress. In particular, the constitutional entitlement to health and civil society action to maintain health equity’s place on the social policy agenda are seen as important facilitating factors. This paper concludes that health equity goals are critically dependent on the central involvement of the disadvantaged in decision-making about who should receive priority, what services should be delivered and how equity-promoting initiatives should be implemented.
Equity in Health
Whilst the World Health Organisation-embraced strategy for controlling tuberculosis (TB) has been successful in treating and curing TB, its current format restricts the extension of this success to the poor: although TB treatment is free, diagnosis is not, and so the first gateway to treatment is often shut to the poorest. The restrictions, caused primarily by lack of funds, are outlined in a specially commissioned id21 report by Dr Bertie Squire of the Liverpool School of Tropical Medicine, which points to the tasks ahead if the WHO target to halve TB deaths by 2010 is to be achieved.
At the closing of the first International Treatment Preparedness Summit (ITPS) in Cape Town, South Africa, last month, participants detailed a number of priority actions to address the inequalities that prevent millions of people living with HIV/AIDS from securing access to treatment. At the end of the four-day meeting attended by over 120 representatives of treatment advocacy groups from 67 countries across the world, delegates agreed that current treatment efforts were insufficient. One of the things they called for was for national governments to develop treatment plans detailing how they intend to implement the World Health Organisation's goal of ensuring ARV treatment for at least 3 million people in the developing world by 2005.
An expert group has reaffirmed that unsafe sexual practices are responsible for the vast majority of HIV infections in sub-Saharan Africa, and that safer sex promotion must remain the primary feature of prevention programmes in the region. Following a review of evidence, which included recent articles suggesting that a majority of HIV infections in sub-Saharan Africa are due to unsafe medical practices, particularly injections, the experts concluded that such suggestions are not supported by the vast majority of evidence and that unsafe sexual practices continue to be responsible for the overwhelming majority of infections. While a combination of prevention measures are required to tackle all modes of HIV transmission, safer sex promotion must remain the primary feature of prevention programmes in the region.
The enthusiasm surrounding last month's proposal by US President George W Bush to triple government spending on HIV/AIDS in Africa has been tempered with calls from activists for more practical details. In his State of the Union address, Bush urged Congress to approve US $15 billion in funds to battle HIV/AIDS in the hardest-hit countries in Africa and the Caribbean over the next five years. But activists were cautiously optimistic. "The exact details of the president's plan for global AIDS are still unclear. We could be shipping AIDS medications to hospitals and clinics next month, not promising to treat two million people in five years," treatment lobby group, Act-Up Philadelphia said in a statement.
While the South African Treasury and Department of Health number-crunch to determine whether government can afford anti-retroviral (ARV) treatment in public health, a number of small ARV programmes are already up and running. Several others are in the pipeline, the most ambitious being the SA Medical Association pledge to raise R80-million to set up two ARV pilot projects in each province to treat 9 000 people.
"Let us not be mistaken that the resounding announcement by G.W. Bush, of a 10 billion dollars commitment to the fight against AIDS, serves essentially one objective: to renege on commitments made in November 2001, at the WTO conference in Doha, to allow access to generic drugs," says a statement from lobby group Act Up.
Women's rights advocates are condemning President George W. Bush for using his promised AIDS relief package to expand the so-called global gag rule. Calling the move the latest battle in the administration's war against women, many groups are mounting a campaign to draw attention to what they say are the Bush administration's plans to further restrict abortion rights.
Confusion is the only certain ingredient in government's approach to HIV/AIDS. President Mbeki, his lapel no longer sporting an AIDS ribbon, said government would continue to implement its "comprehensive HIV/AIDS strategy" when he opened Parliament last week. But his two dull sentences on the disease - as over 10 000 people massed outside to demand treatment for people with HIV - did little to convey the impression of a caring government committed to helping its 4,5 million citizens living with the disease.
The latest row about the use of state hospital beds by private medical schemes has raised again a contradiction between expressed constitutional aims on the one hand and government policy and practice on the other. The rights to "healthcare, food, water and social security" are contained in clause 27 of the Bill of Rights. This clause obliges the state to "take reasonable legislative and other measures within its available resources to achieve the progressive realisation of these rights". In essence, this means every effort should be made to ensure that all South Africans have equal access to quality healthcare.