Photo courtesy of the Treatment Action Campaign, http://www.tac.org.za/

1
Preventing Mother-to-child Transmission of
HIV in South Africa A Case Study of Civil
Advocacy Policy Change Melanie E. Campbell,
M.Sc. melanie.campbell_at_utoronto.ca University of
Toronto, with academic support from the
University of Cape Town Funded by the Canadian
International Development Agency
Photo courtesy of the Treatment Action Campaign,
http//www.tac.org.za/

• Background
• South Africa (SA) is home to the greatest number
  of HIV people in the world. Studies suggest
  that the second leading mode of transmission,
  from mother-to-child during pregnancy and birth,
  could be reduced by 50 through a prevention
  program using a two-dose Nevirapine regimen. The
  SA Government initially stalled full rollout of
  such a program, opting for an 18-site pilot
  program instead. In response, an advocacy group,
  the Treatment Action Campaign (TAC), successfully
  challenged and overturned the governments policy
  in court.
• Description of Study
• This case study relied primarily on qualitative
  interviews with 21 policy stakeholders to
  understand the historical, political, social and
  cultural legacies and beliefs that shaped the
  Nevirapine policy process. In particular, it
  examines the role and activities of the TAC and
  physicians/researchers in challenging the
  governments initial prevention of
  mother-to-child transmission (PMTCT) policy. It
  further explores the motivations behind this
  initial piecemeal policy.
• Results i. Understanding the Governments Role
  in PMTCT Policy Development
• Based on the data collected for this study, a
  number of themes emerged which shed some light on
  why the South African Government initially
  adopted a piecemeal, 18-site pilot program rather
  than a nation-wide, universal program, despite
  evidence that Nevirapine was safe and effective.
• The themes include
• A post-Apartheid policy environment of relative
  inaction with respect to AIDS. One concrete
  example of this is the limited adoption of the
  1994 NACOSA plan for AIDS the innovative plan
  was developed through a series of consultative
  processes with local stakeholders but only
  implemented in part.
• Micro-sociological issues such as the
  disposition of certain key governmental actors
  namely President Mbeki and Health Minister
  Tshabalala-Msimang. These two actors were seen
  as central to the PMTCT policy issue.

• Macro-sociological factors such as a culture of
  loyalty within the African National Congress (the
  governing party in SA), which seemed to limit
  most party members from expressing public dissent
  against the governments initial limited-access
  policy.
• Resources. First, there are large gaps in the
  distribution of resources among and within
  provinces, particularly for the training of
  health care providers and the provision of health
  services. Second, although the cost of a
  universal PMTCT program was partially offset by
  manufacturer Boehringer Ingelheims 5-year
  Nevirapine donation, the cost of acquiring and
  training staff, providing milk formula, and in
  some cases refurbishing clinic sites would have
  to come from a limited pool of money, already
  barely able to cover the countrys other health
  needs.
• ii. Understanding the Response to Government
• This studys exploration of the roles of two key
  groups in advocating for improved access to PMTCT
  interventions yielded the following insights
• The Treatment Action Campaign
• The TACs strategies were particularly effective
  for a number of reasons the TAC was skilled in
  grassroots mobilization, honed by some key
  members experiences in the anti-Apartheid
  struggle, and the TAC was adept at legal and
  political maneuvering or elite activism, its
  roots being in the successful AIDS Law Project.
• Grassroots mobilization With public education
  strategies and programs for school children, the
  TAC is seen as a visible community member and
  voice for many people living with HIV/AIDS.
• Elite activism The TACs court case
  demonstrated their political savvy, high level
  understanding of scientific and technical detail,
  as well as their ability to engage NGOs and
  researchers internationally.
• Physicians/Researchers
• Physicians and researchers advocacy efforts
  included writing affidavits for the TAC court
  case, educating patients, creating
  income-generation projects for patients and their
  families, as well as more covert forms of
  advocacy.
• Covert activism A number of physicians had
  found ways to subvert the governments official
  limited-access program, for example, by getting
  donations to purchase drugs or by setting up
  research programs with drug provision as part of
  the protocol.