ARV rollout: Why it worked

ARV rollout: Why it worked
30th November 2014 | Spotlight

A number of people have over the years played a role in the development of the TAC and our battle for antiretrovirals. There are too many to mention. In the following pages a small group of people who played a role in one way or another and represent various constituencies, share their recollections of the past and their dreams for the future.

Dr Helen Schneider provided an expert affidavit during the PMTCT case on the capacity of South Africa’s health system to support this programme showing how there was in fact significant latent capacity to support the provision of Nevirapine in eight out of nine of South Africa’s provinces.
Dr Helen Schneider provided an expert affidavit during the PMTCT case on the capacity of South Africa’s health system to support this programme showing how there was in fact significant latent capacity to support the provision of Nevirapine in eight out of nine of South Africa’s provinces.

At the South African AIDS Conference in Durban in June 2013, I chaired a panel of South Africans convened to answer the question: +2 million on treatment: what enabled this in a troubled health system? The panel consisted of a Deputy Director General in charge of the HIV programme in the national Department of Health, a leading HIV clinician, a provincial MEC, and a TAC activist – all deeply immersed in thinking about and acting on the promise of universal access to ARVs.

Their considered responses identified the following factors:
A shared collective vision and focused leadership by government, especially following the new political term in 2009.
An approach to the governance of the ARV programme that has enabled the participation of clinicians, activists and researchers, and which has engaged communities and citizens.
Nationally ring-fenced resources and funding.
An existing infrastructure of primary healthcare clinics, healthcare workers, community based programmes and a district health system through which access could be ensured.
A programme culture embracing innovation, information, and new scientific evidence and technologies.
The drive to efficiency through measures such as task shifting and intelligent procurement of anti-retrovirals.
Supportive implementation processes that engaged directly with frontline providers.

Together these factors represent a bringing together of bottom-up innovation and mobilisation with good stewardship from the top. This did not happen by accident: Access to ARVs was forged out of bitter conflicts, suffering and loss in which South Africans ultimately declared that things had to change. The ARV programme grew out of this as a truly home-grown effort and has shown that under the right conditions our much maligned public health system is capable of producing public value at scale.

However, there are worrying signs: Weak and corrupt provincial administrations are making it difficult to sustain the supply chain, delivery systems and provider motivation, which are key to access, civil society organisations are under threat, and external consultants are increasingly being brought in to ‘fix’ what are ultimately failures of governance and accountability within social institutions. The programme of universal access to ARVs has been a demonstration of the meaning of a progressive realisation of social and economic rights. To defend access to ARVs is to defend the core values enshrined in our constitution.