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The article proposes to shift the financial burden of purchasing antiretroviral medication (ARVs) to HIV positive people who can “afford” as a response to the looming funding gap for ARV treatment (ART). While the increasing funding retreat by international donors is a serious concern that needs to be dealt with, making the already vulnerable group of HIV positive people pay for their treatment is the last option that should be considered.
It is an inappropriate measure which initially might be wrongly perceived as saving money. Spending less on ARV’s by the government and international agencies means a forecast of more spending on dealing with complications, resistance and interrupted virus suppression. Not only will this cost lives, it will also needlessly overload the health services, discourage health workers and deter people from coming forward for testing and treatment. Realistic patient contributions are limited in contributing to ARV availability and can be huge compared to the average revenue of a household. Providing Aids diagnosis and treatment free of charge to those who need it is a medical measure, as it directly influences both quality of care and potential impact on the HIV epidemic.
Most of the people accessing ART through the government system are genuinely vulnerable people who are already overburdened by additional costs for services such as drugs for opportunistic infections, fees for registration, x-rays, laboratory tests, transport fees and economical cost of absenteeism to work/school, and so on.
According to the National Aids Council (Nac), 436 000 people are on ARV treatment on the Government programme in Zimbabwe out of over 600 000 who are in need of the drugs. With more than 350 000 people living with HIV and Aids facing a potential risk of failing to access anti-retroviral drugs due to lack of funds by 2018, as highlighted by the Nac, it is imperative that feasible mechanisms be worked out so that there is no access disruption for those in need.
How will the differentiation be made between those who can pay and those who cannot? What mechanisms can be put in place that will not, in the process, mean treatment interruption for people on treatment? No doubt, the financial disengagement of major donors will have a considerable impact on patients currently under treatment and presents a risk for those who are eligible and waiting for their treatment to begin, to be sent home for lack of available drugs. This would signify a worrying return to the beginning of the year 2000, when caregivers had to choose which of their patients had the greater chance to survive, a choice that is totally unacceptable and inconceivable in 2012.
The unpredictability of one’s payment capacity would bring the HIV response in danger as it would create drug resistance! Indeed, if one month you have the money, then the next month you don’t…. and the third one you have it again — this will ultimately lead to the resistant strain!
HIV is no longer personal, it’s an epidemic which affects the whole society. Therefore society should be responsible for tackling it, not the individual. Putting it on the individual shoulders would indeed bring us back to defining culprits instead of saving lives. Treatment is indeed prevention, we cannot have the Aids response resting on individual shoulders – it is the society, both local and international, which needs to support treatment programmes in order to prevent new infections and lay down the basis for the future HIV control.
Currently, those who are on medical aid can manage to access ART through private clinics. Already the formally employed are contributing three percent towards the Aids levy and further taxing an already over taxed worker is asking for too much for someone struggling to put food on the table.
So clearly, mechanisms and solutions have to be found. However, the proposals highlighted in the reports are not an acceptable solution. In the worst case they will ultimately plunge the country back to that year 2000 era, and threaten the progress made in the last decade, as more and more patients will either default or not be able to access treatment through the public health system, if they cannot afford it.
We have to recognise that the HIV and Aids emergency in Africa is far from over. And it cannot be ended with domestic funds alone – the numbers are still too high. While the Government’s commitment to address the issue of sustainable financing for HIV is demonstrated by the establishment of the National HIV and AIDS levy, there is a need to further develop sustainable financing which will strategically focus on increasing domestic and international funding, strengthening effectiveness and efficiency in the use financial resources in service delivery and prioritisation of the national response strategies.
As outlined in the Zimbabwe National HIV and AIDS Strategic Plan 2011-2015, it is important to strengthen strategies to mobilise and increase domestic funding from government and private sector in particular through strengthened public – private partnerships. This may entail consideration for incentives including tax exemptions of funds used to support HIV and Aids related work.
Strengthening strategies for the collection and management of the HIV and Aids levy tax must be prioritised. This includes more engagement of the informal sector so as to ensure that they also contribute towards the Aids levy. With practical mechanisms in place, it is possible to reduce donor dependency and to increase the national contribution for the purchase of ARVs.
There is also an international responsibility. Therefore, MSF continues to urge donor countries to make sufficient funding available for the continuation of current HIV and Aids programmes, and also to guarantee the future scale-up of treatment and prevention activities in Zimbabwe. The Health Transition Fund, which aims at reducing the country’s high maternal and child mortality rates, should be extended to cover the provision of ART for its target group of beneficiaries, which are mothers and infants.
Numerous studies the world over show that charging for health services is detrimental to the overall socio-economic development of countries– free healthcare is cheaper in the long run than sustaining the high mortality brought about by lack of accessibility. We know now that getting patients on treatment early keeps them healthy, it avoids overloading health facilities and it reduces the spread of the virus. And better drugs are available, such as Tenofovir which is less toxic and easier to take on a daily basis than previous ones. We need to act on that knowledge and Zimbabwe needs to continue on that progressive path it has taken.
The hope of controlling the HIV and Aids epidemic has never been greater. The decentralisation of care, achieved by task delegation and community involvement, has allowed the significant scale up of HIV treatment in the decade. It will take more mobilisation of domestic and external resources so that the population benefits of ART in reducing infections, deaths, and illness can be fully realised. But while we agree that the Government needs to put in place strategies to tackle the problem of sustainability, it is not right and not feasible to put that burden on the back of an already vulnerable patient.
* Fasil Tezera is the MSF Head of Mission in Zimbabwe. MSF is an international, independent, medical humanitarian organisation that delivers emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare. In Zimbabwe, MSF has been running HIV/AIDS programmes since 2004, currently supporting the care of more than 46 000 HIV positive people, provides support to survivors of sexual violence and responds to disease outbreaks such as cholera, typhoid and measles. Globally, 170 000 people with HIV are receiving antiretroviral treatment from MSF in 19 countries.
Online Reporter