Questions raised about the South African AIDS initiative

After denying for years that there is an AIDS problem, the South African government has apparently made an about face and announced that it will be funding the largest anti-AIDS programme on the continent.

In his medium-term budget policy statement on November 12, 2003, South African minister of finance Trevor Manuel announced that R12 billion would be made available over the next three years for the rollout of a national HIV/AIDS plan that includes the provision of anti-retroviral drugs (ARVs).

In August 2003, the South African cabinet had instructed National Health Minister Manto Tshabalala-Msimang to develop a detailed operational plan for the provision of ARVs by the end of September. It appeared that this sudden turn on by the government emanated from concerns about the national elections due to take place in 2004.

Several key figures in the African National Congress (ANC) pointed out that the party has neither answers nor a strategy to deal with criticisms of how the pandemic has been handled.

When Manuel presented his statement, the cabinet had yet to consider the Department of Health’s draft roll-out plan. Top South African AIDS scientist Glenda Gray urged an end to the government’s delaying tactics:

“I hope the roll-out happens quickly and without any hiccups. As doctors we are sick of being undertakers and look forward to being healers.”

The plan was eventually announced on November 19, more than one-and-a-half months after the deadline given to the Health Department in August. The main features of the plan are as follows:

* One service point in each health district across the country and, within five years, one service point in each municipality.

* Stepping up the prevention program.

* Expanding programs aimed at boosting immune systems of HIV-positive people and slowing down the effects of HIV infection, including traditional health treatments for those who wish to use them.

* Improved efforts at minimising and treating opportunistic infections.

* Ensuring that the health system can manage the rollout effectively, including the recruitment of thousands of additional health professionals and the implementation of training programs to ensure that health workers have the knowledge and skills to effectively administer anti-retroviral drugs.

Health Minister Tshabalala-Msimang has remained silent on the timetable for the rollout, saying it was impossible to predict when drugs would reach eligible individuals. Government officials also cautioned that ARVs would not be available for AIDS patients soon.

Nevertheless, the responses to Manuel’s statement and the announcement of the roll-out plan were mostly positive. Dr Fareed Abdullah, head of the HIV/AIDS program in the Western Cape, hailed the announcement of the roll-out plan as “one of the most important days in the history of South Africa.”

Tshabalala Msimang was reportedly stony-faced, and did not acknowledge the applause of a group of activists present at the announcement. The Treatment Action Campaign (TAC) responded more cautiously. “We can only forgive when people get medicines, and not yet—not one person has medicines yet,” said the TAC chair, Zackie Achmat. He pointed out that more than 500,000 people require immediate treatment if their lives are to be saved, whilst the roll-out plan will provide ARVs to only 10 percent of this number. However, the TAC has decided to throw its weight behind the government’s efforts to provide ARVs to eligible patients.

Despite the relief expressed by AIDS activists, health professionals and those infected with the virus, there is cause to believe that the roll-out plan is not all that it seems. Jeremy Nattrass, professor of economics and director of the Centre for Social Research at the University of Cape Town, interviewed by the Mail and Guardian, points out that the budget statement “combines substance with a hefty dose of spin.”

Nattrass continues, “[I]t is an election budget designed to give the ANC cover for its largest failings—most notably AIDS policy and unemployment.”

According to Nattrass, 60 percent of the funds are channelled to provinces via the “equitable share allocation.” Provinces can then essentially spend these funds as they please and not necessarily on HIV/AIDS treatment.

This assertion is confirmed by research carried out by the Institute for Democracy in South Africa (IDASA). According to the institute, “[I]t must be stressed that the R12 billion over the next three years recorded as funds allocated to HIV/AIDS, includes funds that are to be sent via the equitable share to the provinces. Although national government is requesting that these funds be used for HIV/AIDS, provinces have full discretion to allocate equitable share funds according to their own budget processes.”

IDASA researchers have suggested it is unlikely that all of the funds would be allocated for HIV/AIDS treatment. They point out that in the 2003/04 financial year, “R1.1 billion was added to the equitable share intended primarily for HIV/AIDS treatment and care. However, the research found that in reality the provinces had only allocated R356 million from their own health budgets in 2003/04 specifically for HIV/AIDS.”

In other words, only 32 percent of the money destined for HIV/AIDS treatment was actually used for that purpose.

Professor Nattrass maintains that “it is pure spin to describe the budgeted increases in the provincial equitable shares as if they were fixed and mandated allocations for AIDS.” His conclusion is that “a cynic might say that by opting to allocate additional AIDS money via the equitable share, Manuel is killing two birds with one stone. On the one hand, he can portray the government as caring about AIDS and have this message lapped up by the press. On the other hand, he can give extra resources to provinces, almost all of which are fully controlled by the ANC, to spend as they please—that is, in ways that maximise their chance of re-election.”

He mentions other indicators that point to the short-term political nature of Manuel’s budget statement. Even if one assumes that all of the money allocated for HIV/AIDS is actually used for that purpose, then it would be sufficient to cover the treatment rollout in the 2004/05 financial year, but, Nattrass says, “this happy scenario is manifestly not the case for years 2005/06 and 2006/07, where the AIDS allocation falls short of the government’s own estimates.

“The strong implication is that the government is not intending to fund a full roll-out, and that soon after the election, will dampen the increase in social expenditure so as to prevent the deficit from growing.”