Ensuring universal treatment access through sustainable public health systems David McCoy and Rene Loewenson, Equinet There is no question that an effective and urgent response is needed to extend access to antiretroviral therapy (ART) in southern Africa. The efforts of treatment activists, national governments, the World Health Organisation and the Global Fund to highlight this unmet health need are commendable. However, after decades of under-investment, harmful structural adjustment programmes and de-skilling, many health systems face significant obstacles in rising to the challenge of meeting the treatment needs. Treatment activism now needs to join with broader public health activism to ensure that treatment can be extended in ways that are sustainable, effective and equitable. This paper draws on work carried out by EQUINET and others to discuss the threats and opportunities entailed with the expansion of ART access in Southern Africa- threats that must be managed and opportunities tapped to realise aspirations of treatment access for more than a minority. The threats are raised and exemplified in terms of the opportunity costs of expanding ART in under-resourced health systems, the possibilities of reinforcing or worsening health care inequities, the potential for harm to wider health systems in a disease-focussed ART expansion; and the possibility of drug resistance if services are unable to ensure adequate treatment compliance. Evidence is led of ways in which poorly designed programmes ultimately fail to deliver sustainable treatment access. The greatest threat however is not tapping the significant opportunity that exists for ensuring sustainable and widening treatment access through strengthening health systems, particularly given the global attention and resources being directed towards AIDS. The paper presents the argument from a wide range of southern African and international organisations that resources should now go towards ART expansion through comprehensive health systems development. In order to ensure this outcome, a number of principles need to be adhered to: § Fair, transparent processes to make informed choices § Joint public health and HIV/AIDS planning § Integrating treatment into wider health systems § Realistic targets for treatment access with clear guidelines and monitoring systems for ensuring equity in access and quality of care. § Treatment resources integrated into regular budgets, supported by long term external commitments and through fair financing approaches § Prioritising human resource development in the health sector § Strengthening essential drugs policies and systems nationally and regionally § Linking the challenge of ART expansion to the challenge of reforming the broader global political economy These principles are informing national, regional and international follow up work to inform national debate; to gather evidence of good practice and for translation into practical strategies and programmes; to provide a wider framework for research aimed at understanding the costs and benefits of approaches to ART access; to inform policy, advocacy and activism and as a basis for monitoring of current practice.