Nicoli Nattrass

Gender and Access to Antiretroviral Treatment in South Africa

Abstract This paper explores the gender dimensions of access to highly active antiretroviral therapy (HAART) in South Africa. It shows that women are more vulnerable to HIV infection than men, but that women access HAART in disproportionately large numbers. Regression analysis on data from the South African Demographic and Health Survey suggests that men in general access health services less readily than women. This ‘masculinity factor’ accounts for most of the difference between men and women when it comes to accessing HAART. Although men were more likely to favor traditional medicine than women, this was not a statistically significant factor, and it appears that visiting a traditional healer is complementary to, rather than a substitute for, accessing HAART. In short, it seems that gendered norms that make it difficult for men to admit weakness and seek medical attention are the main probable cause for the low proportions of men accessing HAART.

Democracy and distribution in highly unequal economies: the case of South Africa

Given that incomes in South Africa are distributed very unequally, it might be expected that the establishment of representative democracy would result in the adoption of redistributive policies. Yet overall inequality has not declined since 1994. The electoral and party system provides uneven pressure for redistribution. The fact that poor South Africans have the vote ensures that some areas of public policy do help the poor. The post-apartheid government not only inherited a surprisingly redistributive set of social policies (welfare, education and health care), but has made changes that entail even more redistribution. But these policies do little to help a core section of the poor in South Africa: the unemployed, and especially households in which no one is working. Other public policies serve to disadvantage this marginalised constituency: labour market and other economic policies serve to steer the economy down a growth path that shuts out many of the unskilled and unemployed. The workings of these policies remain opaque, making it unlikely that poor citizens will use their vote to effect necessary policy reforms.

Trading off Income and Health?: AIDS and the Disability Grant in South Africa

Despite high levels of unemployment, South Africas welfare system is premised on full employment: only those who are too young, too old or too sick to work qualify for social assistance. A government committee recently recommended the introduction of a universal Basic Income Grant (BIG) to address this hole in the welfare net. Now that highly active antiretroviral thereapy (HAART) is being rolled out through the public health sector for people sick with AIDS, the case for a BIG is even more compelling. People sick with AIDS qualify for a disability grant. The HAART rollout offers them the chance of restored health – but it comes at the cost of losing the disability grant because they will be deemed well enough to work. Given South Africas high unemployment rates, many will not be able to find work, and hence will face a trade-off between health (taking HAART) and income (keeping the disability grant). This could undermine adherence to HAART and/or reduce the effectiveness of the treatment by compromising the nutritional status of patients, thereby facilitating the growth of drug-resistant HIV. Introducing a BIG could help resolve this unintended tension between health and welfare policy.

South Africa's 'rollout' of highly active antiretroviral therapy: a critical assessment

Summary:The number of people on highly active antiretroviral therapy (HAART) in South Africa has risen from <2000 in October 2003, to almost 200,000 by the end of 2005. Yet South Africas performance in terms of HAART coverage is poor both in comparison with other countries and the targets set by the governments own Operational Plan. The public-sector HAART “rollout” has been uneven across South Africas nine provinces and the role of external assistance from NGOs and funding agencies such as the Global Fund and PEPFAR has been substantial. The National Treasury seems to have allocated sufficient funding to the Department of Health for a larger HAART rollout, but the Health Minister has not mobilized it accordingly. Failure to invest sufficiently in human resources-especially nurses-is likely to constrain the growth of HAART coverage.

Class, Distribution and Redistribution in Post-Apartheid South Africa

Jeremy Seekings and Nicoli Nattrass outline the class structure of post-apartheid South Africa and examine the redistributive consequences of the government’s economic growth path.

Paying to waste lives: the affordability of reducing mother-to-child transmission of HIV in South Africa

It is estimated that each HIV-positive child in South Africa costs the government more in terms of health and welfare expenses than it does to reduce mother-to-child transmission (MTCT) of HIV through the use of antiretroviral regimens (where the mother continues to breast-feed). Programmes to reduce MTCT of HIV/AIDS are, thus, clearly affordable. Using Nevirapine (according to the HIVNET 012 Protocol) saves more lives and [corrected] is more cost-effective than using Zidovudine (CDC 2 weeks regime).

Controversies About Capitalism and Apartheid in South Africa: an Economic Perspective*

The controversy about the relationship between apartheid and capitalism is reviewed from an economic perspective. On the methodological side it is argued that different understandings of wage determination and of the distinction between the interests of capital and capitalism, have been a source of confusion. The old ‘liberal‐radical’ debate was concerned with the clash between neo‐classical and revisionist Marxist economic ideas to the detriment of alternative economic perspectives. Over the past decade, however, social‐democratic ideas have become more popular and represent a potential middle ground between the old extremes.

Poverty, sex and HIV.

There is an ongoing debate about the relative importance of economic factors (notably poverty) and sexual behavior in driving the AIDS epidemic. This paper draws on relevant research and cross-country regression analysis to argue that the impact of economic determinants is dwarfed by contextual factors within Africa. The regression analysis suggests that controlling for per capita income, calories per capita and the ratio of female to male participation rates (none of which were statistically significant): being a Southern African country increases expected HIV prevalence 8.3 times; being in the rest of Sub-Saharan Africa 3 times; being a predominantly Protestant country 2.5 times; and being a predominantly Muslim country reduces expected HIV prevalence to 62% of the base case. Including the share of income going to the poor did not improve the model and was itself statistically insignificant. The analysis suggests that poverty may play a role in the HIV epidemic in some countries (and may well be a factor affecting the vulnerability of some people to HIV infection in all countries) but that its overall impact is dwarfed by social and behavioral factors.

Unemployment and AIDS: The Social-Democratic Challenge for South Africa

Addressing Aids and unemployment is one of the greatest challenges facing South Africa at present. Health and welfare interventions will be costly and are likely to meet with resistance from taxpayers. Expanding employment (which will help alleviate poverty and expand the pool of taxpayers) is thus necessary. An inclusive social accord could help, but only if organised labour is prepared to make concessions, as was the case in the new social accords in Australia, Ireland and the Netherlands.Addressing Aids and unemployment is one of the greatest challenges facing South Africa at present. Health and welfare interventions will be costly and are likely to meet with resistance from taxpayers. Expanding employment (which will help alleviate poverty and expand the pool of taxpayers) is thus necessary. An inclusive social accord could help, but only if organised labour is prepared to make concessions, as was the case in the new social accords in Australia, Ireland and the Netherlands.

What Determines Cross-Country Access to Antiretroviral Treatment?

Despite the recent international effort to expand access to highly active antiretroviral therapy (HAART) in developing countries, its coverage still varies significantly from country to country and is strongly correlated with per capita income. However, regional and political variables are also important. Cross-country regressions indicate that, controlling for political and economic characteristics and the scale of the HIV epidemic, Latin American and African countries have better coverage than predicted. Whereas the level of HIV prevalence was a significantly (negative) factor when accounting for HAART coverage in June 2004, this effect had disappeared by December 2004. The improvement appears to have benefited democratic countries in particular.