IN THE HIGH COURT OF SOUTH AFRICA (TRANSVAAL PROVINCIAL DIVISION) In the matter between TREATMENT ACTION CAMPAIGN AND OTHERS Applicants and MINISTER OF HEALTH AND OTHERS Respondents AFFIDAVIT: PROFESSOR HELENE SCHNEIDER I the undersigned HELENE SCHNEIDER 1. I am associate professor of Public Health at the School of Public Health, University of Witwatersrand. I hold the degrees of MBChB (UCT) and MMed (Wits). I am a community health specialist, health policy analyst and health systems researcher. I attach marked HS1 a copy of my curriculum vitae. 2. On the basis of my training, experience, skills and research I am professionally qualified to provide the information and express the opinions set out in this affidavit. The contents of this affidavit are true and correct to the best of my knowledge and belief. 3. In this affidavit I endeavour to answer two questions: 3.1 Does the South African health system, specifically the public sector, currently have the capacity to implement mother-to-child-transmission prevention (PMTCT) beyond the existing provincial pilot sites? 3.2 Is it within the capacity of the health system to plan for universal access to a comprehensive package of interventions for PMTCT? 4. I do not deal with questions of efficacy and cost-effectiveness, which I understand have been addressed by others. 5. By a comprehensive package of interventions for PMTCT, I refer to the following interventions: 5.1 voluntary HIV testing and counselling of pregnant women; 5.2 limiting certain invasive procedures on HIV-positive women during labour e.g. early rupture of membranes; 5.3 administration of nevirapine to HIV-positive women during labour and to their infant/s after delivery; 5.4 mechanisms for safe feeding of infants e.g. provision of breast milk substitutes, pasteurisation of breast-milk; 5.5 empowerment of HIV-positive women to make informed choices regarding the feeding of their infants; 5.6 provision of ongoing counselling and support in the post natal period. Capacity of the health system 6. Health systems can be considered as having both a demand and a supply side. 7. The demand side is concerned with the use of health services by the population and the factors influencing this (e.g. trust in the health system, costs associated with accessing health services). With respect to PMTCT, a key demand side issue is the extent to which pregnant women and their infants currently utilize existing health services. 8. The supply side of the health system includes the health services (clinics, hospitals etc.) and the managerial and organisational infrastructure to support these services. With respect to PMTCT, the key supply side issues are the availability of HIV testing and counselling facilities to identify HIV-positive women who may benefit from interventions; staff time to implement the interventions; mechanisms to update the practices of health professionals in the light of changing evidence; effective drug procurement and distribution systems; procurement and distribution of breast milk substitutes; provider openness and positive attitudes to people with HIV. 9. Table 1 below summarises the current evidence regarding the capacity of the health system to deliver a comprehensive package of PMTCT interventions. Evidence is drawn from three South African surveys: 9.1 The South African Demographic and Health Survey, conducted in 1998 (referred to as SADHS 1998). This is published by the national Department of Health, with a foreword by the Minister of Health. Relevant data extracted from the SADHS 1998 are attached as HS2. 9.2 Surveys of primary health care (clinic) facilities in 1998 and 2000 and a survey of hospitals in 1998, commissioned by the Health Systems Trust (referred to as HST 1998 and HST 2000). The Health Systems Trust is a non-governmental agency that commissions and channels funding for health systems research. The surveys referred to were carried out by teams at the Universities of the Free State and Witwatersrand, by individuals that are well known and respected. Relevant data extracted from the HST 2000 and HST 1998 are attached as HS3. 9.3 A recently conducted assessment of the integration of AIDS care and support into primary health care clinics in Gauteng Province (unpublished data, Centre for Health Policy, referred to as CHP 2001). Relevant data from this survey are attached as HS4. Table 1: Health system capacity to deliver PMTCT Aspect of health system Current capacity Demand side Utilization of health services by pregnant women 94% of women make use of antenatal services during pregnancy. This is universally high across all provinces (SADHS 1998). Antenatal care is available through both the private sector and the network of public sector primary health care facilities, which include more than 3000 clinics/health centres ('fixed clinics') and a further 650 satellite and mobile clinics. In 2000, 87.4% of fixed clinics provided antenatal care (HST 2000). Utilization of health services for delivery 84.4% of women deliver in the health system i.e. under the supervision of a health professional. This varies from 74.6% in the Eastern Cape to 96.1% in the Western Cape (SADHS 1998) Utilization of health services after delivery /in infancy 93.3% of children attend the health service for their first immunizations at 6 weeks. 76.4% of children receive their third immunizations at 14 weeks. Rates for the third dose of DPT vary from 62.3% (Kwazulu-Natal) to 89.0% (Northern Cape) (SADHS 1998). Supply side HIV testing Over half (56.2%) of fixed clinics in South Africa offer HIV testing. This varies from 14.6% in the Northern Province to 100% in Gauteng, and the Northern and Western Cape Provinces (HST 2000). HIV counselling 83% of fixed clinics provide HIV counselling. This varies from 61% in Mpumalanga to 97% in the Western Cape (HST 2000). Aspect of health system Current capacity Supply side (cont.) Staff time In 2000, the daily patient load of nurses in fixed clinics was reported to be 19.8, well below suggested norms of between 28-40 patients per day, depending on the patient mix. The load varied from a high of 27.3 in Kwazulu- Natal to a low of 14.8 in Mpumalanga (HST 2000). Mechanisms to update the practices of health professionals Over a one-year period, 56.6% of fixed clinics had at least one person who underwent skills upgrading in the area of HIV/AIDS management (HST 2000). In 1998, 82.2% of district and regional hospitals had conducted some form of continuing education for staff (HST 1998). Effective drug procurement and distribution systems In 2000, 92% and 84.9% of fixed clinics had cotrimoxazole and ciprofloxacin tablets, respectively, in stock. These tablets are two antibiotics essential in the management of HIV and sexually transmitted infections. Availability varied from a low of 79.8% (cotrimoxazole, Eastern Cape) to 100% (ciprofloxacin, Free State) (HST 2000). Procurement and distribution of breast-milk substitutes In 2000, 65.8% of fixed clinics had infant nutrition supplements in stock. This varied from 25% in Mpumalanga to 90% in the Western Cape (HST 2000). Attitudes of providers The negative attitudes of health workers towards patients, especially poor pregnant women and people with HIV, have been documented in a number of settings. This problem is one of the most common complaints of the public health system made by users and communities. However, recent evidence from Gauteng Province (CHP 2001) suggests that well trained counsellors are having a positive impact on the "patient-centredness" of the health system, and that many providers have accepting attitudes to people with HIV/AIDS. 10. In the light of the above, does the South African health system, specifically the public sector, currently have the capacity to implement mother-to-child- transmission prevention (PMTCT) beyond the current provincial pilot sites? 11. The evidence from SADHS 1998 is that utilization of maternal and child health services by pregnant women and their infants is high. Except for the 16% of women who deliver their children outside of the health system, the target population for PMTCT is already being reached by the health system; 12. Apart from the Northern Province, where only 14.6% of clinics have HIV testing facilities, all provinces have HIV testing facilities in 39% or more of their fixed clinics; in 6 of the 9 provinces HIV testing is available in 50% or more of the fixed clinics. This does not include testing facilities available within the district hospital infrastructure. It is highly likely that in all but the Northern Province, HIV testing is available outside of the PMTCT pilot sites; 13. The existing evidence suggests that several other key aspects of health service capacity – counselling services, effective drug supplies, in-service training, and staff time – extend well beyond 2 pilot sites per province; 14. It is unclear whether the "infant nutrition supplements" documented in HST 2000 would cater for additional needs related to PMTCT outside of pilot sites; 15. Provider attitudes are enduring barrier to effective PMTCT. However, these should not be seen as universally bad or static. 16. The best available evidence thus suggests that the health system has the immediate capacity to provide a PMTCT programme on a scale larger than the pilot sites, in at least 8 of the 9 provinces. 17. The marginal costs (financial and otherwise) of a passive extension of the PMTCT programme, i.e. meeting the demand from patients and health professionals for the programme, are likely to be small. It would require the following: 17.1 Coordination of HIV testing and counselling facilities with those of antenatal services where these are not available in the same facility; 17.2 Coordination of clinic-based antenatal and postnatal services with hospital based delivery services; 17.3 Distribution of protocols for the comprehensive management of HIV-positive pregnant women and their infants to clinics and hospitals; 17.4 Introducing nevirapine into the routine drug supply systems of all facilities doing deliveries of babies (maternities). 18. The anecdotal evidence is that the large amount of public attention to PMTCT has stimulated considerable demand for the programme beyond PMTCT pilot sites. Meeting this need may signal a responsiveness of the health system to felt needs of both patients and providers, a factor which will increase the trust in other HIV related health system interventions. 19. Is it within the capacity of the health system to plan for universal access to a comprehensive package of interventions for PMTCT? 20. This requires that the following be addressed: 20.1 Expansion of the voluntary counselling and testing (VCT) infrastructure within antenatal services. VCT is a stated government priority, and as indicated by the HST surveys, a basic infrastructure is already in place. Planning for an expansion of VCT is entirely compatible with public health sector goals; 20.2 Managing the complex ethical, socio-economic and cultural problems associated with preventing the transmission of HIV through breast-feeding. While the public health sector cannot address all the factors associated with poverty in the short term it can create an enabling environment for safe infant feeding. This includes provision of breast milk substitutes and nutrition support to infants, children and their families, promoting research into other mechanisms of safe feeding, and intersectoral action at local level to address poverty, such as increasing access to child maintenance grants; 21. Given the health system inequities between provinces, it is likely that an uneven implementation of a PMTCT programme would occur. Rather than being a factor preventing planning for universal access, a PMTCT could provide a focus for highlighting and addressing inequities. 22. The complexity of a PMTCT programme is no greater than tackling malnutrition, tuberculosis and other chronic diseases – aspects that the South African health system has committed itself to dealing with. Two provinces, Western Cape and Gauteng have already developed plans for comprehensive roll out of the PMTCT programme. 23. The challenges associated with PMTCT should be seen as meeting the goals and objectives of the health system and the country. The risks associated with implementing a PMTCT programme are no greater than programmes already implemented by government such as free primary health care, the school feeding programme, and the introduction of new vaccines in childhood. SIGNED AND SWORN TO BEFORE ME AT ON NOVEMBER 2001, THE DEPONENT HAVING TAKEN THE OATH IN THE PRESCRIBED MANNER COMMISSIONER OF OATHS Rispel L, Price M and Cabral J. 1996. Confronting Need and Affordability: Guidelines for Primary Health Care Services in South Africa. Johannesburg: Centre for Health Policy, University of Witwatersrand. 1 1