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In the matter between

TREATMENT ACTION CAMPAIGN AND OTHERS                                         Applicants


MINISTER OF HEALTH AND OTHERS                                                Respondents


I the undersigned

                                HELENE SCHNEIDER

1.     I am associate professor of Public Health at the School of Public Health,
       University of Witwatersrand. I hold the degrees of MBChB (UCT) and MMed
       (Wits). I am a community health specialist, health policy analyst and health
       systems researcher. I attach marked HS1 a copy of my curriculum vitae.

2.     On the basis of my training, experience, skills and research I am professionally
       qualified to provide the information and express the opinions set out in this
       affidavit. The contents of this affidavit are true and correct to the best of my
       knowledge and belief.

3.     In this affidavit I endeavour to answer two questions:

3.1    Does the South African health system, specifically the public sector, currently
       have the capacity to implement mother-to-child-transmission prevention
       (PMTCT) beyond the existing provincial pilot sites?

3.2    Is it within the capacity of the health system to plan for universal access to a
       comprehensive package of interventions for PMTCT?

4.     I do not deal with questions of efficacy and cost-effectiveness, which I understand
       have been addressed by others.

5.     By a comprehensive package of interventions for PMTCT, I refer to the following
5.1    voluntary HIV testing and counselling of pregnant women;
5.2    limiting certain invasive procedures on HIV-positive women during labour e.g.
       early rupture of membranes;
5.3    administration of nevirapine to HIV-positive women during labour and to their
       infant/s after delivery;
5.4    mechanisms for safe feeding of infants e.g. provision of breast milk substitutes,
       pasteurisation of breast-milk;
5.5    empowerment of HIV-positive women to make informed choices regarding the
       feeding of their infants;
5.6    provision of ongoing counselling and support in the post natal period.

Capacity of the health system

6.     Health systems can be considered as having both a demand and a supply side.

7.     The demand side is concerned with the use of health services by the population
       and the factors influencing this (e.g. trust in the health system, costs associated
       with accessing health services). With respect to PMTCT, a key demand side issue
       is the extent to which pregnant women and their infants currently utilize existing
       health services.

8.     The supply side of the health system includes the health services (clinics,
       hospitals etc.) and the managerial and organisational infrastructure to support
       these services. With respect to PMTCT, the key supply side issues are the
       availability of HIV testing and counselling facilities to identify HIV-positive
       women who may benefit from interventions; staff time to implement the
       interventions; mechanisms to update the practices of health professionals in the
       light of changing evidence; effective drug procurement and distribution systems;
       procurement and distribution of breast milk substitutes; provider openness and
       positive attitudes to people with HIV.

9.     Table 1 below summarises the current evidence regarding the capacity of the
       health system to deliver a comprehensive package of PMTCT interventions.
       Evidence is drawn from three South African surveys:

9.1    The South African Demographic and Health Survey, conducted in 1998 (referred
       to as SADHS 1998). This is published by the national Department of Health, with
       a foreword by the Minister of Health. Relevant data extracted from the SADHS
       1998 are attached as HS2.
9.2    Surveys of primary health care (clinic) facilities in 1998 and 2000 and a survey of
       hospitals in 1998, commissioned by the Health Systems Trust (referred to as HST

       1998 and HST 2000). The Health Systems Trust is a non-governmental agency
       that commissions and channels funding for health systems research. The surveys
       referred to were carried out by teams at the Universities of the Free State and
       Witwatersrand, by individuals that are well known and respected. Relevant data
       extracted from the HST 2000 and HST 1998 are attached as HS3.
9.3    A recently conducted assessment of the integration of AIDS care and support into
       primary health care clinics in Gauteng Province (unpublished data, Centre for
       Health Policy, referred to as CHP 2001). Relevant data from this survey are
       attached as HS4.

 Table 1: Health system capacity to deliver PMTCT
            Aspect of health Current capacity
Demand      Utilization of     94% of women make use of antenatal services during
side        health services    pregnancy. This is universally high across all provinces
            by pregnant        (SADHS 1998). Antenatal care is available through both
            women              the private sector and the network of public sector
                               primary health care facilities, which include more than
                               3000 clinics/health centres (‘fixed clinics’) and a further
                               650 satellite and mobile clinics. In 2000, 87.4% of fixed
                               clinics provided antenatal care (HST 2000).
            Utilization of     84.4% of women deliver in the health system i.e. under
            health services    the supervision of a health professional. This varies from
            for delivery       74.6% in the Eastern Cape to 96.1% in the Western Cape
                               (SADHS 1998)
            Utilization of     93.3% of children attend the health service for their first
            health services    immunizations at 6 weeks. 76.4% of children receive
            after delivery /in their third immunizations at 14 weeks. Rates for the third
            infancy            dose of DPT vary from 62.3% (Kwazulu-Natal) to 89.0%
                               (Northern Cape) (SADHS 1998).
Supply      HIV testing        Over half (56.2%) of fixed clinics in South Africa offer
side                           HIV testing. This varies from 14.6% in the Northern
                               Province to 100% in Gauteng, and the Northern and
                               Western Cape Provinces (HST 2000).
            HIV counselling 83% of fixed clinics provide HIV counselling. This
                               varies from 61% in Mpumalanga to 97% in the Western
                               Cape (HST 2000).

               Aspect of health Current capacity
Supply         Staff time       In 2000, the daily patient load of nurses in fixed clinics
side                            was reported to be 19.8, well below suggested norms of
(cont.)                         between 28-40 patients per day, depending on the patient
                                mix.1 The load varied from a high of 27.3 in Kwazulu-
                                Natal to a low of 14.8 in Mpumalanga (HST 2000).
               Mechanisms to    Over a one-year period, 56.6% of fixed clinics had at
               update the       least one person who underwent skills upgrading in the
               practices of     area of HIV/AIDS management (HST 2000). In 1998,
               health           82.2% of district and regional hospitals had conducted
               professionals    some form of continuing education for staff (HST 1998).
               Effective drug   In 2000, 92% and 84.9% of fixed clinics had
               procurement and cotrimoxazole and ciprofloxacin tablets, respectively, in
               distribution     stock. These tablets are two antibiotics essential in the
               systems          management of HIV and sexually transmitted infections.
                                Availability varied from a low of 79.8% (cotrimoxazole,
                                Eastern Cape) to 100% (ciprofloxacin, Free State) (HST
               Procurement and In 2000, 65.8% of fixed clinics had infant nutrition
               distribution of  supplements in stock. This varied from 25% in
               breast-milk      Mpumalanga to 90% in the Western Cape (HST 2000).
               Attitudes of     The negative attitudes of health workers towards patients,
               providers        especially poor pregnant women and people with HIV,
                                have been documented in a number of settings. This
                                problem is one of the most common complaints of the
                                public health system made by users and communities.
                                However, recent evidence from Gauteng Province (CHP
                                2001) suggests that well trained counsellors are having a
                                positive impact on the “patient-centredness” of the health
                                system, and that many providers have accepting attitudes
                                to people with HIV/AIDS.

10.       In the light of the above, does the South African health system, specifically the
          public sector, currently have the capacity to implement mother-to-child-
          transmission prevention (PMTCT) beyond the current provincial pilot sites?

 Rispel L, Price M and Cabral J. 1996. Confronting Need and Affordability: Guidelines for Primary Health
Care Services in South Africa. Johannesburg: Centre for Health Policy, University of Witwatersrand.
11.    The evidence from SADHS 1998 is that utilization of maternal and child health
       services by pregnant women and their infants is high. Except for the 16% of
       women who deliver their children outside of the health system, the target
       population for PMTCT is already being reached by the health system;

12.    Apart from the Northern Province, where only 14.6% of clinics have HIV testing
       facilities, all provinces have HIV testing facilities in 39% or more of their fixed
       clinics; in 6 of the 9 provinces HIV testing is available in 50% or more of the
       fixed clinics. This does not include testing facilities available within the district
       hospital infrastructure. It is highly likely that in all but the Northern Province,
       HIV testing is available outside of the PMTCT pilot sites;

13.    The existing evidence suggests that several other key aspects of health service
       capacity – counselling services, effective drug supplies, in-service training, and
       staff time – extend well beyond 2 pilot sites per province;

14.    It is unclear whether the “infant nutrition supplements” documented in HST 2000
       would cater for additional needs related to PMTCT outside of pilot sites;

15.    Provider attitudes are enduring barrier to effective PMTCT. However, these
       should not be seen as universally bad or static.

16.    The best available evidence thus suggests that the health system has the
       immediate capacity to provide a PMTCT programme on a scale larger than the
       pilot sites, in at least 8 of the 9 provinces.

17.    The marginal costs (financial and otherwise) of a passive extension of the PMTCT
       programme, i.e. meeting the demand from patients and health professionals for
       the programme, are likely to be small. It would require the following:
17.1   Coordination of HIV testing and counselling facilities with those of antenatal
       services where these are not available in the same facility;
17.2   Coordination of clinic-based antenatal and postnatal services with hospital based
       delivery services;
17.3   Distribution of protocols for the comprehensive management of HIV-positive
       pregnant women and their infants to clinics and hospitals;
17.4   Introducing nevirapine into the routine drug supply systems of all facilities doing
       deliveries of babies (maternities).

18.    The anecdotal evidence is that the large amount of public attention to PMTCT has
       stimulated considerable demand for the programme beyond PMTCT pilot sites.
       Meeting this need may signal a responsiveness of the health system to felt needs
       of both patients and providers, a factor which will increase the trust in other HIV
       related health system interventions.

19.   Is it within the capacity of the health system to plan for universal access to a
      comprehensive package of interventions for PMTCT?

20.   This requires that the following be addressed:

20.1 Expansion of the voluntary counselling and testing (VCT) infrastructure within
     antenatal services. VCT is a stated government priority, and as indicated by the
     HST surveys, a basic infrastructure is already in place. Planning for an expansion
     of VCT is entirely compatible with public health sector goals;
20.2 Managing the complex ethical, socio-economic and cultural problems associated
     with preventing the transmission of HIV through breast-feeding. While the public
     health sector cannot address all the factors associated with poverty in the short
     term it can create an enabling environment for safe infant feeding. This includes
     provision of breast milk substitutes and nutrition support to infants, children and
     their families, promoting research into other mechanisms of safe feeding, and
     intersectoral action at local level to address poverty, such as increasing access to
     child maintenance grants;

21.   Given the health system inequities between provinces, it is likely that an uneven
      implementation of a PMTCT programme would occur. Rather than being a factor
      preventing planning for universal access, a PMTCT could provide a focus for
      highlighting and addressing inequities.

22.   The complexity of a PMTCT programme is no greater than tackling malnutrition,
      tuberculosis and other chronic diseases – aspects that the South African health
      system has committed itself to dealing with. Two provinces, Western Cape and
      Gauteng have already developed plans for comprehensive roll out of the PMTCT

23.   The challenges associated with PMTCT should be seen as meeting the goals and
      objectives of the health system and the country. The risks associated with
      implementing a PMTCT programme are no greater than programmes already
      implemented by government such as free primary health care, the school feeding
      programme, and the introduction of new vaccines in childhood.


                                                     COMMISSIONER OF OATHS


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