E-DRUG: Hard choices - rationing ART for HIV/AIDS in Africa
[A useful electronic Lancet paper; thanks to Andy for spotting it. Copied as
fair use. WB]
Sydney Rosen, Ian Sanne, Alizanne Collier, Jonathon L Simon
Published online December 31, 2004
Center for International Health and Development, Boston University School of
Public Health, Boston, MA 02118, USA (S Rosen MPA, A Collier MA,J L Simon DSc);
and Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg,
South Africa (I Sanne MBBCh)
Correspondence to: Sydney Rosen email@example.com
As the world intensifies its fight against the global AIDS epidemic, African
countries have begun to develop large-scale prevention and treatment
programmes. A combination of funds from African governments and international
donors are paying for drugs, diagnostics, clinic and laboratory infrastructure,
and medical personnel.
Although these funds, which reach into the billions of dollars,1 will pay for
antiretroviral therapy for many thousands of HIV-positive Africans, there is
almost no chance that African countries will have the human, infrastructural,
or financial resources to treat everyone who is in need, at least in the early
years. The numbers of patients targeted for treatment are ambitious, but they
are only a small fraction of those who are eligible for antiretroviral drugs on
even the most conservative medical grounds. In Zambia, for example, the
first-year target for treatment is 10 000 patients; 100000 Zambians have
already reached the clinical threshold of fewer than 200 CD4 cells per uL, and
thousands more become eligible each year.2 Ghana is targeting 12 000 patients
for therapy in the first 2 years;3 58 000 are believed to be medically eligible
now.4 Kenya's target is 50% coverage,5 as is the global target of WHO's 3by5
initiative.1 Economists call any policy or practice that restricts consumption
of goods a rationing system.6 As used by economists, rationing is
value-neutral, ie, it does not imply intent to deprive people of a good
resource, but rather describes the allocation of a scarce resource. In the
marketplace, rationing is based on price. Non-market goods, such as free
medical care, are rationed in other ways. Ambitious targets for treatment of
HIV/AIDS still represent only a few of those in need; therefore, the rationing
of treatment services is inevitable. Rationing of antiretroviral therapy for
HIV/AIDS will be necessary as long as demand exceeds supply.
What are the options?
The most accepted criterion for rationing antiretroviral therapy is disease
progression. WHO guidelines and many national guidelines in Africa call for
treating only patients with a CD4 count of less than 200 cells per uL or an
AIDS-defining illness.7 These criteria affect demand dramatically: researchers
doing a study in South Africa found that if treatment programmes applied the
guidelines of the US Department of Health and Human Services, which call for
starting treatment at a CD4 count of 350 cells per uL rather than WHO
guidelines, the proportion of HIV-positive people eligible for therapy would
increase from 975% to 5673%.8 Even if health-care providers use WHO's
conservative guidelines for when treatment should begin, medical criteria alone
will not avert the need to ration antiretroviral therapy. Socioeconomic
criteria will also be needed. In some countries, governments will set explicit
criteria for who will be eligible for antiretroviral therapy first, or at
lowest cost. In other countries, implicit rationing systems will arise. To help
to clarify the differences among the various rationing strategies that might be
adopted, we have defined four general types of systems. Two are explicit and
two are implicit. Some policies and programmes use explicit socioeconomic
criteria to define the populations that have priority. The most widely adopted
example of a programme that explicitly targets specific populations is
MTCT-Plus, a programme that makes antiretroviral therapy preferentially
available to HIV-positive mothers of new infants to stop mother-to-child
Skilled workers also could be targeted, because they produce goods and services
and generate economic growth. Governments can preserve human capital by giving
treatment priority to doctors, nurses, teachers, judges, police officers, or
postsecondary students, among others. Kenya, for example, has indicated that it
will target health-care workers.10 Some programmes prioritise poor people for
treatment because they have the lowest probability of being able to afford
private medical care, and many people believe poor people should have
preferential access to publicly funded treatment programmes.11 Governments can
also make rules for access that explicitly favour certain individuals or
groups, without specifying particular socioeconomic target populations. One
obvious way to ration treatment is to restrict it to those who live in
specified geographic areas. These targeted areas can be distributed equitably
throughout the country, concentrated in regions with high rates of HIV
infection, or sited in urban centres or politically important regions. Another
way to ration treatment is to require patients to make copayments. If
programmes require patients to contribute even a small share of the cost of
treatment, the number of people with access to therapy probably will fall
Other conditions limit access implicitly. For a patient to have access to
treatment, he or she must be identified as HIV-positive and medically eligible,
have the means to reach a treatment site, be seen by a health-care
professional, and receive the prescribed medications within a period that is
both medically and economically feasible. Programmes can limit access at each
step in this process. If HIV tests or CD4 counts are not available in a
particular area, it will curtail demand for treatment. For some patients,
transport costs pose an insurmountable obstacle. Most facilities probably will
treat everyone who is medically eligible on a first-come, first-served basis
until they run out of drugs or expertise. Patients who arrive after that
happens might be asked to return later, sent to another facility, or simply
sent away. Other patients will wait in a queue outside the clinic or pharmacy
door. Patients will not get treatment if their jobs, child-care
responsibilities, or other obligations prevent them from waiting the hours or
days needed to reach the front of the queue. All the rationing systems
mentioned above result from formal policies, rules, or procedures. Rationing
can also be based on informal, and often illicit, arrangements that favour
specific groups or individuals implicitly. In countries where enforcement of
rules tends to be weak and informal arrangements common, members of the social,
economic, or political elite who believe they need therapy will get it. A high
degree of queue jumping, which allows certain groups or individuals to move to
the front of the treatment line, should be anticipated. Black markets for
antiretroviral drugs, which allow low price medications to be resold at higher
prices to those who can afford them, have already been reported in
Zimbabwe,12 Swaziland,13 and other countries.
Evaluation of the systems
Different ways to ration antiretroviral therapy will have different social and
economic consequences for African populations. Understanding these outcomes is
important if the decisions made about resource allocation and programme design
are to help a nation accomplish its goals for fighting HIV/AIDS and sustaining
economic development. We have identified seven criteria for assessment of
rationing systems and we provide an example of how each criterion might be
First, does the rationing system produce a high rate of successfully treated
patients? Requiring patient copayments could improve medical effectiveness by
favouring highly motivated, and therefore adherent, patients. Investigators in
Botswana, however, report that patients most commonly stop therapy because they
cannot afford the copayment.14
Second, is the cost per patient treated low, compared with other approaches?
Queuing is an inexpensive rationing strategy from the perspective of the
public-health system, but it imposes a substantial opportunity cost on patients
in the form of waiting time.
Third, are the human and infrastructural resources needed to implement the
programme available? If programmes limit the number of sites at which they
deliver treatment, they will use expertise, distribution systems, and
laboratory capacity efficiently; however, providing access only to patients who
live within the site's designated catchment area might not be feasible because
of the administrative and ethical difficulties of excluding patients who live
Fourth, to what extent does the system of distributing treatment reduce the
long-term effects of the HIV epidemic on economic development? Preferentially
treating skilled workers, for example, strongly supports the preservation of
human capital - the accumulated skill, knowledge, and expertise of workers15 -
whereas queuing favours those whose time has the least economic value - ie, the
Fifth, do all medically eligible patients have equal access to treatment? A
rationing strategy that targets mothers, such as MTCT-Plus, is generally
supported by those who favour a social-justice definition of equity, which
argues for preferential access for poor or disadvantaged subpopulations. But
under a narrower definition of equal access, MTCT-Plus is highly inequitable
because it excludes all men and the women who are not currently bearing
Sixth, can the system be sustained? Targeting poor people is an attractive
strategy while donor funding lasts, but it could become an unaffordable luxury
when donor support ebbs.5 Last, to what extent does treatment reduce the rate
of HIV infection? Preferentially targeting core transmitters, such as sex
workers or truck drivers, might have the greatest effect on HIV infection rates.
There is no single rationing system, or combination of systems, that will be
optimum for everyone. Other criteria could be considered. African societies
will place different weights on the values inherent in goals, such as equity
and efficiency. Rationing systems that are efficient - targeting skilled
workers, for example - are generally inequitable. Those that seem equitable,
such as first-come, first-served, are highly inefficient. Hard choices are
Who will decide?
Decisions about rationing will be made at many levels of society. International
funding agencies express their priorities through the amounts and conditions of
their grants. Legislation might govern the allocation of resources at the
national level. Ministries of health, local departments of health, and managers
of treatment facilities will all create guidelines. Once a facility becomes a
treatment site, the frontline health-care professionals who work there -
doctors, nurses, and counsellors - will be forced to ration access according to
their clinic's criteria or even their own.16 At each level, politicians,
interest groups, influential individuals, and patients will bring pressure. At
each decision-making level, it will be easier to use implicit systems of
rationing than to make and enforce hard choices. Because access to
antiretroviral drugs is a matter of life or death for AIDS patients, choices
about rationing systems matter deeply. African governments can ration
deliberately, on the basis of explicit criteria, or they can allow implicit
rationing to prevail. Without analysis and debate about public policy, people
will make arbitrary decisions about access to treatment, and implicit rationing
will foster both inequity and inefficiency. We believe that governments that
make deliberate choices about rationing antiretroviral therapy, and then
explain and defend those choices to their constituencies, are more likely to
sustain economic development and social cohesion and secure a socially
desirable return from the large investments now being made.
All authors contributed to developing the ideas presented in this paper and
edited the manuscript. S Rosen drafted the manuscript.
Conflict of interest statement
I Sanne is the Chief Executive Officer of Right to Care, a not-for-profit
organisation in South Africa that provides treatment to patients with HIV/AIDS.
Funding for the research presented in this paper was provided by the
South Africa Mission of the US Agency for International Development through the
Child Health Research Project, G/PHN/HN/CS, Global
Bureau, USAID, under the terms of Cooperative Agreement number
HRN-A-00-96-90010-00, the Applied Research on Child Health (ARCH)
Project, and by the South Africa Mission of USAID through Cooperative
Agreement number 674-A-00-02-00018 to Right to Care. The opinions expressed
herein are those of the authors and do not necessarily reflect the views of the
US Agency for International Development. The funding agency did not influence
the conduct or outcomes of the analysis or exercise any editorial control over
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