Our failing Provincial Health Systems by National Strategic Plan

NSP Review Engaging with South Africa’s National Strategic Plan for HIV, STIs and TB

Edition 5

November 2012 – February 2013

A publication of the Treatment Action Campaign and SECTION27

Our failing Provincial Health Systems

Provincial budget blues: Common budgeting problems explained Corruption in the Eastern Cape: We talk to Mr Fix It Section 100: When may the national executive step in to fix provincial problems?

Contents NSP Review, November 2012 – February 2013

Editorial by Mark Heywood.................................................................................................................... 1 Provincial budget blues: We can fix it ...........................................................................................6

This NSP Review is jointly published by the Treatment Action Campaign and SECTION27.

The Treatment Action Campaign (TAC) advocates for increased access to treatment, care and support services for people living with HIV and campaigns to reduce new HIV infections. Learn more about TAC’s work at www.tac.org.za.

The struggle in Gauteng...........................................................................................................................12 Section 100 .........................................................................................................................................................18 The mess in Mpumalanga ..................................................................................................................... 20 Squinting into the future .......................................................................................................................22 The production and distribution of this magazine were paid for by the South Africa Development Fund.

This is the fifth issue of NSP Review. We aim to provide quality analysis and monitoring of the implementation of the current NSP. It is our hope that this publication will increase awareness of, and critical engagement with the NSP. We will try to keep it relevant with evidence from new research and feedback from the various district offices of the Treatment Action Campaign as well as organisations with which we work closely. Our vision is a vibrant, evidence-based publication that will help all stakeholders drive a more successful response to HIV, STIs and TB. We encourage you to get in touch with us should you want to contribute to future editions of NSP Review. You can e-mail the editor at nsp@tac.org.za.

NSP Review is now online at www.nspreview.org

The Task is so Big

Editor: Marcus Low Assistant editor: Thania Gopal Copy editor: Cathy Goudie Contributors: Mark Heywood, Daygan Eagar, Sibongile Nkosi, Mara Kardas-Nelson, David McNaught, Simonia Mashangoane, Nathan Geffen Cover photo: Members of the Treatment Action Campaign and AIDS and Rights Alliance for Southern Africa during a march to demand more funding for the fight against HIV and tuberculosis. Photo by Samantha Reinders. Design: Design for development (www.d4d.co.za) Printing: Tandym Print

SECTION27 catalysts for social justice

SECTION27 is a public interest law centre that seeks to influence, develop and use the law to protect, promote and advance human rights, particularly the right to health. Learn more about SECTION27’s work at www.section27.org.za.

Photo by Luckyboy Mkhondwane, courtesy of the Treatment Action Campaign Archive

Corruption in the Eastern Cape .......................................................................................................14

Crumbling Provincial Health Departments Cost Lives and Will Affect NSP Outcomes Over the last year reports to TAC and SECTION27 of drug shortages, vital medical equipment breakdowns, staff shortages, corruption and mismanagement have become almost a daily occurrence. Often these breakdowns bring tragic consequences, such as the preventable deaths of women and infants kept waiting too long for caesarean operations, or people dying of cancers because of the failure of oncology services. However, less understood is the impact of the health systems crisis on people who for example, require antiretrovirals (ARVs), tuberculosis (TB) medicines and drugs for chronic conditions; people who tire of getting short supplies or no supplies, and become non-adherent or stop taking their medicines altogether. It is unfortunate that the Department of Health has no systems for monitoring the quality of its health services, rather than just their quantity. If we did we might see a different story from the official version. The tragedy is that this crisis has been anticipated for a long time. The harbinger was the Free State ARV moratorium in 2009, when ARVs stopped being provided to new patients for over three months. As a result of that crisis the government undertook various interventions and analyses of the health system. The most important of these exercises was the Integrated Support Teams (ISTs) set up by former Minister of Health Barbara Hogan, which undertook an analysis of the budgeting and management procedures of each provincial health department, as well as the national department. The IST teams produced detailed reports and recommendations which were made public in 2010 by Minister of Health Aaron Motsolaedi. But these reports, or at least their recommendations appear to have been forgotten. (The reports are online at http://section27. org.za.dedi47.cpt1.host-h.net/2010/09/03/reports-of-theintegrated-support-teams/ ) Since that time Motsoaledi has promised a major revamp of the health system. This overhaul would be a vital part of preparing the ground for a system of National Health Insurance (NHI). A new National Strategic Plan on HIV, TB and STIs has been agreed featuring ambitious targets of over three million people on treatment by 2016. But neither the NSP nor NHI can succeed outside of a functional health system. And

Photo courtesy of the TAC Archive

EDITORIAL

the great plans for the future have not stopped the disastrous crumbling in the present. The crisis we declare has nothing to do with Dr Motsoaledi’s heroic efforts and vision. Yet it cannot be separated from a political crisis that pays loud lip service to efficiency and accountability, but which for self-serving reasons is unwilling and unable to enforce the standards required for an effective health system. These standards are also demanded by our constitution. In 2012 it has become clearer than ever that the crisis is overwhelmingly one of management rather than a shortage of funds. Corruption and nepotism join forces with a lack of accountability and oversight to give most officials apparent de facto tenure in their positions, able to destroy hopes and lives with impunity. Rarely are health officials held accountable or interventions launched to stem the crisis. In this context TAC and SECTION27 welcomed the use of Section 100 powers in the constitution over the Limpopo Department of Health in December 2011 (see article by David McNaught on p 18). However we have still to question whether a Section 100 intervention – which gives the national department short term powers to take over a provincial department in order to maintain essential standards – is really suitable for fragile ecosystems such as our health system. It seems self-defeating for the National Department of Health to observe the system being weakened and wait for it to break – for the rot to really set in – and only then try to fix it. There is also reason to be sceptical about whether the powers of the constitution are really being used to protect and advance health, or whether there is underlying political agenda behind their deployment. For example, whilst Section 100 has been used in Limpopo, other provinces with health systems in a similar state of cardiac arrest appear – for political reasons – to be untouchable. Thus, despite rumours of massive corruption in the Gauteng Department of Health, combined with the actual collapse of parts of the health system to the level where there are no vaccinations for children in some areas of the province, there has been no action in Gauteng. In the last three years there have been three Health MECs and Heads of Health. Yet in this time nobody has been found accountable for health

service failures or held criminally responsible for corruption. For this reason in October 2012 TAC and Corruption Watch jointly launched an official request under the Promotion of Access to Information Act (PAIA) for access to a report by the police Special Investigating Unit (SIU) into corruption in the Gauteng Department of Health. A similar situation exists in the Eastern Cape. In this poor and predominantly rural province of 6.8 million people public-minded doctors and nurses are deserting health facilities because they cannot work under the unbearable pressures of staff, medicine and equipment shortages. Unusually, the provincial department has a Head of Health, Dr Siva Pillay, who has integrity and qualifications to run the department. But he is unable to do so without political interference. Once again, despite the evidence of collapse, despite suggestions that corruption may cost the province as much as R800m per annum, there has been no action. No measures have been taken against the Eastern Cape MEC for Health or other officials tainted with corruption directly or a failure to fulfil their legal duties to report and act against graft. In this respect, TAC and SECTION27 are in possession of official documents detailing the corruption. They have decided to launch a campaign of community mobilisation and litigation to rescue some of the provinceâ&#x20AC;&#x2122;s ailing hospitals from the crisis of insufficient health workers. For these reasons, we believe that more important than emergency interventions will be the Office of Health Standards Compliance (OHSC), an independent statutory body that has been agreed to by Parliament in 2012. The OHSC will create a system allowing anyone to report failures and poor quality services in the health system. The question is: will they be acted upon? Faced by the evidence, and hearing the cries of people denied the health services they are entitled to by law, we cannot help but believe that many essential parts of the public health system are in a near-fatal condition. TAC and SECTION27 offer our full support to the vision, passion and plans of Dr Motsoaledi. But more is needed than a good Health Minister and Director-General. We need all the decent and honest people in the health system to stand up and work for the constitutional right to health and dignity. We need all those who steal and sleep on duty to be removed. We need a demonstrated political will from the President and his Cabinet, that brings action, inspires trust and encourages effective managers to return to advancing the public good through public health. Mark Heywood, Executive Director, SECTION27

Photo by Oupa Nkosi, courtesy of the Treatment Action Campaign Archive

Underspending on Hospital Revitalisation Grants Eastern Cape by R191 million (52% underspent) KwaZulu-Natal by R228 million (full budget figure missing) Free State by R134 million (35% underspent) Limpopo by R89 million (27% underspent) Northern Cape by R158 million (37% underspent)

Eastern Cape underspent its HIV/AIDS grant by R105 million and its forensic pathology budget by R14 million. Limpopo underspent its HIV/AIDS grant by R49.5 million and its forensic pathology budget by R1.2 million.

Source: Bateman, C. â&#x20AC;&#x2DC;Will our public healthcare sector fail the NHI?â&#x20AC;&#x2122; South African Medical Journal, Vol 102, No 11 817-817, (2012).

The Task is so Big

Pic.

HIV in your province There are signs that South Africa is slowly turning the tide against the HIV epidemic. The rate of new infections seems to be declining, life expectancy is increasing, and the number of HIVpositive people receiving treatment continues to grow. However, in many of our provinces stockouts of essential medicines, shortages of health workers, corruption and poor budgeting are threatening to undo much of the progress of recent years.

ASSA 2008: The ASSA (Actuarial Society of South Africa) released its first AIDS and Demographic model in 1996. ASSA 2008 is the Societyâ&#x20AC;&#x2122;s sixth AIDS and Demographic model. It was released in March of 2011, and is the most recent version available. The model and a user guide are available online at www.actuarialsociety.org.za.

HIV Prevalence

Limpopo (L)

Gauteng (G)

North West (NW) Freestate (FS)

1% NC

Mpumalanga (M)

13% EC 6% FS

9% M Kwa-Zulu Natal (KZN)

Northern Cape (NC)

8% NW

5% WC

7% L

22% G

Eastern Cape (EC)

28% KZN

Western Cape (WC)

Source: ASSA 2008

HIV Incidence Source: ASSA 2008

250,000 200,000

The Task is so Big

150,000

KZN

100,000

G EC NW

50,000

WC 0

1985

1987

1989

1991

1993

1995

1997

1999

L FS

NC 2001

2003

2005

2007

2009

2011

Infant mortality rate

Mother-to-child transmission

As at 2011. (Number of deaths per 1000 births)

% at 4-8 weeks in 2010, 95% Confidence Interval (CI).

South African average

KZN

(3.8–8.0) (4.1–7.3) (2.4–7.0) (2.9–5.9) (1.9–5.8) (1.4–5.8) (1.7–4.0) (1.5–3.6) (0.1–3.4) (2.9-4.1)

34 South African average

15,721

26,645

5,995

2011

The Task is so Big

2007

18,722

30,747

21,488

215

1,391

1,384

1,105

1,836

2,591

5,901

7,766

1,502 2003

143,112

WC FS

37,830

82,903

96,223

19,562

Source: ASSA 2008

70,755

358,328

ART coverage EC

Source: Goga AE, Dinh TH, Jackson DJ for the SAPMTCTE study group. ‘Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT) Programme Measured at Six Weeks Postpartum in South Africa’, 2010. South African Medical Research Council, National Department of Health of South Africa and PEPFAR/US Centers for Disease Control and Prevention. 2012.

Source: ASSA 2008

KZN G

76,276

KZN

83,298

*It is important to note that for the Eastern Cape and Northern Cape provinces the point estimates are correct but the sample precision was less (wider confidence intervals). This was due to the lower sample realisation rates.

NW WC

92,925

Note: The national rate of mother-to-child transmission (MTCT) of HIV by 8 weeks is 3.5% (95% Confidence Interval (CI): 2.9-4.1%), with an almost threefold difference between provinces. The lowest rate of 1.4% (95%CI: 0.1-3.4) was found in the Northern Cape and the highest rate of 5.9% (95%CI: 3.8-8.0) in the Free State.

28 26

95,043

3.6% 2.9% 2.5% 1.4% 3.5%

298,742

5.9% 5.7% 4.7% 4.4% 3.9%

Provincial budget blues

Terrible conditions prevail at Edenvale Hospital in Johannesburg where there are too few doctors and wards available to deal with the influx of patients. Many patients resort to sleeping in the corridors of the hospital.

Provincial budget blues By Daygan Eagar

Sorting out provincial budgets is not as hard as we are led to believe

Over the past three years the Treatment Action Campaign (TAC) has trained many of its members to analyse budgets and monitor expenditure at the primary health care level. With assistance from the Centre for Economic Governance and Aids in Africa (CEGAA), SECTION27 and other organisations involved in the Budget and Expenditure Monitoring Forum (BEMF), TAC has not only managed to produce detailed budget analyses but also to meaningfully engage decision makers on complex budget issues.

There may be many reasons why we avoid doing so. We may believe that it is government’s responsibility to find answers to these problems. Or we may not feel qualified to offer meaningful solutions. Very often we simply forget that our criticism, as far as possible, should be constructive. It is mainly government’s responsibility to fix snafus in health care, but civil society has an important role to play in identifying what needs fixing and how to go about it. Civil society participates in the health system in ways that few government officials do. Good activists talk to community members, patients, health care professionals and facility managers to find out about what they think is wrong with health services. As members of the public and as patients, activists often use these services themselves. They therefore have first-hand knowledge of what is and is not working – experience that decision makers sitting in air-conditioned offices may lack. Members of civil society are often led to believe that they lack the technical expertise for constructive input on fixing ‘complex’ budget issues. But as we have seen in the fight for a comprehensive public sector response to HIV/AIDS, this is not true. With a little work to develop a solid grasp of the science of ARVs and the economics of universal access to treatment, ordinary members of society can become highly effective activists. In much

the same way, the Treatment Action Campaign (TAC) is discovering through its Budget Monitoring and Expenditure Tracking (BMET) project that understanding the management of public finance is most certainly not too ‘complex’.

Building on the work of others Even if we do not have the time or capacity to analyse what lies behind the problems that plague provincial health services, many independent bodies regularly investigate such issues. These bodies make findings and recommendations on what must be done to rectify the problems. Every year the office of the Auditor-General of South Africa (AGSA) audits the financial statements and systems of provincial departments. AGSA then publishes a report on its findings complete with recommendations. In addition, provincial departments can and do commission investigations into flaws within their own systems. These, too, yield reports containing key recommendations. The Integrated Support Team (IST) reports, commissioned by former Minister of Health Barbara Hogan, into the finances of all provincial health departments are an important example of this. Both regular reports by bodies such as AGSA and special investigations by expert commissions established in times of crisis provide a wealth of vital information. We can combine this material with our own experience to generate recommendations, advocate for practical solutions and monitor government’s progress in fixing systemic faults.

Provincial budget blues

Yet so much is wrong with the way in which health care services are budgeted for and how that money is spent that it becomes difficult to advocate for a few interventions that would significantly improve service delivery. All too often we speak about how the system is ‘broken’ and how ‘systemic’ difficulties prevent government from delivering on its constitutional obligations. But we do not offer practical solutions to these problems.

Five common problems The health budget crises in the Eastern Cape and Gauteng offer a good illustration of how we can harness our own knowledge to the outcome of formal investigations. By doing so we can generate more than enough information to campaign for solutions to the budget chaos. We know that both provincial health departments have overspent on their budgets. We can also see that this has compromised service delivery by forcing these departments to implement both planned and unplanned austerity measures. Importantly, we are also familiar with some causes of this overspending and what needs to be done to clean up the mess. We have identified five of the most pressing flaws in provincial health systems that contribute to overspending and the inefficient use of resources. In each case, we have also identified potential solutions.

Problem 1: Every year provincial health departments overspend on their budgets for employee compensation. Ballooning employee compensation is the single largest contributor to overspending in provincial health budgets. In order to pay staff, departments have been siphoning money away from budgets for infrastructure, medical equipment and medicines.

Provincial budget blues

There are a number of reasons for this overshoot:

In order to pay staff, departments have been siphoning money away from budgets for infrastructure, medical equipment and medicines.

Firstly, in many provinces the allocations for employee compensation that are made at the beginning of the financial year do not adequately provide for salary increases or the employment of new staff.

Secondly, each year AGSA reports and others such as the IST, have found that provincial health Personnel and Salary (PERSAL) systems are in a shocking state. Departments do not actually know with certainty how many staff they are paying and if those remunerations are accurate. In some cases payments are made to staff who no longer work for the department. In other cases existing staff members are paid too much – often through corrupt processes.

Finally, a poorly planned and managed OccupationSpecific Dispensation (OSD) – intended to attract and retain health workers – means that more staff than expected receive payments under the dispensation. The impact of these higher-than-anticipated outlays continues to strain budgets more than five years after the introduction of OSD. To a large extent dealing with two key issues could solve these problems. The first issue is that most provincial departments do not have the Human Resource Plans that are required by the National Health Act. If they do, they are often outdated. Consequently there is no clear plan outlining staff requirements, making it impossible to plan and budget appropriately each year.

Counting warm bodies The second issue is that PERSAL systems should be fully audited and amended so that they genuinely reflect how many warm bodies a department employs. The process would also ensure that all staff receive the remuneration to which they are entitled. These changes would not only save money but also allow departments to develop more accurate personnel budgets each year. They would, however, require the retraining of staff responsible for managing PERSAL systems.

Around 1500 activists and concerned citizens handed a memorandum to the Gauteng Department of Health regarding ARV stockouts and other essential medicine in health facilities across the province in June 2012. Photo by Luckyboy Mkhondwane, courtesy of the Treatment Action Campaign Archive

Provincial departments should be assessed primarily on the quality of services they deliver and not only on their ability to achieve a clean audit.

Problem 2: Unfunded mandates are programmes or interventions that are already underway but were not budgeted for. Examples include initial phases of the OSD, the introduction of dual therapy for prevention of mother-tochild transmission (PMTCT) of HIV, or promises made by MECs such as the building of a new clinic.

Political priorities While there is little doubt that many of these programmes are essential, decisions to implement them are often made by a provincial executive more focused on political mandates than on the availability of resources.

Unfunded mandates contribute directly to overspending. They also compromise the delivery of services in other areas. Before executive or political decisions are put into action it is important that additional funds are allocated for that purpose. It does not make sense, for example, to commit to building a clinic in one area if you have not allocated funds for this construction, especially if it means that money will have to be shifted from another vital infrastructure project to pay for this. So whenever a key political decision is made to expand services, we must always ask the question, â&#x20AC;&#x2DC;Where will the funds for this come from?â&#x20AC;&#x2122;

Provincial budget blues

Unfunded mandates place unsustainable pressure on provincial budgets

Problem 3: The ‘provincialisation’ of basic administrative tasks is highly inefficient and ineffective. ‘Provincialisation’ of functions refers to centralising administrative responsibilities – such as the buying of basic goods and services (food, cleaning products, basic medical supplies, facility maintenance) and the hiring and firing of staff – away from facility or district management and onto the provincial administration.

The decision This is being done in most to centralise provinces as a way to deal with administrative administrative problems in districts and health facilities. functions has for the It requires the establishment most part failed to improve of new systems and additional accountability and shown layers of decision-making. Such bureaucracy makes basic few benefits for service administrative functions slow delivery. and inefficient. The decision to centralise these functions is based less on the need to improve service delivery than on the fear of not

achieving a clean audit from AGSA. Unfortunately, not only has centralisation failed to secure a clean audit, in most provinces it has compromised service delivery. An example is furnished in a report by the Pillay Commission, which was established in 2005 to investigate public finance management in the Eastern Cape provincial government. The report found that due to centralisation it took up to three months for basic supplies such as cleaning materials and toilet paper to reach health facilities. The decision to centralise certain functions has, for the most part, failed to improve accountability and shown few benefits for service delivery. That said, not all health facilities or even districts have the capacity to take control of their own administration. While this capacity is being developed in certain facilities and districts, provinces should fulfil these functions. Where there is sufficient local administrative capacity, provincial departments should only play an oversight and support role.

Problem 4:

Provincial budget blues

Corruption robs provincial health systems of millions of rand every year.

AGSA’s audits of provincial health financial statements, special audits by private accounting firms and investigations by government bodies such as the Special Investigations Unit (SIU), all reveal that massive corruption, particularly around tenders, continues to rob public health systems of millions of rand every year. For example, an investigative report by the SIU into the Eastern Cape Health Department, published in May 2012, found that the department lost more than R800 million to corruption between January 2009 and June 2010. Despite the fact that provincial departments are well aware of rampant corruption within their ranks, few investigations take place to identify the culprits. Even where these investigations do occur, little or no action is taken against offenders. Few law-breakers are fully disciplined, let alone charged with a crime.

The Eastern Cape Department of Health lost more than R800 million to corruption between January 2009 and June 2010.

Fraud and corruption are criminal offences and should be treated as such. Many sound investigative techniques are available for rooting out corruption. Major accounting firms also have the capacity to undertake independent forensic audits of contracts and financial transactions. Where suspects are identified they must be charged with criminal offences. The cost of such investigations is often given as the reason for their rarity. What is not taken into account, however, is the long-term cost of doing nothing.

Problem 5: Comprehensive Monitoring and Evaluation (M&E) systems are often not in place, or dysfunctional. M&E is essential to the effective functioning of any health system. A well-oiled M&E system allows a department to:

an essential part of improving service delivery and accountability, few provincial departments have robust M&E systems in place.

• Track progress in achieving targets;

The IST reports, for example, argue that even where M&E systems do exist and data are being collected for this purpose, the information gathered is seldom analysed properly or used at all.

• Provide information on what is working well and what is not; • Develop and adapt policy based on actual need rather than unfounded assumptions; and • Use the information that the M&E provides to plan and budget effectively. Despite the fact that government – including all provincial health departments – recognise M&E as

As with full forensic audits, even though M&E systems are pricey the cost of doing without them is far greater. M&E should be a government priority in practice, not confined to the pages of well-meaning documents on strategic planning.

M&E systems are pricey but the cost of doing without them is far greater.

Lack of political will

This is where people who are interested in social justice, have a responsibility to act. We need to identify a set of fundamental issues facing the health system, which may or may not include those discussed above. We must use the knowledge and evidence we have generated as well as the many commissioned reports that enter the public domain each year. Using these, we can apply pressure on government to take action. If we employ solid evidence to succeed with a small set of fundamental issues, we can achieve great change in health service delivery. We must believe, however, that our voices in seemingly complex technical matters are just as important as those of any technocrats. Daygan Eagar is a researcher with SECTION27. Photo by Luckyboy Mkhondwane, courtesy of the Treatment Action Campaign Archive

Provincial budget blues

All of the issues discussed above are widely documented in reports and analyses. Yet government has been slow to rectify them. This is not because answers are beyond its reach. Rather, it is because the will to make difficult decisions and take firm action is often absent.

The struggle in Ekurhuleni

TAC receives reports of medicine shortages throughout Gauteng. The majority of these reports relate to clinics and hospitals in Ekurhuleni District.

March 2011

TAC’s national secretariat issues a press statement condemning the shortage of the drugs efavirenz and lopinavir/ritonavir especially in Gauteng and most notably in Ekurhuleni clinics and hospitals.

26 May 2011

TAC sends a letter of concern to the Gauteng Provincial Department of Health (PDoH). The letter requests a meeting with MEC for Health Ntombi Mekgwe, in order to discuss service delivery problems in the public health system.

31 May 2011

Reports indicate that ART shortages are worsening. Some health facilities also run out of basic laboratory requirements like sputum vials and labels for samples. TAC responds by visiting and contacting most clinics in Ekurhuleni and around Johannesburg to establish the extent of the problem. It becomes clear that the NHLS is facing bankruptcy and collapse because Gauteng and other PDoHs have not paid their bills. People suffer as the initiation of new patients on ART is delayed. In the same month, the Auditor-General’s office releases a report on a performance audit of infrastructure delivery at provincial departments of Education and Health. The report exposes that the Gauteng PDoH has lost millions of rand through maladministration.

July 2011

The meeting with the PDoH that was requested in May finally takes place on 28 July. The following issues are raised: • Medicine shortages • Access to isoniazid preventive therapy for tuberculosis (TB) prevention in clinics and prisons

Nov 2011

The MEC responds to TAC’s memorandum of 12 December 2011, stating that she is addressing the nonpayment of service providers, including the NHLS. Mekgwe claims that all outstanding debts will be paid by 30 June 2012.

Dec 2011

TAC Gauteng pickets the offices of the MEC for Health on 12 December to draw attention to the collapse of the provincial health system. Mekgwe refuses to receive the memorandum in person, sending her Chief of Staff Malibongwe Khanjana to accept it on her behalf.

• Closure of three TB clinics in Gauteng

Gauteng

• Dysfunctional district AIDS councils

Photo courtesy of Gallo Images

27 Jan 2012

Photo by Luckyboy Mkhondwane

In Gauteng, as in the rest of the country, the struggle for quality universal health care continues.

Photo by Luckyboy Mkhondwane Photo courtesy of Gallo Images

1,500 activists and concerned citizens take to the streets to deliver a memorandum to the Gauteng PDoH regarding stockouts of essential drugs. Mekgwe is once again unavailable, so Director of the HIV/AIDS unit Zukiswa Pinini accepts the memorandum and promises to pass it on to the MEC. The DoH does not respond to this communication.

20 April 2012

14 June 2012

TAC and SECTION 27 write jointly to MEC Mekgwe, again drawing her attention to the medicine shortages. We copy in Head of Department for Health Nomonde Xundu, Minister of Health Aaron Motsoaledi and DirectorGeneral for Health Precious Matsoso. • The letter raises the problem of patients receiving ARV supplies for only eleven days at a time. The writers point out that this makes it harder for patients to adhere to treatment, especially those who live far from health facilities and those who work. • TAC and SECTION27 request that the matter be resolved by 24 April 2012. Their letter remains unanswered.

Hope Papo is appointed as the new Gauteng Provincial MEC for Health – the third person to occupy that post in two years. His appointment comes soon after the Gauteng Department of Health and Social Development is split in two to improve service delivery.

6 July 2012

17 July 2012

TAC writes again to Mekgwe regarding the substandard delivery of health care in Gauteng. The letter is copied to the Minister of Health, Minister of Finance and Gauteng MEC for Finance.

TAC holds a press conference to highlight the appalling service delivery problems in the Gauteng PDoH.

27 July 2012

TAC leadership together with the Budget and Expenditure Monitoring Forum (BEMF), SECTION27 and the Centre for Applied Legal Studies (CALS) meet with the new MEC for Health to discuss continuing stockouts of essential medicines and shortages of clinical and support staff at all health facilities. The MEC defers to the Head of Department to respond to these issues.

29 July 2012

October 2012

The office of the AuditorGeneral releases its overall findings on the PDoH. It highlights unauthorised expenditure of R1 billion, irregular expenditure of R1 billion, and R155 million in wasteful expenditure.

TAC formally writes to the Special Investigating Unit (SIU) to request access to its report of an important investigation into corruption in the Gauteng Health Department.

Gauteng

Public health care in Gauteng Province is plagued by drug shortages, poor service delivery and the breakdown of the National Health Laboratory System (NHLS). For the past two years, the Treatment Action Campaign (TAC) in Gauteng has been receiving reports that not only essential drugs like antiretrovirals (ARVs) and insulin but even basics like paracetamol have been unavailable In health facilities.

Photo courtesy of the Treatment Action Campaign Archive

eastern cape

Corruption in the Eastern Cape By Mara Kardas-Nelson

168 clinics and 17 hospitals lack piped water

The stories are numerous, and often mind-boggling. They range from the department’s Chief Financial Officer awarding millions of rand in contracts to the businesses of family members, to departmental employees fraudulently receiving government grants. These practices further wrack an already fragile, if not terminally ill, health system. When Pillay took up his role as SG, the Eastern Cape Department of Health was wholly bankrupt. The situation had become so dire that the Provincial Treasury subsequently took over management of the department. Among the Treasury’s first steps was a hiring freeze on all health posts within the province, much to the chagrin of clinics and hospitals that are desperate to fill essential jobs. One need only google “Eastern Cape health” to learn from the list of alarming results that the province is in a shambles.

Audit milestone Pillay has bravely attempted to turn this around. Under his stewardship, the department cleared an audit for the first time in a decade. In his first year as SG, the department was considered the most improved in the Eastern Cape. Health indicators have improved; the TB conversion rate* is up, and the rate of under-five child mortality is down. “I think we can be proud of what we’ve done,” he says. But his biggest claim to fame is tackling corruption. Pillay has focused extensively on shady practices amongst tender suppliers, explaining that the province’s poorly managed supplier database is an invitation to unchecked abuse. “The whole supplier database is corrupt… more than 3,000 people … are registered more than once, there are people that have got multiple companies,” he says.

operate via generators

68% of hospitals lack essential medical equipment 16% of facilities have no telephones and are accessible by road only in good weather Overall staff vacancy rates stand at 46% (mostly clinical posts) requiring an additional R9 billion to fill Source: Bateman, C. ‘Will our public healthcare sector fail the NHI?’ South African Medical Journal, Vol 102, No 11 817-817, (2012).

An internal investigation placed irregularities in the supplier database under the microscope. It found thousands of instances in which different suppliers listed the same bank account, phone number, physical address, and/or postal address. Single suppliers were seen to have multiple bank accounts. Different suppliers sported the same vendor code. All of these discoveries point to a handful of dubious individuals profiting from a multitude of supposedly separate companies that are in fact owned by the same group of people.

* TB conversion rate: The rate at which a series of sputum samples from patients with TB are found to be negative for TB bacteria after the patients have begun treatment.

Double dipping Duplicate payments to single companies were also uncovered, and the financial toll of this particular practice is dizzying in itself. For transactions over R15,000 alone, this single investigation found R34,109,375.56 in duplicate payments. Sometimes ghost payments surfaced; the investigation showed that nearly R700,000 in payments were made without naming a specific beneficiary. And Pillay explains that this is likely to be just the icing on the cake, given that accurate records are incredibly difficult to track down. “The supplier database is with Treasury, and in some cases, the physical files were all tampered with when I came in,” he says. “This had been happening for years. When I came here there was no document system. Anyone could make changes.”

eastern cape

Known for his crackdown on rampant, widespread graft within the department, since his appointment in 2010 Pillay has led a series of investigations into low- and high-level corruption. This scrutiny has exposed what he calls an “endemic” problem. No part of the department is untouched. Corruption has even taken root in clinics, along the supply chain, within the tender process, and in human resource management.

42 health facilities have no proper electricity and

Photo courtesy of Gallo Images

I make the mistake of asking Dr. Siva Pillay to give me “just a few examples” of corruption that he’s uncovered as Superintendent-General (SG) of the Eastern Cape Department of Health. After 30 minutes of back-to-back examples, I interrupt him to ask another question, but Dr. Pillay stops me. “We’ve only covered about 10% of cases,” he points out.

Tender fraud Pillay considers tender fraud to be the “most expensive” form of corruption. Tender fraud manifests itself in a variety of ways. In some cases supposedly “multiple” suppliers owned by the same individual(s) bid against each other, flouting the requirement for real competition. Or, perhaps most egregiously, those writing the tender specifications also benefit, either directly or indirectly, from the tender award. Sometimes both of these fraudulent practices occur in relation to a single tender. Investigations have found such scams practised throughout the department, including by Pillay’s former Chief Financial Officer, Phumla Vazi. An internal investigation found that under Vazi’s tenure, 120 companies owned by members of her family—namely her sister, daughter, and husband—were awarded R6,898,345.76 from 2003-2010. This was not just a case of oversight; in some cases, Vazi physically signed off on the contracts awarded to family members. “If you look at some of what she was signing off on, she knew it was from her daughter,” says Pillay. “If you got three quotes from a stranger you wouldn’t know that all three quotes were from the same person, but for your daughter, you know that the three companies are from her.”

eastern cape

“For years, there have been no checks and balances and monitoring and evaluation and disciplinary action,” he says. “People never believed they would get caught.”

Corrupt officials are now setting their sights on juicier targets. Rather than fraudulently applying for contracts of around R10,000, Pillay says that corruption is instead taking place primarily with contracts of R30,000 or more. Companies regularly exploit the system of black economic empowerment (BEE) by claiming to have previously disadvantaged people within their management in order to secure more tender points. “That to me is not empowerment in any way, that is corruption,” he comments. Low-level dishonesty is also widespread. An internal investigation found that 10,221 employees of the department’s 47,000 were illegally receiving government grants. “That’s a quarter of my department,” says Pillay. “It’s a joke.”

Pillay says that swindling is perpetuated because it has, over the years, become the norm, rather than the exception. “There’s a culture that is existing where people do not care... If a guy doesn’t think he’s doing something wrong, then how can you deal with it? Now if you don’t do it, you’re considered foolish...everyone’s sharing in it, so who’s going to talk about it?” Pillay points out that the Eastern Cape is not an exception, and corruption is found across the country. “It’s everywhere! In other provinces it’s the same. I went into another province...and when I looked at the things there it was the exact same, it’s just that no one’s bothered to check it. “I don’t think that the country understands what we are going through,” he observes. “We need to explain to people that this is the situation that we have to deal with.”

Death threats Pillay claims that his efforts to unearth such practices have resulted in death threats and a vindictive investigation brought against him by former MEC Bevan Goqwana. The investigation came with a price tag of R3 million but yielded nothing of interest. Pillay’s contract expires in January 2013, and he is convinced that it will not be extended. He does not seem especially concerned. “I’m a doctor, so I can go back to medicine, to entrepreneurship, to development, I can do many things,” he says. Pillay hopes that his efforts to sniff out, and punish, corruption, will frustrate future attempts. “We put up a multi-agency working group [on corruption]; we put in a document management system; we conducted audits; we did qualifications of people in the [supplier] database,” he says. “There are a lot of things that we put in place that make it difficult for corruption to continue in the future... You’ve got to keep doing this. You have to have monitoring and tools.” Still, Pillay does not want to get his hopes up that this legacy will continue, even if his position does not. “I don’t want to speculate about anything as to what’s going to happen in the future. No-one can look into a crystal ball....You’ve got a sphere of influence of what you can change, [and] what you can’t change you can’t change. You have to rely on the Lord for the rest of that.”

Due to a shortage of staff, patients have to endure a long waiting period before being treated at Madwaleni Hospital. Photo by Thembinkosi Dwayisa, courtesy of Times Media

Madwaleni Hospital is a 180-bed hospital in the rural Eastern Cape, about 100km from Mthatha. It serves a community of 120,000 mostly poor people. As recently as 2009, articles were written about the remarkable successes achieved at the hospital. In less than three years things have fallen apart drastically. At the time of writing, Madwaleni has only one doctor left. According to the hospitalâ&#x20AC;&#x2122;s organogram, it is supposed to have 14. A moratorium on appointing new critical staff in the Eastern Cape public health system has made it almost impossible to fill these vacant posts.

The Legal Resources Centre (LRC), acting for TAC and SECTION27, has engaged with the Department of Health and Treasury in relation to the crisis. At the time of writing, the problems have not been resolved and it is likely the LRC may have to take the matter to court. In correspondence the Provincial Treasury blames the Provincial Department of Health and vice versa. However, as a result of pressure there now seems to be moves to expedite the appointment of additional doctors. TAC and SECTION27 will continue to monitor the situation.

Some details in this article were sourced from the Health-e News service (www.health-e.org.za)

eastern cape

One doctor for 120,000 people

A paediatric ward at the Chris Hani Baragwanath Hospital in Soweto. The hospital, which is one of the largest hospitals in the world, came under scrutiny again this year after reports surfaced describing how staff shortages and overcrowding led to at least two avoidable infant deaths in January alone. Photo by Sangini Shah, courtesy of Photoshare

Section 100 Section 100

By David McNaught

When provinces fail to deliver on their constitutional obligations, the national government may intervene. The basic rules for such interventions are described in Section 100 of the South African constitution.

In this way Section 100 acts as a safeguard. It balances the autonomy of provinces with the recognition that South Africa is a single sovereign state in which all sections of government share a duty to respect, promote and fulfill constitutional rights.

Remedial action Section 100 enables a two-part process for remedial action. First, under Section 100(1)(a) the national executive may issue a directive to the provincial executive instructing it to comply with its constitutional and other obligations and stating the steps necessary for it to do so. This is expected to be a collaborative process with both national and provincial departments working together to remedy problems. The Constitutional Court has held that intervention by the national executive is also limited to an approach, “authorised by the Constitution or by legislation enacted in accordance with the Constitution.” This ensures that powers exercised under Section 100(1)(a) are confined to directing the province to comply with an existing statutory or constitutional obligation. It is under the second step, section 100(1)(b), that the national executive may go further and actually “assume responsibility” for the obligation. This power may only be invoked after attempts to resolve the problem under section 100(1)(a) have failed and the provincial executive has not complied with a directive. Section 100(1)(b) applies where more direct intervention is needed to maintain (i) essential national standards or minimum standards for the provision of a service; (ii) economic unity; (iii) national security, or (iv) to prevent unreasonable or prejudicial action by a province. Although Section 100 (1)(b) is a discretionary power the national executive may have to use it in order to carry out its own constitutional duties. Once invoked Section 100(1)(b) not only empowers the national executive but also requires it to discharge the obligation itself. This point was recently made clear by J Plasket in The Centre for Child Law and Others v The Minister

of Basic Education and Others. Plasket noted: “…in terms of [Section] 100(1)(b) … [the national executive] assumes the powers of the provincial administration, and it also assumes its obligations.”

South Africa is a single sovereign state in which all sections of government share a duty to respect, promote and fulfill constitutional rights.

Although the constitution places a clear responsibility on the national executive this was one of several cases in which litigation became necessary in order to clarify a Section 100 intervention. Indeed the ongoing need to establish through court judgments the extent and nature of the duty placed on the national executive has been challenging. It has further delayed addressing instances where fundamental human rights have already been seriously undermined. The intervention and suspension of provincial autonomy is intended only to be temporary. It should include building the provincial department’s ability to successfully carry out the obligation itself. However in practice intervention has often been a prolonged, openended process. In December 2011, for example, Cabinet invoked Section 100 to address problems in the Limpopo Department of Education. Almost one year later these problems remain unresolved.

Furthermore, the structure of Section 100 often means that by the time Section 100(1)(b) is invoked attempts at cooperation between national and provincial departments will likely have failed. The relationship may therefore have become strained and uncooperative, making it all the more difficult to establish accountability and resolve problems swiftly.

A last resort In response to these difficulties the South African government has introduced the Monitoring, Support and Intervention Bill. The Bill aims to clarify and regulate Section 100 interventions. As we have discussed, these interventions arise because a province is in breach of one or more of its constitutional obligations. They should therefore be a last resort, used only in cases where serious breaches warrant exceptional steps. Section 100 guarantees a vital power but to be effective it must be exercised in a spirit of cooperation and willingness to assume responsibility. David McNaught is a researcher with SECTION27.

* The national executive = The President and Deputy President, as well as Ministers and Deputy Ministers in the Cabinet.

Section 100

The Constitution of the Republic of South Africa allocates powers to three areas of government: national, provincial and local. Generally one area may not usurp the powers of another. However, in exceptional circumstances where a provincial government fails to discharge a constitutional obligation, Section 100 of the constitution empowers the national executive* to intervene in order to remedy the problem.

The Mess in Mpumalanga By Simonia Mashangoane

Mpumalanga is one of the provinces where South Africa’s plan to fight HIV and TB has been most poorly implemented. Now, after years of dysfunctional provincial and district AIDS councils, there may just be some light at the end of the tunnel.

Mpumalanga’s Provincial AIDS Council (PAC) was launched in November 2009, almost three years after the National Strategic Plan on HIV, STIs and TB (2007- 2011). It might have taken even longer, had it not been for pressure exerted by civil society organisations including the Treatment Action Campaign (TAC) in Mpumalanga.

Mpumalanga

“After the official launch of the … PAC it was still a difficult task to convene … meetings[. They] were not properly coordinated and were poorly constituted,” says Thandi Maluka, an Advocacy Communication Coordinator at TAC Gert Sibande.

Once formed, the PAC appears to have done little meaningful work. According to Maluka the Provincial Strategic Plan (PSP) 2007-2011 was drawn up by the PAC mainly for compliance purposes. The drafting process concluded in 2010 a year before the end of the plan itself. “The PSP was never implemented due to its lateness”, Maluka recalls. Late 2011 saw the launch of the 2012-2016 National Strategic Plan for HIV, STIs and TB (NSP). This time the Mpumalanga PAC rose to the challenge and began developing a new PSP. It also reviewed the previous plan, concluding that poor coordination had lead to its failure.

The PAC then realised that they were not in fact meant to draw up a PSP, but instead a provincial operational plan (POP) aligned to the principles of the NSP. With input from stakeholders the POP was duly drawn up and identified the following priorities for Mpumalanga: •

Increase HIV awareness especially among highrisk populations such as young people and farm labourers.

•

Intensify case finding and follow-up for HIV, STIs and TB.

•

Expand HIV Counselling and Testing (HCT) campaigns.

•

Use combination prevention strategies to maximise HIV and TB prevention.

•

Maintain the health and wellbeing of all Mpumalanga residents.

•

Promote the core values of the South African constitution to reduce stigma and discrimination.

•

Strengthen the PAC, district AIDS councils (DACs) and local AIDS councils (LACs) to encourage participation from all sectors of Mpumalanga communities.

The National Association on AIDS Spending was called in to assist with costing the POP. However, not all stakeholders have taken part in the costing. It has therefore become more of a desktop exercise by the consultant involved than a fully inclusive process. An external consultant has also been drafted in to help finalise the monitoring and evaluation (M&E) framework and to enable districts to align their own M&E plans to the provincial plan.

Photo by Simonia Mashangoane, courtesy of the Treatment Action Campaign Archive

Lack of leadership Poor implementation of the PSP was partly due to a lack of political will from Premier Mabuza, who delegated his responsibilities as Chair of the PAC to the MEC of Health. The message implicit in this action has had a trickle-down effect as a result of which few district and local AIDS councils were formed to carry forward the implementation of the PSP. TAC and other civil society groups have repeatedly called for Mabuza to chair the PAC, but without success. To effectively implement the NSP at a local level it is essential for the PAC to support district AIDS councils. DACs should also participate in the PAC. However, so far only two of the three districts in Mpumalanga – Gert Sibande and Ehlanzeni – are active in the PAC. In most provinces DACs are chaired by district mayors. However in the absence of a directive from the Mpumalanga Premier’s office making this a requirement, it doesn’t always happen. This contributes to the dysfunctional HIV response in the province. In

On 8 August 2012, TAC, SECTION27, COSATU and the South African Council of Churches convened a meeting with civil society partners involved in HIV/ AIDS work in Mpumalanga. They aim to create a united civil society coalition to collectively advocate for effective AIDS councils in Mpumalanga.

addition, district mayors cannot hold municipal mayors accountable for LACs and many ward councillors do not chair clinic committees as they should.

Revolving door The revolving door of political appointees in some districts further contributes to the lethargy in DACs and LACs. In Gert Sibande, for example, the DAC is currently chaired by the third mayor in a year. This lack of continuity has stalled progress on HIV and TB issues. Furthermore, civil society groups represented on the PAC are relatively fragmented, and government departments often send different representatives to each meeting, most of whom have limited decision-making powers. Simonia Mashangoane is a researcher with TAC. Thandi Maluka and Patrick Mdletshe, both TAC leaders, also contributed to this article.

Mpumalanga

The development of the provincial operational plan should be inclusive, targeting all stakeholders. It is also a knowledge-building activity that can help to sensitise political leadership, civil society, managers and health practitioners to the needs of our communities.

Squinting into the future By Nathan Geffen

In Isaac Asimov’s Foundation science fiction series, which is set far in the future, mathematical modelling of human society has reached such a sophisticated level that the characters can predict the fall and rise of their civilisation thousands of years ahead. The series’ main mathematician is even able to determine a set of interventions that will shorten the period of barbarism between the collapse of his society and the rise of the next one. Alas, in 2012, we are barely able to predict the trajectory of a single disease in one country even a few years into the future. It may seem like fiction of another kind that mathematical models could ever generate enough controversy to involve the president of a country. Yet when the Actuarial Society of South Africa (ASSA) published their AIDS models in the early 2000s, this is exactly what happened. Public debate ignited because contrary to the AIDS denialist views of then President Mbeki, the ASSA models showed that millions of people in South Africa had HIV, hundreds of thousands were dying annually of AIDS, life-expectancy had plummeted and – in the absence of antiretroviral treatment (ART) – the worst was yet to come.

the future

Mathematical models of epidemics estimate important information such as the prevalence, incidence and effect on life expectancy of an epidemic disease at time-points for which there have been no direct measurements. They usually tell us about the state of an epidemic now and in the future under different scenarios.

Incidence: The number of new cases of a disease that occur in a specific population at or over a given time.

Prevalence: The total number of cases of a disease in a certain population at or over a set time.

New studies show the complexity and importance of HIV epidemiological modelling

Model myths It is seldom that people outside the field have a good understanding of the details of mathematical models. Models can often seem mystical. Perhaps this is why there is a myth that epidemiological models are just based on abstract mathematics and not on real-world measurements. But this is not true. Good models have a large number of parameters that must be set using the best available peerreviewed data. Such parameters might be, for example, the risk of a sexual act resulting in HIV transmission, or the effect of ART on a person’s infectiousness. Once all the parameters are set models must be calibrated against reliable epidemiological data, so that their outputs match what is known about the epidemic. This is analogous – albeit in a much more complex way – to calibrating a scale before you weigh yourself. You make sure that the scale points to zero, so that when you stand on it, it will not understate or exaggerate your weight. Likewise, a good mathematical modeller will make sure that if the countrywide HIV epidemic was measured by a reliable survey to be, say, 9% in 2001, that when a model is run, it calculates close to 9% prevalence for that year. If it does not, then the modeller has to revisit the model’s parameters and calculations. It is hard work and good modelling is a highly skilled undertaking. There is also a belief that models are entirely dependent on the assumptions and biases of the people who develop them, which is partially true, and therefore have no value, which is not true. A household budget is a mathematical model, and many readers of this article have no doubt made one. If done carefully, they are based on real-world measurements and usually predict future expenditure quite well. Most of us find them very valuable. At the risk of oversimplification, the difference between a household budget and the most sophisticated mathematical models of the HIV epidemic is mainly one of complexity.

A comparison of models

The open access journal PLoS Medicine has published a set of articles looking at the cost and effectiveness of using antiretroviral treatment to reduce HIV incidence. These papers debate the assumptions, methodologies and conclusions of mathematical models and consequently the affordability and benefits of treatment as prevention.

Dramatic benefits One of these papers was co-written by the developers of 12 different epidemiological models, including the Granich model. Jeffrey Eaton, Timothy Hallett and colleagues explain, “Each of these models has predicted dramatic […] benefits of expanding access to ART[. B]ut models appear to diverge in their estimates of the possibility of eventually eliminating HIV using ART, the cost-effectiveness of increasing the CD4 threshold for treatment eligibility, and the benefits of immediate treatment compared to treatment based on the current World Health Organization eligibility guidelines. Directly comparing the models’ predictions is challenging because each model has been applied to a slightly different setting, has used different assumptions regarding other interventions, has been used to answer different questions, and has reported different outcome [figures].” The aim of the research described in the paper was to systematically compare the 12 models by standardising a set of antiretroviral treatment scenarios and reporting a common set of outputs. The intervention scenarios were consistently implemented across the different models with the purpose of controlling “several aspects of the treatment programme and isolat[ing] the effects of [variations in the] model[s] …”

Three variables were controlled across the models and systematically varied: the CD4 threshold for starting treatment, the proportion of eligible people who access treatment and the retention of patients on treatment. PLoS Medicine’s editor explained the methodology: “To exclude variation resulting from different model assumptions about the past and current ART program, it was assumed that ART is introduced into the population in the year 2012, with no treatment provision prior to this […I]nterventions were evaluated in comparison to an artificial […] scenario in which no treatment is provided.” To compare the models, the authors used a standard scenario based on the World Health Organization’s recommended threshold for ART initiation, although it does not reflect current provision in South Africa. The methodology of these twelve models varied greatly. For example: • They used two different modelling methods. Four used microsimulation. In such models, each individual in a population is simulated. Random events that affect their risk of HIV infection are applied to them. This is the most computationally intensive of the modelling methods. Microsimulations can take hours or even days to produce results. The remaining eight models divided the population into groups “according to each individual’s characteristics and HIV infection status and use[d…] equations to track the rate of movement of individuals between these groups.” • Ten of the models explicitly provided for both sexes and heterosexual HIV transmission. • Six of the models included age, but the degree to which age affects disease progression, the risk of HIV infection, and the risk of transmission varied amongst these models. • One model simulated the HIV epidemic in Hlabisa, KwaZulu-Natal, while the remaining models dealt with the national South African epidemic. The models were compared under three different CD4 cell count thresholds: 200 or lower, 350 or lower, and treatment for all regardless of CD4 count. The proportion of eligible individuals who eventually began treatment was also varied as follows: 50%, 60%, 70%, 80%, 90%, 95%, and 100%. So was the percentage of people still on treatment after three years, excluding those who died, as follows: 75%, 85%, 95%, and 100%.

the future

Today we see new controversies in HIV demographic modelling, albeit much more interesting and rational than the AIDS denialist arguments of the early 2000s. In 2009 Reuben Granich and colleagues published the results of their model in the journal The Lancet. They predicted that the HIV epidemic in South Africa could be eradicated by 2050 if universal voluntary testing and immediate treatment for all people with HIV were introduced. But using different assumptions about treatment uptake and drug resistance Bradley Wagner and Sally Blower of the University of California Los Angeles reached different conclusions. They published the results of their model in a paper titled, “Voluntary universal testing and treatment is unlikely to lead to HIV elimination: a modeling analysis”.

Outcomes of the different models The estimates of adult male HIV prevalence in South Africa in 2012, assuming there was no ART, ranged from 10% to 16% across the models. Female prevalence ranged from 17% to 23%. Male incidence ranged from 1.1 to 2.0 per 100 person-years and female incidence ranged from 1.7 to 2.6. Under the scenario where no treatment is provided, the models varied in their predictions about the future path of the epidemic. Calculations ranged from almost no change in HIV incidence to a 45% reduction over the next 40 years. All the models predicted that treatment would reduce incidence by a large percentage compared to the no-treatment scenario. Their estimates varied, but only across a narrow range. For example, if 80% of HIV-positive individuals began treatment a year after their CD4 count dropped below 350 and 85% remained on treatment after three years, the estimated drop in incidence ranged from 35% to 54% lower eight years after the introduction of ART compared to not providing ART at all. The number of person-years of ART per infection averted over eight years ranged between 5.8 and 18.7. As expected, the further into the future the models went the more their results diverged. This scenario, incidentally, reflects current WHO treatment guidelines coupled with the UNAIDS definition of universal treatment access. i.e. reaching 80% of those in need.

Effect of ART on incidence in South Africa

the future

The authors then did a separate analysis using seven of the models to determine the effect of the actual ART rollout in South Africa on HIV incidence by comparing it with a no-treatment scenario. Models either used their own existing calibrations of the number of people on ART in South Africa or were calibrated using estimates of the number of adults starting and already on ART in each year from 2001 to 2011.

All of the models predicted that ART has reduced HIV incidence. The estimates ranged from 17% to 32% lower in 2011 than in the absence of ART. Interestingly, the models gave widely different estimates of the effect of ART on prevalence. For example, one model estimated prevalence at 8% higher than it would have been without treatment, while two others calculated no net change in current prevalence. It is worth bearing in mind that an increase in prevalence does not mean a failed response to the HIV epidemic. On the contrary, the only

way prevalence can decrease is if more people die than are infected. Since ART keeps people alive, it is unsurprising that several models predict an increase in prevalence. Incidence, not prevalence, is the measure of the success of prevention efforts.

Test and treat The impact on incidence of a CD4 threshold of 200 versus 350 versus treatment with very high rates of HIV screening and the removal of CD4 eligibility â&#x20AC;&#x201C; the latter known as the test-and-treat approach â&#x20AC;&#x201C; were also compared across the 12 models. Here the results were not consistent. Some models showed that moving from 200 to 350 would not make a substantial difference, but that moving from 350 to treating everyone would. Others found that moving from 350 to treating everyone made little difference. In an intervention treating all HIV-positive adults with 95% ART access and 95% retention, only three of nine models predicted that HIV incidence would fall below 0.1% per year by 2050, the virtual elimination threshold proposed by Granich and colleagues.

Explaining the differences between models The authors put forward three hypotheses to try and explain the differences between their models. These were (1) differences in the fraction of transmission that occurs after people become eligible for ART in the no-treatment scenario, (2) differences in how effective ART is at reducing transmission and (3) different assumptions about what happens to patients who drop out of care. These hypotheses were tested and only accounted for some of the differences in model outcomes. Although the modelsâ&#x20AC;&#x2122; estimates diverge, collectively they can help policy makers and provide approximations of how successful antiretroviral treatment will be at reducing incidence. Also, we should remember that the models were not all designed to answer the identical questions. The effectiveness of treatment as prevention is a question that will have to be answered more definitively with clinical trials as well as observational studies of actual practice. Over the next few years, controlled trials in South Africa, Zambia, Tanzania and Botswana will hopefully provide these answers.

The future of mathematical modelling It is important to realise that disease modelling at the level of sophistication seen in these models is a relatively new field, made possible by the tremendous increase in computer power over the last few decades. Microsimulations in particular stretch the capabilities of even today’s computers and computer programmers. The widely different methodologies and assumptions used should be seen as pioneering efforts in a new science. Hopefully over time, and as the predictions of models are compared to what actually happens, modellers will be able to identify techniques that are robust and standardise the science. Just as the 95% confidence interval and the correspondence of a p-value less than 0.05 with significance are a standard part of medical statistics today, similar standard concepts might emerge in the modelling field. And just as R and STATA are standard software tools used by the vast majority of medical statisticians, so there will hopefully one day be standard tools for both deterministic and microsimulation mathematical models. An effort to standardise modelling is already underway. Wim Delva and colleagues have published an article in the same PLoS Medicine collection summarising extensive discussions between mathematical modellers. They describe nine principles for modellers and those who depend on HIV models to make policy decisions. The (edited) principles are: 1. The model must have a clear rationale, scope and objectives. 2. The model structure and its key features must be explicitly described.

4. The way the model has been calibrated must be explained and justified. 5. The model’s results must be clearly presented including uncertainties. 6. The model’s limitations must be described. 7. The model must be contextualised. In other words previous studies must be referenced and the similarities and differences explained. Differences in the results of the model and previous models must be described. 8. The model must show epidemiological impacts that can be used for studies of health economics. 9. Models must be described in clear language. These principles surely apply to all disease modelling, and not just to HIV. Disease modelling is important. Models help us understand the relative contribution of different factors to the present state of the HIV epidemic. They also give us some understanding of what would happen in the future under different interventions. Models are valuable for making policies with short and medium-term impacts. Longer-term projections, such as to the year 2050, are less useful given that so many unpredictable technological and demographic changes are likely to occur over such a long period of time. Aside from the practical value of disease modelling, this is a fascinating theoretical field featuring elegant mathematics and computer algorithms.

Sources: Granich RM et al. ,‘Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model.’ Lancet 373: 48–57. doi:10.1016/S0140-6736(08)61697-9. (2009). http://www.thelancet.com/ journals/lancet/article/PIIS0140-6736%2808%2961697-9/abstract; Wagner BG and Blower S. 2009. ‘Voluntary universal testing and treatment is unlikely to lead to HIV elimination: a modeling analysis.’ doi:10.1038/npre.2009.3917.1 (2009) http://precedings.nature. com/documents/3917/version/1/html; Eaton JW et al.. ‘HIV Treatment as Prevention: Systematic Comparison of Mathematical Models of the Potential Impact of Antiretroviral Therapy on HIV Incidence in South Africa.’ PLoS Med 9(7): e1001245. doi:10.1371/ journal.pmed.1001245 (2012) http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001245 ; Cohen M et al.. ‘HIV Treatment as Prevention: Debate and Commentary—Will Early Infection Compromise Treatment-as-Prevention Strategies?’ PLoS Med 9(7): e1001232. doi:10.1371/journal.pmed.1001232 (2012). http://www.plosmedicine.org/article/info:doi/10.1371/journal. pmed.1001232 ; Delva et al. 2012. ‘’HIV Treatment as Prevention: Principles of Good HIV Epidemiology Modelling for Public Health Decision-Making in All Modes of Prevention and Evaluation.’ PLoS Med 9(7): e1001239. doi:10.1371/journal.pmed.1001239. http:// www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001239

the future

3. The model parameters must be well-defined and justified.

How to keep ART patients in long-term care

The Task is so Big

ART Adherence Club report and toolkit now available Piloted by Médecins Sans Frontières/Doctors Without Borders (MSF) in Khayelitsha, the award-winning ART Adherence Club model focuses on patient participation and peer support, for improved treatment adherence. This simple model allows patient groups to collect pre-packed, two-month supplies of treatment from lay health workers either at the clinic or outside of the clinic – whether at a local library or at a fellow patient’s home. ART Adherence Clubs give stable adherent HIV patients easier access to their treatment, while unclogging clinics and freeing up scarce nurses and doctors to manage new or at-risk HIV patients.

Today, the Cape Town Metro is home to more than 400 of these clubs as part of a partnership between MSF, the Western Cape Department of Health, Cape Town’s City Health and the Institute for Healthcare Improvement. Due to growing interest in replicating the model, a report and practical toolkit is now available free online. This includes a step-by-step, ‘How-to’ guide, two short films and additional information on tailoring the model to various contexts.

To download the report and toolkit, go to www.msf.org.za/publications or email msfb-khayelitsha-acs@msf.org.za