TAC Statement on South African Elections

ANC Has Received an Unequivocal Mandate to Deliver on Health, Employment, Social Security, Education and Housing - Ordinary Citizens Have A Critical Role Between Elections

The Treatment Action Campaign (TAC) congratulates the African National Congress (ANC) on its election victory. We also commend all the other parties who demonstrated the vibrancy of democracy in our country. Support for the ANC across the country represents an unequivocal mandate from South Africa's citizens for the ANC government to deliver meaningful social improvements in our lives. In the context of the HIV/AIDS epidemic this means building a better public health care system, improving government's response to the HIV epidemic by energetically rolling out antiretroviral treatment, treating opportunistic infections, increased social security and improving and increasing HIV prevention efforts.

During the election campaign, President Thabo Mbeki visited many communities across the country and learnt of hunger, homelessness and ill-health. This work was commendable. We believe that a specific focus on HIV/AIDS by ANC leaders during the election would have made a significant impact on government efforts to prevent new infection, eradicate stigma and to treat HIV/AIDS. TAC did not make the 2004 election about HIV/AIDS because we accepted the good faith of the change in government policy, the increased allocation of resources and the beginning of antiretroviral roll-out in key provinces. We refused to give succour to parties who wanted to make HIV/AIDS a party-political issue. However, we welcome the common view among all the major opposition parties that a comprehensive treatment and prevention strategy is required for HIV/AIDS. We urge the ANC to call all parties together in Parliament and to form an all-party group on HIV/AIDS to ensure that legislation, regulation and constituency needs are addressed by all legislators.

It would be tragic if government believed that its increased majority at the polls is a justification for the unnecessary confusion and confrontation on HIV/AIDS between 1999 and 2003. In fact, a majority of TAC members voted for the ANC. Two recent scientific reports should alert the new ANC government, all other political parties, the private sector, labour and all of civil society to the crisis that unfolds quietly.

In April 2004, the South African Medical Journal published a report based on registered deaths between 1998 and 2003. These statistics are taken from the Department of Home Affairs registers. The total number of adult deaths for this period increased by 68%. After taking into account population growth and improved registration, the increase in premature death is at least 40%. Women aged 20-49 years were worst affected with 190% increase in registered deaths. The scientists conclude: "The uncertainty about the precise number of AIDS deaths should not allow people to dismiss the impact of HIV/AIDS on mortality. There has been a massive rise in the total number of adult deaths in the last 6 years. Given the ages at which these additional deaths occurred and the change in the cause of death profile, they can largely be attributed to HIV/AIDS. Such rises in the mortality should renew Government's resolve to implement the comprehensive plan to prevent and treat HIV/AIDS as rapidly as possible."

AIDS-related illnesses and deaths are increasing along with new HIV infections. Just as with deaths, new infections show that women and girls are at greatest risk. The first national population study of youth aged 15-24 by the Reproductive Health Research Unit at Wits University showed that 10.2% of all young people age 15-24 are already infected with HIV. At age sixteen 2% of boys and 4% of girls are already infected with HIV. Among the 10% of youth who have HIV, 77% are women. The study showed dramatic awareness and knowledge on HIV/AIDS transmission. This is commendable and is due largely to the efforts of government and many civil society actors. But the majority of youth do not believe that they are personally at risk of HIV infection.

These facts call for:

- Leadership and community mobilisation at every level to prevent HIV infection and to treat HIV/AIDS.
- Massive health and treatment literacy campaigns that actively encourage voluntary counselling and testing for HIV.
- Openness about HIV/AIDS to reduce stigma and discrimination.

There has been real progress in many areas of life over the last ten years. Yet, for millions of poor people the quality of public health-care has worsened. A combination of factors can explain this: the impact of HIV/AIDS on the health system; lack of training of personnel; profiteering by private hospitals, medical scheme administrators and pharmaceutical companies. Bad political management of health-care at national level has also played a role.

TAC calls for the Cabinet and Parliament to pay special attention to transforming and improving the national Ministry of Health and Provincial Health Departments. Increased investment in public health-care will improve the hiring and retaining of nurses, doctors and pharmacists and the rollout of antiretroviral treatment. HIV/AIDS will be one of the great tests of delivery for the ANC government in its next term. TAC invites the government to participate in the national People's Health Summit to be hosted by the TAC, the Rural Doctors Associatioin, health unions and the Eastern Cape Council of Churches in June 2004.

Finally, we believe that it is critical and feasible for government to increase social budgets substantially, albeit responsibly, and to tackle poverty through the introduction of a Basic Income Grant. The ANC commitment to increased investment in public works is commendable and will improve the lives of many people who are unemployed.

To achieve delivery, it will be necessary for ordinary citizens to become more involved in social action. Partnership, constructive criticism and watchfulness from civil society are critical to successful delivery and ensuring that the ANC's massive election victory is turned into a better life for all. In this, we join the people's contract.

[END OF STATEMENT ON ELECTIONS]

Report on TAC Public Meetings to Mobilise for Treatment Rollout - February to April 2004

Introduction

The TAC welcomed the adoption of an operational care and treatment plan that included the provision of antiretrovirals on 19 November 2003. The Western Cape immediately made plans to rollout and had over 1000 people on treatment by February 2004. However, it became clear in early 2004, that all other provinces were not proceeding because the Minister of Health was obstructing the rollout of the plan, primarily by failing to purchase an interim supply of antiretrovirals -- while a lengthy tender process for the medicines was being followed -- to distribute to hospitals and clinics that were ready to rollout. Following the Minister of Health's obstructions, the TAC proceeded with a public mobilisation campaign to highlight government's intransigence, as well as litigation. The public mobilisation campaign consisted of holding open meetings in cities across six provinces and inviting senior provincial representatives to account for the rollout in their provinces.

While it is too early to claim that this strategy has been entirely successful, there have been concrete results. Gauteng has started antiretroviral treatment in five hospitals and there are as yet unconfirmed reports that Kwazulu-Natal has also started. Pressure from the TAC also contributed to announcements by Free State and North-West provinces that rollout would proceed. The publicity caused by the public meetings and the threat of a court case resulted in the Minister of Health conceding to the TAC's demands and agreeing to purchase an interim supply of antiretrovirals. Nevertheless, the precise extent of the rollout at this stage is difficult to determine, but it is certainly not extensive. Progress in Limpopo, Mpumalanga and the Eastern Cape remains unacceptably slow. The TAC will have to monitor provinces closely over the next few months and possibly renew public pressure coupled with the threat of litigation to ensure the rollout proceeds with urgency.

This document briefly describes the public meetings held from February to April by the TAC. Meetings are listed in chronological order.

Johannesburg

Over 1000 activists packed the Johannesburg City Hall on 25 February. Speakers included Molefe Tsele, General Secreatry of the SACC, Zwelinzima Vavi of COSATU, Chez Milane of FEDUSA, a health worker from Vaal and two TAC activists who live with HIV.

Critically, the meeting was attended by Mbazima Shilowa, the Gauteng Premier, Gwen Ramakgoba, the MEC for health, Ram Saloojee, the chair of the Health Portfolio committee and a range of other health department officials - who listened to all the speakers. Shilowa promised to introduce treatment as soon as possible at facilities that have capacity, at least in the major hospitals in the Province. The TAC met with him for 20 minutes afterwards, and he also instructed health officials to meet with the TAC to plan joint work. By all accounts, the Premier has stuck to his word so far.

Louis Trichardt

On the 5th of March, a public meeting was was held at the Makhado Show Ground in Louis Trichardt (Limpopo Province). Two hundred activists came together to discuss the rollout. Speakers from the health department promised they would come but did not. The office of the MEC for health in Limpopo said that " the MEC would have liked to come to the meeting but he is busy." Last minute attempts to get speakers also produced no results at all. Nevertheless, the meeting proceeded and the TAC in Limpopo is committed to ensuring that treatment is rolled out in this province.

Cape Town

About 1000 activists packed the Cape Town City Hall on 8 March. Speakers included Vuyani Jacobs, John Vellenhoven and Zackie Achmat all of whom live with HIV and take antiretroviral treatment. Tony Ehrenreich from COSATU gave the trade union's backing to TAC's pressure on the Minister of Health. Dr. Fareed Abdullah of the Western Cape Department of Health described the rollout in the Western Cape, saying that over 2000 people were already on treatment and the department's goal was to have approximately 45 sites started within a year and 5,000 people on treatment. He committed to putting every child with AIDS on treatment in the Western Cape within a year.

Also, on 21 March, NACOSA Western Cape, Triangle Project, Hope World Wide, Sizophila, Positive Muslims and TAC organised a seminar for people with HIV/AIDS at Jameson Hall on the University of Cape Town. About 800 people attended. The meeting examined the needs of the rollout programme and treatment literacy. It was addressed Dr. Fareed Abdullah and Dr. Linda-Gail Bekker.

Durban

Nearly a thousand people attended the public meeting held on 16 March at Durban City Hall, started. The meeting was opened by observing a moment of silent to remember all comrades and fellow South Africans who have died of AIDS, most of them without access to antiretroviral treatment.

The chairperson for the day, Sbu Khanyile, welcomed welcomed and acknowledged the presence of different NGO, doctors and nurses. Mama Ritta, explained how she lost two children, one in 1998 and the second in 2000, because they had no access to affordable treatment. She had difficult times and was stigmatised and isolated in her community, so she decided to stand up and joined TAC.

Cecelia Hlabisa told the meeting that her child is on treatment through the TAC Treatment Project. Her child was sick and confined to in bed before going on treatment but now her daughter can walk and smile. Her daughter was also present.

Dr Kim Langley from Stanger Hospital spoke next and made an inspiring speech in favour of treatment.

The fourth speaker was Zodwa Ndlovu, a TAC activist and a nurse by profession. She spoke about the frustrations felt by nurses working in HIV/AIDS. She explained that they need proper training and resources.

There was disappointment that MEC for Health, Dr Zweli. Mkhize, cancelled at the last minute. He sent apologies and sent the Durban District Health Manager, Mr D.M. Msiza. He simply apologised and said he had no mandate to speak on behalf of the KZN Department of Health. Instead he spoke on general issues such as the antiretroviral training held for two days by doctors and co-ordinators.

Mark Heywood, TAC's National Treasurer spoke on the national treatment plan and shared information on what is happening in other provinces. He expressed sadness that the KZN Premier and the MEC for Health were not present and asked, "Where is the political commitment and leadership".

The meeting resolved to seek an urgent meeting with the MEC of Health and to ask him to announce a rollout date.

Queenstown

A public meeting was held on 18 March 2004 at the Queenstown Multi-Purpose Centre.It was attended by at least by 500 people, most of them people with HIV/AIDS (PWAs) from rural communities.The programme was well structured with PWAs sharing their experiences. The government was represented by Nomalanga Makwedini, HIV Director for the Eastern Cape Provincial Department of Health.

Meeting attendents demanded the date for the provision of antiretrovirals stating that they already know the date for the elections. As expected the director failed to give the date but at least acknowledged the importantance of antiretrovirals.

Port Elizabeth

A public meeting was held at City Hall on 18 March. About 200 people attended. There are only two active branches and there is no physical office in Port Elizabeth so this turnout was expected. The meeting was entirely organised by volunteers. Dr. Pailman from the Provincial Department of Health gave an overview of sites for antiretroviral rollout. She mentioned that the department is waiting for drugs but emphasised that in the meantime they need a working relationship with TAC as they recognise TAC's skills in Treatment Literacy and community mobilisation.

Ncumisa Nonongo gave an overview of the treatment plan emphasising that the government committed to start to distributing antiretrovirals by the end of 2003 but up to now no rollout has taken place. The Public Service Accountability Monitor presented the budget of the government and pointed out that there was no provision for antiretroviral rollout.

Speakers living openly with HIV demanded the expected date of antiretroviral rollout from Dr Pailman but she could not give it. She promised to involve people with HIV in monitoring of patients who are taking antiretrovirals. She also promised to call upon TAC when they are ready to rollout.

Polokwane

On 25 March, a meeting was held in the capital of Limpopo, Polokwane. Over 200 people attended the meeting. There was lively singing and, branches had developed their own locally remixed songs. Attempts to get the MEC for Health or a person from his department were unsuccessful. First the provincial department promised to he would come but it was postponed apparently because the MEC was busy. However his absence did not dampen the spirit of the meeting.

The meeting discussed what the TAC should be doing in Limpopo to make sure that the rollout is successful. It was pointed out that there is nothing much that is happening in terms of the rollout. Some of the identified hospitals are said not to have counselling rooms, unreliable laboratory access and small pharmacies. Many people raised their concerns that Limpopo health department is not moving fast enough to address these issues.

The meeting resolved to:

- Write a letter to the MEC requesting a meeting and an update on the antiretroviral rollout in Limpopo
- Picket outside the provincial health department if the response to the above letter is inadequate
- Clarify the issue of NAPWA and TAC to members
- Hold another public meeting soon to get an update

Lusikisiki

On 26 March TAC held its biggest event yet in the rural town of Lusikisiki, Eastern Cape. Lusikisiki serves one of the poorest rural areas in South Africa, but it is home to a fledgling antiretroviral project administered by Medecins Sans Frontieres, with a strong TAC presence and office. The approximately 40 people on treatment in public facilities in Lusikisiki constitute all the people currently on treatment through the government treatment programme in the Eastern Cape.

The meeting started at the townhall where Akhona spoke. About 1000 people marched through Lusiksiki main Street. The march stopped at the taxi rank and the hospital where Nolusapho and other spoke. The district manager, who is hard to track down for any meeting, and district pharmacist had been waiting there from 10h00 until the crowds arrived at 12h00.

Unfortunately the MECs office and the HIV directorate had sent an apology the day before that they would not be able to attend. This dampened the spirit slightly, but not much.

The main speakers were Mzimkhulu Zibi of SADTU, about six people with HIV, Thembi Ntlangulela, the district manager and Mandla Majola of TAC.

Nozibele Mditshwa was critical of the MEC who says that uneducated people should not get ARVs. She is uneducated and ARVs have saved her life. When elections come everyone is equal. Even if we are uneducated we can vote. Why should we not be equal when it comes to medicines. The called on the MEC to announce the date of antiretroviral rollout before the elections.

Thembi repeated the now old information of having one site per district municipality and not knowing when the drugs will come. Phase one should have started last year and phase two now etc.

Mandla emphasised that the Eastern Cape is always the last area to implement programs and that little leadership was coming from the MEC. In election time every village can have a voting station, why not a clinic. He also pointed out that antiretrovirals are cheaper because of TAC's battles with drug companies.

East London

A public meeting was held in the Mdantsane Indoor Sports Centre on 29 March. Over 700 people attended. The Department of Health in the district excused themselves from the meeting by saying that their comments at the Queenstown meeting applied to the whole Eastern Cape

The meeting took the following resolutions:

- Release a statement expressing disappointment that the provincial department did not send any representatives
- Request a meeting with the MEC of Health
- If no adequate response is received to a request for a meeting with the MEC, take further urgent actions with the advice and support of the National Office.
- Brances must broaden work with other organisations so that the messages of treatment and prevention can be spread to them.

Neslpruit

Over 700 people crammed into the Nalsville Hall in Nelspruit for a public meeting on 7 April. The MEC for Health was invited, but she sent a director from the Provincial Department of Health in her place. He, however, refused to speak or answer any questions, claiming he was just there to listen. The central question that he was asked was: when is rollout beginning in Mpumalanga? The attendants were disappointed with the attitude of the provincial health department. The TAC has received a complaint from a member of the public who claimed that the personal assistant to the MEC for Health told her that it would be lucky if treatment were available before 2008. TAC Mpumalanga finds this unacceptable and will step up its campaign in this province within the next few weeks until treatment is rolled out.

[END OF PUBLIC MEETINGS]

TAC Sends Letters to Some MECs for Health Expressing Concern About Slow Pace of Rollout - Requests Updates on Progress

The TAC has sent letters to the MECs for Health in Limpopo, Mpumalanga, North-West, Northern Cape and Eastern Cape provinces expressing concern about the slow pace of the treatment rollout and requesting updates on progress. Below is the letter sent to Mpumalanga. Similar ones were sent to the other provinces.

7 April 2004

Ms Busi Coleman MEC for Health: Mpumalanga 7 Government Boulevard, Building 5 Riverside Park, Extension 2, NELSPRUIT

Per fax: (013) 766-3471

Dear Ms Coleman


IMPLEMENTATION OF THE OPERATIONAL PLAN FOR COMPREHENSIVE HIV AND AIDS CARE, MANAGEMENT AND TREATMENT FOR SOUTH AFRICA IN MPUMALANGA

1. In November 2003, the Treatment Action Campaign (TAC) welcomed the release of the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa ("the Operational Plan"). In our view, the Operational Plan is the product of discussions that had been taking place for over 18 months and is the culmination of several years of work in the area of HIV/AIDS prevention and treatment. We view the Operational Plan as a useful practical vision, which if implemented urgently and reasonably, could potentially save the lives of many people living with and affected by HIV/AIDS.

2. While we have also welcomed the initial public provision of antiretroviral (ARV) treatment in the Western Cape, KwaZulu-Natal and Gauteng, as well as the Free State's commitment to begin providing ARV treatment on 1 May 2004, we note with concern that Mpumalanga has neither begun providing ARV treatment nor has it committed to any particular date upon which public health facilities will begin dispensing ARV medicines. This is particularly disconcerting given the following:

2.1 Mpumalanga has set up a Provincial Steering Committee and a Provincial Accreditation Team.

2.2 12 treatment sites in Mpumalanga have been identified by your offices, and thus far six (two in each of three health districts) have been accredited by the National Department of Health (NDoH) as having the requisite capacity to provide the interventions listed in the Operational Plan.

2.3 Project facilitators have also been appointed at each of the 12 identified treatment sites.

2.4 According to a presentation made by your offices to the NDoH on 4 March 2004, health care workers were trained earlier in the year whilst a second round of training was due to take place in March 2004.

2.5 There are no obstacles to the procurement of ARV medicines:

2.5.1 To ensure the provision of ARV treatment pending the finalisation of the formal tender process for the procurement of ARV medicines, the health MinMEC decided on 23 March 2004 to procure such medicines in the interim through a national price quotation system. According to the NDoH, the formal tender process will be completed only by June or July 2004.

2.5.2 This means that there is no bar to the procurement of ARV medicines before the formal tender process is finalised. Provinces can purchase ARV medicines to meet interim needs by making use of the national price quotation system.

2.5.3 Copies of the correspondence in this regard were sent to the office of the Premier. Kindly note that provinces are expected to inform or confirm with the NDoH site readiness and patient numbers in order to access an interim supply of ARV medicines.

2.6 Funds for the implementation of the Operational Plan in the fiscal year 2004/2005, in the form of conditional grant allocations, have been accessible since 1 April 2004. There are therefore no financial barriers to procuring an interim supply of ARV medicines immediately.

2.7 Any delay in the provision of ARV treatment where it is medically indicated will result in a significant number of deaths and/or loss of life years of persons who should and could be on treatment.

3. The TAC is committed to ensuring that the Operational Plan is reasonably and successfully implemented in all provinces. We would therefore like to ascertain to what extent the Operational Plan has been implemented in Mpumalanga and how, if at all, we can help you with its urgent and continued implementation. We trust that we will be able to assist your offices with community mobilisation, treatment literacy, support and training at the six sites that have already been accredited.

4. Aside from these sites, please also advise what steps you will be taking to increase the number of treatment sites over the next few months so that in the short and medium term there are additional sites that will be ready to administer ARV treatment.

We look forward to a mutually constructive and beneficial relationship. Once again, we hope that we can be of assistance to you by providing treatment literacy and community support at the six accredited sites as well as at future designated sites.

We look forward to hearing from you shortly.

Yours sincerely





Zackie Achmat
Chairperson

Sipho Mthathi
Deputy Chairperson

cc: Premier NJ Mahlangu

[END OF LETTER TO PROVINCES]

Malady of medicine

By Jonathan Berger and Fatima Hassan, Published in ThisDay, 20 April 2004 (Berger and Hassan are lawyers with the Law and Treatment Access Unit of the AIDS Law Project and members of the TAC)

Your throat aches every time you swallow. Your doctor says you have thrush and writes a prescription for fluconazole. But the clinic pharmacy is out of stock. You are told to come back the next day.

You have used up all your sick leave and can't afford to take off another day waiting in line for free medicines. It's two weeks to payday. You have no money to purchase the drugs at your local pharmacy. What do you do?

Right now you could be in luck. Your prescribing doctor, who also dispenses medicines, may help out. But come the beginning of next month, your doctor will no longer be permitted to dispense medicines unless she or he is expressly licensed to do so.

Placing such restrictions on the dispensing of medicines clearly limits access to essential medicines. So why then is government intent on introducing a regulatory framework to license dispensing practitioners? Why prevent doctors from performing such an important service?

Those seeking to regulate the practice recognise the important role played by many dispensing practitioners. But they also acknowledge that the right to dispense has often been abused. This has been possible because the linkage of prescribing and dispensing creates perverse incentives, with the prescribing doctor having a direct financial interest in what he or she dispenses. This is not the case when doctors prescribe and pharmacists dispense, as is the ordinary course of events.

The practice has sometimes resulted in the prescription of what's in stock rather than what's actually needed, or even the prescription of stock that's about to expire. More common and similarly problematic is over-servicing, where medicines are prescribed simply to generate a dispensing fee. Also, where doctors practice on a flat-rate fee that includes both consultation and medicines, the perverse incentive may be to prescribe cheaper - and possibly inappropriate - medicines to cut costs and boost profits.

Such practices have to be stopped. Simply put, there is a need to separate prescribing and dispensing wherever possible, only permitting the practice where it can be shown that the service is indeed required.

This is what the new law seeks to achieve. The Medicines Act now requires that health practitioners apply for licences before they can dispense medicines - inconvenient perhaps, but not particularly problematic.

This approach is endorsed by the World Health Organisation and practised in many countries. Why then are dispensing practitioners so outraged?

As is often the case, the devil is in the detail. Take the application form for a license as an example. In specifying the geographical area to be serviced, applicants must not only supply information on its population size, but also "the disease patterns and health status of the population". Further, the "names and addresses of other similar existing services in the catchment area of the proposed new service" must also be supplied, including those of pharmacies, hospitals and clinics.

Such information is clearly necessary if the licensing process is to be fair and accountable. But should the collation of such data not be the work of government rather than health care practitioners? Are we not requiring applicants for licences to jump through too many hoops?

As currently drafted, the application form is cause for concern. Some health practitioners believe they are being asked to do the impossible. What if the relevant data is not accessible or affordable? Upon which data must the information be based? The department's application form guidelines are not particularly helpful in answering these questions.

What is needed is a bit of give and take on all sides. The right of access to health care services must come first.

The government needs to concede that the regulatory framework requires fine-tuning. Until its District Health Information System can provide the requisite data for accurate assessment, it must be less prescriptive and more lenient. A good start would be a new application form that requires applicants simply to make out a case why their services are essential.

For their part, dispensing practitioners need to accept the system in good faith. If licences are unreasonably denied they can and should seek appropriate legal redress.

[END OF MEDICINES ACT DISPUTE]

[END OF NEWSLETTER]