On-line version ISSN 2078-5135
Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.98 n.12 Cape Town Dec. 2008
With a pragmatic new health minister eager to redress the tragic legacy of South Africa's political prevarification on HIV/AIDS and a gloomy recession-hit health care delivery outlook, AIDS-efficient businesses are up-scaling programmes and mentoring key partners.
The spur is an estimated 500 000 new HIV infections per annum and treacle-slow implementation of the National Strategic Plan on HIV/AIDS and Sexually Transmitted Diseases, described by one scenario planner, AIDS actuary Nathea Nicolay, as 'failing'.
An estimated 5.6 million South Africans are HIV positive,1 the largest number of any country in the world. The lowest take-up rate of ART is in KwaZulu-Natal, the hardest hit province, at 43% and the highest take-up is in the Western Cape at 74%.
According to Harvard School of Public Health researchers, more than 330 000 lives were lost to HIV/AIDS in South Africa between 2000 and 2005 because 'a feasible and timely' ARV treatment programme was not implemented. In addition, 35 000 babies were born with HIV because a feasible PMTCT programme using nevirapine was not implemented.2
By 2005 South Africa had 23% ART coverage and less than 30% PMTCT coverage. Botswana by comparison (PMTCT begun in 1991, 4 years before SA and ART in 2001, 3 years before SA) reached 85% ART coverage and more than 70% PMTCT by 2005.
Namibia, the other comparable neighbour, achieved coverage of 71% ART and 70% PMTCT by 2005.
Nicolay and scenario guru, AngloGold's Clem Sunter, facilitated urgent brainstorming cross-sectoral partnership ideas in Cape Town in separate forums in October. The South African Business Coalition on HIV/ AIDS (SABCOHA) also convened a conference in Johannesburg in November questioning the country's ability to lower infection rates and seeking solutions.
Sunter and Nicolay, convenor of the Actuarial Society of South Africa's AIDS Committee, said the sub-prime mortgage-driven global recession demanded up-scaling of HIV/ AIDS treatment and prevention and innovation like never before.
Said Sunter, setting the global context for a workshop on improving health care delivery: 'I've never witnessed such (economic) tumult in my entire life, the last comparable major event was the Second World War.. .since the beginning of the year the USA have lost 750 000 jobs and London is carnage with lay-offs'.
Nicolay, Metropolitan's AIDS Risk Consulting chief, told a 'Work the Future' road show that even under her 'Summer for All' and 'Autumn of Limited Opportunity' AIDS scenarios it was 'questionable' whether the health system would be able to handle the over a million people estimated to be on ART by 2025. The road show was a collaboration by SABCOHA, Business Unity South Africa (BUSA) and Metropolitan Health Group (MHG).
Sustainability of ART rollout questioned
Nicolay said even the country's current relatively high levels of access to ART might not be sustainable with low economic growth and increasing health care demands. 'If business does not successfully address prevention, we might see a "Winter of Discontent" scenario (characterised by weak and self-serving leadership, stigma and denialism, with few partnerships), with 8.7 million new infections and 8.1 million deaths over the 20 years from 2005 to 2025,' she warned.
Her message was backed by Professor Wiseman Nkuhlu, former economic advisor to past-president Thabo Mbeki and former Chief Executive of the Secretariat of the New Partnership for Africa's Development (Nepad), who gave the keynote speech at the road show that travelled to every province between October and December.
Nkuhlu said that in terms of reaching the international community's target of providing universal access to HIV/ AIDS treatment, care and support by 2010 (reaffirmed at the Mexico International AIDS Conference in August), South Africa was 'far behind'.
'We make a clarion call to business in particular to redouble efforts to broaden and deepen private public partnerships that would scale up our impact, both in terms of treatment and prevention; urgent action is essential,' he said.
Some of the ideas to emerge included applying business management principles to public clinics and hospitals whose CEOs should be given 'real autonomy', and identifying 'pockets of excellence' for replication. Among the 'pockets' cited were the private/ publicly-run Enkosi Albert Luthuli Hospital in Durban, Johannesburg General Hospital's oncology department, Chris Hani/Baragwanath's antenatal unit and the Red Cross Children's Hospital burns unit.
Sunter suggested using what he termed the 'world-class' South African Revenue Services (SARS) as a benchmark for all other government departments (new Health Minister Barbara Hogan helped overhaul SARS).
SA losing global economic status
He said that in spite of having 21% of the continent's GDP, South Africa had fallen from 38th place to 50th in the International Institute for Management Development's World Competitiveness 2007 Yearbook. It had gone from 29th position to 35th on the World Bank's 'ease-of-doing business' rankings. It was the first time the country had fallen out of the top 30 since the surveys began 5 years ago.
'We have the usual suspects: violent crime, HIV/AIDS shortening the lifespan to 52, infrastructure showing signs of deficiency, some industries looking distinctly uncompetitive (e.g. textiles) - in soccer terms we are now in the relegation zone after having been in the Premier League in 1994,' Sunter said.
If relegated to the 'second division' (where the bulk of the poor but peaceful Third-World countries were), there would be 'no money for a better life for all'. If conflict erupted to combine with declining competitiveness, 'a failed-state scenario' was not 'altogether improbable'.
Sunter said the road back to the 'middle of the Premier League' required low-key brave leadership that got things done (in stark contrast to charismatic populist leadership).
'We need a leader who appeals not only to the Polokwane faithful but to the rest of us. We need performance on the job that has nothing to do with sisterhood, brotherhood or struggle credentials.'
Footprints and quality
Outlining four scenarios for health care, Sunter said the two most important variables were how wide the footprint of health care was and how far it extended. Another crucial variable was quality of service.
South Africa was in his 'cruel world' scenario, where quality of service existed but the footprint was limited. Existing 'pockets of excellence' in the public health sector needed urgent replication.
'Basically "cruel world" means that it's pretty difficult to be healthy and poor' - if you have the money, you pay for longevity. A 'hollow justice' scenario meant widening the footprint in an arbitrary manner, leading to an exodus of skills and 'dumbing everything down instead of raising it up'.
The 'national longevity scenario' was 'where you widen both the footprint and the quality of service'. The reality here however was that HIV/AIDS in South Africa had dropped life expectancy by 10 years - in 10 years.
The fourth and worst scenario was the 'death zone', which had no quality of service and no footprint, 'but I don't think we're there at the moment', he reassured his audience.
To stimulate input Sunter, who is Chairman of AngloGold's Uranium and Gold Division, cited Anglo's 'Zimeli' project where they had set up an investment company exclusively to help small businesses scale up and satisfy Anglo's contract requirements.
Zimeli transformed from a corporate responsibility programme to a proper business programme, wildly exceeding all projections. 'We thought we'd do about R200 million last year, but we actually did R17.5 billion,' Sunter revealed.
Massive prevention campaign needed
Nicolay told her audience that her 'Summer for All' HIV/AIDS scenario was only possible 'if we focus all our efforts on a massive prevention campaign that involves hugely stepping up the ability business has to influence behaviour change'.
As for treatment, only half of the one million people needing ART were accessing it. What was needed was business focussing on the NSP (which closely matched her 'Summer for All' scenario), reducing infections by half by 2011 and expanding access to treatment, care and support to 80% of those needing it.
Vic van Vuuren, CEO of BUSA, said business, government and labour needed to 'move beyond conversation to practical implementation'.
'We encourage companies who are already successfully managing HIV/ AIDS programmes in the workplace to think creatively about how they can share their knowledge and resources, for example using the supplier chain network to open up opportunities and access funding for SMMEs.'
While implementing VCT could be costly, partnering with NGOs who received international funding was another way bilateral partnerships could be fostered.
Nicolay said the nine provinces were in different stages of the HIV epidemic. The Eastern Cape, Western Cape, Northern Cape and Limpopo were still experiencing high numbers of new infections relative to AIDS deaths, leading to rapidly growing HIV prevalence rates. In other provinces the epidemic was approaching maturity with the same numbers of people getting infected each year as were dying of the disease. Adult prevalence for the provinces ranged from 28% in KwaZulu-Natal to 9% in the Western Cape.
2. Chigwedere P, Seage G, Gruskin S, Lee T-H, Essex M. J Acquir Immune Defic Syndr 2008 ( in press). Available online. Last accessed 16 October 2008. [ Links ]