Race, Health Care and the Law 
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ARV Drug Treatment in Africa

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Vernellia R. Randall
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 A. Odutola 
Centre for Health Policy & Strategic Studies 
Lagos, Nigeria 

 

Many countries in Africa barely produce enough food locally to feed their citizenry. Many lack capacity to protect their nationals from the ravages of basic preventable communicable diseases 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 initiative is "to have 3 million people living with HIV/AIDS (PLWA) on anti-retroviral treatment by 2005". 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, Tuberculosis and Malaria  the long term sustainability of these programmes with or without donor funding is questionable.(See article) 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

Nigeria with an estimated population of 130 million people initiated 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 person 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 bedeviled by many logistic problems, including supply chain snafus, lack of awareness by beneficiaries of programme, inadequate provider capacity, 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 resistance (See: article).  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:article) 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 preventable 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 analgesics like aspirin and common antibiotics like penicillin (see: article)

 

Zimbabwe

According to recent reports, Zimbabwe is to begin providing antiretroviral drugs next month; aiming to treat 260,000 by end of 2005. (see article 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: article and inflation is set to hit 700% soon. Its health system is reportedly in shambles (See: article) . Well up to 60% of its health manpower in nurses and doctors are already lost to developed countries including South Africa (See: article .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 especially devastating on the poor. (See: article) 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 treatment programme in the face of competiting national priorities?

 

Ethiopia:

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 proportions. 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 established local pharmaceutical plants to manufacture ARVs. As at date, one of the two Ethiopian plants for ARVs, Bethlehem Pharmaceuticals, lies idle waiting for fund from international donors to procure raw materials for production (See: Article)

 

Swaziland: 

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 "confusing, 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 engaged 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 resistance through improper use! (See: Article)

These are but few examples of disconnect between the health realities and priorities on the ground in most African countries and health policies and programmes induced on African governments from outside. Many of these induced policies and programmes have doubtful sustainability outside of donor funding; offer poor return on counterpart investment expended by African governments and reputedly subvert national health plans and programmes in many African countries (See: Article

Could resources being spent and also earmarked for spending on ARV drug treatment programmes in Africa be better spent to promote more basic health prevention efforts generally as well as for prevention efforts for control of HIV/AIDS specifically? Arguably, yes; according to available evidence (See: Artcle) 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 literature on this subject (See: Article and article). 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? Arguably, no.

The debate is up. More views are welcome.

Related article: John Kilama: "Aids quick-fix won't save Africa

 

Last Updated:
 03/17/2004

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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu

 

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