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South Africa’s ‘Rollout’ of highly active antiretroviral therapy: A critical assessment

CSSR Working Paper No. 158

Nicoli Nattrass

Centre for Social Science Research (CSSR)
University of Cape Town

May 2006

SARPN acknowledges UCT's Centre for Social Science Research as a source of this document:
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The number of people on highly active antiretroviral therapy (HAART) in South Africa has risen dramatically from less than 2,000 in October 2003, to almost 200,000 by the end of 2005. Yet South Africa’s performance in terms of HAART coverage is poor both in comparison with other countries and the targets set by the government’s own Operational Plan. This paper shows that the public sector HAART ‘rollout’ has been uneven across South Africa’s nine provinces and that the role of external assistance from NGOs and funding agencies such as the Global Fund and PEPFAR has been substantial. The National Treasury appears to have allocated sufficient funding to the Department of Health for a larger HAART rollout, but the Health Minister has not mobilised them accordingly. Failure to invest sufficiently in human resources – especially nurses – is likely to constrain any future increase in the pace of the rollout. Not only does this compromise the health and lives of thousands of people in South Africa – it also undermines the chances of achieving international targets to increase access to HAART.


South African AIDS policy has long been characterised by suspicion on the part of President Mbeki and his Health Ministers towards antiretroviral therapy (Nattrass 2004, 2006). The current Minister of Health, Manto Tshabalala-Msimang resisted the introduction of antiretrovirals for mother-to-child transmission prevention (MTCTP) until forced to do so by a Constitutional Court ruling – and she resisted the introduction of highly active antiretroviral therapy (HAART) for AIDS-sick people until a cabinet revolt in late 2003 forced her to back down on this as well. Since then, the public sector rollout of HAART has gradually gained momentum, but it has been uneven and continues to be constrained by a marked absence of political will at high levels.

This paper discusses the South African HAART rollout, paying particular attention to South Africa’s poor performance both comparatively and in relation to the internal targets set by the government’s Operational Plan of late 2003 (Department of Health 2003). This poses problems not only for South Africa, but for the global rollout because half all HAART patients in low- and middleincome countries live in Sub-Saharan Africa, and of this total, one quarter live in South Africa (World Health Organisation 2005a, 2005b). Poor performance in South Africa, thus impacts the aggregate performance of global initiatives such as the World Health Organisation’s ‘3 by 5’ initiative to treat three million people by the end of 2005.

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