Rationing access to public-sector antiretroviral treatment during scale-up in South Africa: implications for equity

As with other large-scale antiretroviral therapy (ART) programmes initiated in developing countries, rationing of ART in South Africa was inevitable in the face of limited human and infrastructural resources. This paper discusses rationing of ART and its implications for equity in South Africa, with a particular emphasis on the national programme in the Free State Province. We examine both the explicit and implicit dimensions of ART rationing, while considering the content of policy, programme design and implementation processes. The explicit rationing criteria included in the national comprehensive plan, as well as the associated treatment guidelines, direct and influence rationing decisions practised locally. However, implicit processes of rationing, which limit demand, are also wittingly and unwittingly introduced in several ways, and at all levels of the health service. Consequences of rationing manifest in the high numbers of patients lost to the system and the difficulties faced by the most impoverished clients in gaining access to ART services on an ongoing basis. Not losing sight of the equity element within rationing is important, and this aspect will have to be formally monitored for eventual success of the country's ART programme. ART roll-out processes also require ongoing efforts to build consensus and confidence in rationing, accomplished with a view to optimal fairness.