http://www.equinetafrica.org/policy.html Zimbabwe's Challenge: Equity in Health Sector Responses to HIV and AIDS in Zimbabwe By Sunanda Ray and Tendayi Kureya, SAfAIDS Introduction HIV has severely affected the overall health of people in the southern Africa region by impacting directly on individuals and their families, and by placing additional burdens on economies, social structures and health services. Poorer people are disproportionately affected because they have fewer resources to deal with the impact of HIV on their daily lives. Public policies are usually inadequate at addressing inequalities that exist within access to healthcare in general, and HIV-related care in particular. Now that international advocacy has led to reductions in process of antiretroviral drugs (ARVs), there is concern that poorer people will not have access to these drugs, and that the patterns of disadvantage that lead them to have lower life expectancy and more ill-health compared to richer people will be perpetuated in the arena of HIV and AIDS care. To examine these issues, a study was commissioned by the Regional Network for Equity in Health in Southern Africa (EQUINET) and Oxfam GB to highlight equity issues in HIV and AIDS, health sector responses and treatment access in four countries in southern Africa. The paper presents the findings from Zimbabwe. The other countries included in the study are Malawi, South Africa and Tanzania. The paper discusses the global and national social, economic, political, legal and institutional factors influencing decision-making and allocation of resources for treatment responses to HIV. A team from SAfAIDS headed by Dr. Sunanda Ray and Tendayi Kureya undertook the review between March and May 2003. Purpose and Objectives The main objective of the study was to develop areview report that can be used to inform the policy debates and advocacy that have grown around the health sector responses to HIV and AIDS in Zimbabwe, particularly with respect to care and treatment access within the country. The work sought to inform policy and advocacy using available evidence on the three issues below: · Equity issues in current health sector responses to HIV and AIDS in Zimbabwe · Public policy choices now being faced and made in relation to the health sector response to HIV epidemic in Zimbabwe, analysing the equity implications of these policy options and the choices currently proposed or being made · Recommendations for including equity in public policy within the health sector, indicating how this can be taken forward. Summary of Findings The review of treatment in Zimbabwe showed that there is more activity related to provision of treatment for AIDS than a year ago. Most of this has been under-minded by the rapid decline in the quality of care provided within the public health services, financial instability in the private sector and poor communication between the different interest groups in the field of HIV and AIDS. Doctors in the private sector are providing treatment for AIDS, but often in an unregulated, chaotic manner. ARVs are available in some pharmacies, but he costs fluctuate with precarious foreign exchange rates, leading to inconsistent use. Several organisations are investigating the feasibility of establishing treatment programmes for the public sector. These initiatives largely depend on a functional health service and are currently constrained by the financial crisis in the country and the collapse of the entire health service. With poor central management of health service delivery and dwindling health budgets, many primary healthcare centres are unable to provide even basic medication for palliative care such as pain relief or anti-diarrhoeal remedies. We heard considerable concern whether health service infrastructure could initiate and sustain provision of ARVs in these conditions or whether they would be provided mainly through small projects, and therefore only available to small selected groups of people. In May 2003,the Ministry of Health and Child Welfare (MoHCW) and the National Drugs and Therapeutics Policy Advisory Committee (NDTPAC) published guidelines for antiretroviral therapy (ART) in Zimbabwe. Most doctors in private and public practice are not yet familiar with these guidelines. Many are keen to prescribe ARVs even through they may not have been trained for this. At the time of writing the paper there was no accreditation requirements for prescribing ARVs. The HIV clinicians of Zimbabwe, an affiliate member of the Southern African Clinician Society is setting up a training programme for doctors for both their private and public sector practice. At present, provision of ARVs is more or less non-existent in the public sector, and when they can afford it. The threat of resistance to current first line ARVs is a very serious one, and will reduce our access to effective affordable therapies if not managed appropriately. Although the impact of AIDS is much worse than TB, we are not yet treating it as a public health hazard with the principles learnt about communicable disease control from past experience. The number of people needing treatment is calculated to be between 200 000 and 600 000. The MoHCW estimates that the 1.8 million HIV positive people in Zimbabwe, while the number of people on ART is as little as 900. We estimated the number of people on regular ART to be probably much higher: between 300-5000 country-wide, based on the data we collected from pharmacies, corporations, NGOs and the Mission hospitals. The burden of disease has increased up to seven-fold in Zimbabwe as a result of HIV-related illness, increasing demand for health services, displacing other health needs and doubling hospital bed occupancy rates. Households have been forced to take on the burden of caring for their family members dying of AIDS with fewer resources to do so in adequate and dignified ways. We therefore concluded that planning for equity was not seriously considered in treatment for HIV and AIDS. Zimbabwe developed a national policy and strategic framework in 1999, and th National AIDS Council (NAC) was set up in 2000 to coordinate responses to the HIV epidemic; mobilise resources; and monitor progress and impact of responses. A 3% levy on all taxpayers was established to feed into a National AIDS Trust Fund (NATF) to support NAC's activities. Disbursement of funds from the NATF has been problematic from the outset, and the fund is insufficient to purchase ARVs for all the people who need them. In May 2002, the country declared AIDS a national emergency to facilitate the importation of low-cost generic medicines under the provisions of the Doha Declaration to the World Trade Organisation Agreements. A National Emergency Taskforce on AIDS (NETA) made up of experts from government, NGOs and the University of Zimbabwe was formed to coordinate activities that would arise from the national emergency. The following organisations are developing new initiatives for ARV provision: · The Medicines Control Authority of Zimbabwe (MCAZ) regulates what drugs can be brought into the country. As of February 2003, MCAZ had approved six patented ARVs and two generic combinations, including one by a local manufacturing company, Varichem Pharmaceuticals. · Most government hospitals provide diagnostic HIV testing, blood screening and clinical services, but are limited by poor access to test kits and other resources. Some centres are running prevention of parent-to-child transmission (PTCT) programmes, sometimes with external funding. Voluntary counselling and testing (VCT) is provided by NGOs and social marketing projects. We identified two church hospitals already implementing ART programmes. The Caring for HIV and AIDS, Prevention and Positive Living (CHAPPL) initiative under the Zimbabwe Association of Christian hospitals (ZACH) plans to implement an occupational health programme for post-exposure prophylaxis for health staff · The Centre, an NGO set up by people living with HIV is providing donated ART to a limited number of people, but has a waiting list of over 3000 people. · Some private corporation such as Delta Corporation are implementing treatment programmes for their staff. Others such as De Beers plan to start soon. We did not encounter any workplace ARV programme that included all employees, apart from the proposal by CIMAS and PSMAS where companies can now contribute an additional amount to their existing medical aid schemes to cover ARVs · Websites and email discussion fora have played a vital role in informing advocates and activists on current issues regarding access to treatment. Conclusions and recommendations The review concludes that there is considerable momentum to establish ART programmes in Zimbabwe, mainly from the non-governmental sector. These efforts, however cannot be extensive enough to provide for the majority of the people who need treatment, who would mainly be provided for through the public sector. An equitable national programme for HIV-related, therefore, needs extensive international and national collaboration to mobilise the financial and technical resources required. Communication continues to be a major problem, with little information dissemination between key institutions and organisations, so that most interested parties struggle to find out what is happening either on the policy front or in practice. The time taken for programmes to be designed and implemented does not reflect the urgency of the HIV crisis in Zimbabwe.