Health systems in a context of HIV/AIDS : an analysis of impact, health policy and health care reform in KwaZulu-Natal and South Africa.
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The development of health systems in sub-Saharan Africa has been seriously challenged in the last two decades by the rise of HIV/AIDS. In this thesis I argue that the interface between health policy and HIV/AIDS in South Africa is poorly understood and that this has been to the detriment of fairly radical health care reforms as well as more general health systems development. The research problem outlined above is two-fold, requiring different types of enquiry and analysis. Firstly, there is a gap in our understanding of the impact of HIV/AIDS on health systems. Empirical evidence is presented from research on health facilities and health management structures in Ugu district, KwaZulu-Natal to address this concern. Secondly, it is asserted that our limited understanding of the impact of HIV/AIDS and the nature of the epidemic have prevented a true appreciation of its significance for health policy. This dimension of the problem is addressed through an analysis of South African health policy from 1994 through to the present, as well as a more theoretical look at the potential future influence of the antiretroviral therapy programme on the health system. Both quantitative and qualitative methodologies are employed in this research to acquire empirical insights. Health service utilisation trends are assessed retrospectively by quantitative analysis of key indicators from district and provincial information systems. Meanwhile, the prospective component of the quantitative research can best be described as repeat cross-sectional surveys of a selection of health facilities in Ugu district. These surveys capture data on the profile of patients seeking care and the resource requirements for managing these patients. Qualitative methodologies (predominantly semi-structured interviews) are used at facility level to gain insight into human resource issues and at the management level to better understand health system functioning in relation to HIV/AIDS. One would expect the increasing HIV prevalence and burden of AIDS illness in South Africa to translate into a higher demand for health care. However, this has not occurred in Ugu district, largely because of difficulties with access to care. Despite this, at lower level health services, namely clinics and district hospitals, HIV-related service provision has outpaced an increase in resources. Specifically, the introduction of the antiretroviral therapy programme and the decentralisation of a range of HIV/AIDS services are causing new strains on the system. In essence, the epidemic has created a need to address barriers to accessing care and to expand support for district health services. HIV/AIDS not only increases the demand for health care, but on the supply side erodes the capacity of the health system to deliver care. My research demonstrates that health care workers in KwaZulu-Natal are being severely impacted by the epidemic, with the nature of their work contributing to both their susceptibly and vulnerability. Not only is HIV/AIDS increasing absenteeism and attrition through escalating morbidity and mortality, but it is also working in more subtle ways to contribute to a range of 'push' factors driving health workers from the public health sector. None of these issues have been addressed because of the narrow definition of 'human resource management', despite the obviously heightened need to monitor attrition trends and develop creative retention strategies. My research looks not only at the impact of HIV/AIDS impact on health services in Ugu district, but also at the impact of the epidemic on higher levels of the health system which constitute management structures. At these levels, the health system is challenged by an urgency to deliver HIV/AIDS services, as well as an increasing involvement of donors and partners such as civil society organisations or faith based organisations. This has resulted in trends towards more centralised control of planning and management and, in some instances, a deflection of resources towards HIV/AIDS issues and programmes. This context has called for a strong focus on capacity development and means to ensure the integration of health programmes. Many of the trends in Ugu district demonstrate the insidious nature of HIV/AIDS impact and give some insight into why these trends have not been adequately addressed by South African health policies. My analysis suggests that despite the appropriateness of the overarching direction of health reforms, some concerns arising from the HIV/AIDS epidemic have received little attention. These include a need to: 1) manage human resource impacts, 2) develop home community based care and establish a continuum of care, and 3) lead and direct the involvement of donors and partners in the health sector. On the other hand, there have been some beneficial policy developments, such as the elimination of user fees for certain services and the attention paid to the way in which a focus on HIV/AIDS care can potentially weaken the health system. Unfortunately, in many instances HIV/AIDS has also widened the gap between policy and implementation and opportunities have been missed to develop the health system in an appropriate manner. The South African antiretroviral therapy programme, launched in 2003, is a source of uncertainty regarding the future development of health policy in the country. My analysis makes use of scenarios to explore the potential future impact of the programme. I consider the ways in which the programme is steering us away from our post-apartheid vision of an equitable and well functioning national health system and towards 'AIDS exceptionalism'. I look to Botswana, the first country in southern Africa to provide antiretroviral therapy in the public health sector, for early lessons as to what we might expect. My case study of this programme suggests that HIV/AIDS care can be integrated with time, so limiting damage to the development of fragile health systems. Only through ongoing reassessment of the South African situation will it become apparent whether such lessons are transferable. Nonetheless, forward thinking should allow us to move from a crisis-orientated response to one that is more strategic. This thesis concludes with four key messages (or recommendations) emerging from both the empirical research and the health policy analysis. Firstly, there is a clear need to establish systems that can provide comprehensive and timely information concerning the impact of HIV/AIDS on public health services. Secondly, trusting relationships have to be built between academics/researchers and health policy makers so that research informs policy. Thirdly, there is a need to (re)establish a shared vision of the national health system and maintain a focus on achieving this vision. Finally, priority programmes and resources allocated to these must be used to strengthen our national health system in creative ways.
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