Ethics, economics and sustainability of ARV drug treatment programmes
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in Africa
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Opinion piece:
Many countries in Africa barely produce enough food locally to
feed their citizenry. Many lack capacity to protect their na-
tionals from the ravages of basic preventable communicable dis-
eases like malaria, tuberculosis, cholera and other childhood
infectious diseases. Yet, almost all Africa countries are being
'induced' to implement vertical programmes like the World Health
Organization's 3 by 5 Initiative among many others. The goal of
the '3 by 5' initiative is "universal access to antiretroviral
therapy for all living with HIV/AIDS". The target of the initia-
tive is "to have 3 million people living with HIV/AIDS (PLWA) on
anti-retroviral treatment by 2005".
(See: http://www.who.int/3by5/about/en/). Over 70% of the
world's population of PLWA is reportedly in Africa (UNAIDS).
Laudable as many ARV drug treatment programmes in Africa may be
and despite the promises of the Global Funds for Aids, Tubercu-
losis and Malaria (See: http://www.theglobalfund.org/en/, the
long term sustainability of these programmes with or without do-
nor funding is questionable.
(See: http://unwire.org/UNWire/20040315/449_14006.asp).
If not sustainable, is it ethical and economically rational to
initiate and implement these programmes in countries that cannot
barely fund basic health care? Given that African countries are
required to put down counterpart funding to procure ARVs from
multinational drug companies at reputedly reduced costs, do ARV
drug treatment programmes for HIV/AIDS care and control have the
best public health ROI (Return on Investment) among the numerous
competing health priorities in African countries today?
To address these questions, it is useful to look at the picture
playing out presently in some sample African countries.
Nigeria:
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Nigeria with an estimated population of 130 million people ini-
tiated sometime late in 2001 into early 2002, what was touted in
international circles as Africa's most ambitious ARV treatment
plan The plan targeted placing 10,000 adults and eventually
5,000 children on ARV drugs within the year at fifteen or so
designated treatment centres. According to reports, an initial
US $3.5 million worth of ARV drugs were imported from India at a
cost of US $320 for a full year course per person. The drugs
were delivered at a subsidized monthly cost of US $7.0 per per-
son in the targeted population of people living with HIV/AIDS
(PLWA). UNAIDS and Nigeria's Health Ministry figures indicate
that around 3.5 million of Nigeria's 130 million people have the
HIV virus as at year end 2003. With this in mind, it is clear
that the near 14,000 people actually enrolled in Nigeria's pilot
ARV programme are just a little drop in the ocean of its PLWA.
Notwithstanding, the pilot programme was bedevilled by many lo-
gistic problems, including supply chain snafus, lack of aware-
ness by beneficiaries of programme, inadequate provider capac-
ity, inability of beneficiaries to bear the cost of ancillary
diagnostic and laboratory services and drug expiration among
others. Many beneficiaries had no continuous supply of ARV drugs
and consequently suffered treatment stoppages that lasted for
over three months in some cases with attendant risks of drug re-
sistance.
(See:
http://www.datelinehealth-africa.net/betav1.0/news/detailnews.asp?news_id=9292)
With new clamour by local activists, another US $3.8 million
worth of ARV drugs has recently been ordered and received by the
Federal Ministry of Health.
(See:
http://www.datelinehealth-africa.net/betav1.0/news/detailnews.asp?news_id=9457)
In spite of this new order, the jury currently out there, is
that Nigeria's ARV treatment initiative has so far not achieved
any desirable public health goal against the background of the
estimated people in need and in the context of other competing
public health needs. For example, many Nigerian communities
still lack access to clean water and basic sanitation. Malaria,
cholera and cerebro-spinal meningitis among many other prevent-
able diseases exert deadly and daily tolls on the citizenry and
many primary health centres across the country lack adequate
personnel and funding. Many regularly have "stock-out" positions
on basic essential drugs such as antimalarials, common analge-
sics like aspirin and common antibiotics like penicillin.
(See:
http://www.datelinehealth-africa.net/betav1.0/news/detailnews.asp?news_id=9363)
Zimbabwe:
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According to recent reports, Zimbabwe is to begin providing
antiretroviral drugs next month; aiming to treat 260,000 by end
of 2005.
(http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=22215)
As in Nigeria, the government of Zimbabwe plans to provide drugs
first through five hospitals to 4,000 patients and three months
later expand the program to reach 260,000 patients by the end of
2005! According to official Health Ministry sources, at least
800 of the first 4,000 patients to be treated will be HIV-
positive children. Recall however, that Zimbabwe is currently
ravaged by massive economic and other woes that are likely to
persist well beyond 2005. Reportedly, the country faces severe
food shortages (See:
http://www.irinnews.org/report.asp?ReportID=38356&SelectRegion=Southern_Africa&SelectCountry=ZIMBABWE)
and inflation is set to hit 700% soon. Its health system is re-
portedly in shambles (See:
http://www.irinnews.org/report.asp?ReportID=39165&SelectRegion=Southern_Africa&SelectCountry=ZIMBABWE)
Well up to 60% of its health manpower in nurses and doctors are
already lost to developed countries including South Africa (See:
http://www.irinnews.org/report.asp?ReportID=35578&SelectRegion=Southern_Africa&SelectCountry=ZIMBABWE)
The health manpower exodus continues daily. The costs of basic
medicines, like cough syrups, antimalarials, analgesics, etc.,
have risen beyond the reach of many Zimbabweans and most espe-
cially devastating on the poor. (See:
http://www.irinnews.org/report.asp?ReportID=37054&SelectRegion=Southern_Africa&SelectCountry=ZIMBABWE).
Governments at all levels are unable to pay the paltry wages
earned by different cadres of health workers as and when due and
health workers' strikes are now frequent. Wherein therefore is
the wherewithal in Zimbabwe to achieve this ambitious ARV treat-
ment programme in the face of competiting national priorities?
Ethiopia:
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Ethiopia is a country that is still has numerous challenges to
overcome in its recovery from the ravages of several years of
war and repressive military governance. It faces severe food
shortages, extensive poverty and massive childhood nutrition and
related problems. Ethiopia does not have a local pharmaceutical
industry that can boast of producing enough vitamin tablets and
syrups, antimalarials, basic analgesics and antibiotics to meet
the essential drug needs of its population. Ethiopia also faces
health manpower and health system challenges of immense propor-
tions. Yet, Ethiopia with a population of 66.5 million and an
estimated 2.1 million people living with HIV/AIDS as at 2001
(see: http://www.cia.gov/cia/publications/factbook/geos/et.html)
is now one of three countries in Africa that has been estab-
lished local pharmaceutical plants to manufacture ARVs. As at
date, one of the two Ethiopian plants for ARVs, Bethlehem Phar-
maceuticals, lies idle waiting for fund from international do-
nors to procure raw materials for production (See:
http://www.irinnews.org/report.asp?ReportID=39951&SelectRegion=Horn_of_Africa&SelectCountry=ETHIOPIA)
Swaziland:
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According to recent reports from the United Nation's Integrated
Regional Information Network (IRIN), the government of Swaziland
bowed to pressures from international donor organisation and
permitted the introduction and distribution of antiretroviral
drugs (ARVs) in the country after many years of resisting.
The situation unfolding in the country is described as "confus-
ing, dangerous and free-for-all" as pharmacies are dispensing
ARVs without prescription or instructions informing patients on
how to take the medication. Taxi drivers are even said to be en-
gaged in selling ARVs freely to their passengers, while people
who are not told to expect side effects reportedly stop taking
their drugs fearing poisoning when they become nauseous, dizzy
and develop flu-like symptoms. A recipe for unmitigated drug re-
sistance through improper use! (See:
http://www.irinnews.org/report.asp?ReportID=39885&SelectRegion=Southern_Africa&SelectCountry=SWAZILAND).
These are but few examples of disconnect between the health re-
alities and priorities on the ground in most African countries
and health policies and programmes induced on African govern-
ments from outside. Many of these induced policies and pro-
grammes have doubtful sustainability outside of donor funding;
offer poor return on counterpart investment expended by African
governments and reputedly subvert national health plans and pro-
grammes in many African countries (See:
http://heapol.oupjournals.org/cgi/reprint/16/1/74.pdf).
Could resources being spent and also earmarked for spending on
ARV drug treatment programmes in Africa be better spent to pro-
mote more basic health prevention efforts generally as well as
for prevention efforts for control of HIV/AIDS specifically? Ar-
guably, yes; according to available evidence (See:
http://www.hopkins-aids.edu/publications/report/sept02_4.html
for views for and against).
Is rationing of limited health funds ethical and economical in
the service of the greatest public health good to the greatest
number of people? Unquestionably, yes; according to the litera-
ture on this subject (See:
http://jme.bmjjournals.com/cgi/collection/rationing and
http://www.bmei.org/jbem/volume8/num2/robbins_the_ethics_and_economics_of_health_care.php)
Is it both ethical and economically rational to spend limited
resources for unsustainable benefits to a few in the face of
other pressing public health needs in African countries? Argua-
bly, no.
The debate is up. More views are welcome.
Related article: John Kilama: "Aids quick-fix won't save Africa"
http://www.scienceinafrica.co.za/2004/january/aids.htm
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ter'. That should work.]
A. Odutola
Centre for Health Policy & Strategic Studies
Lagos, Nigeria
mailto:chpss_abo@yahoo.com