Rationing of treatment inevitable, explicit criteria need open debate

Research into the roll out of antiretroviral therapy in resource-limited settings should include a focus on the consequences of different methods of rationing treatment, say researchers from the United States and South Africa in a commentary given early online publication by The Lancet on December 31^st 2004.

The researchers who include Dr Ian Sanne, one of South Africa’s leading HIV clinicians, say that rationing is already occurring de facto due to lack of resources, and that even after significant investments in treatment, forms of rationing will remain a fact of life in most severely affected countries.

They identify several forms of rationing that are likely to become commonplace:

• Rationing on the basis of clinical criteria to ensure that only the most advanced patients receive treatment, as proposed by WHO guidelines (clinically symptomatic patients)
• Socio-economic rationing, for example prioritisation of free treatment for the poor, or for mothers and children, or skilled workers and health care workers, as is the case in Kenya.
• Geographical rationing, in which some regions have preferential access to treatment, either because of the nature of available infrastructure or explicit decisions made on epidemiological or political grounds.
• Rationing by income, where co-payments are required from patients in order to receive treatment.
• Programmatic rationing: in order to benefit from treatment, patients must know their HIV status, have access to a treatment centre, have access to skilled medical personnel, and drugs must be available consistently.
• Informal rationing due to queue jumping, bribery, favouritism for particular social or ethnic groups.

“Different ways to ration antiretroviral therapy will have different social and economic consequences for African populations. Understanding these outcomes is important if the decisions made about resource allocation and programme design are to help a nation accomplish its goals for fighting HIV/AIDS and sustaining economic development”, say the authors.

They propose that the effects of rationing in treatment programmes should be evaluated by the following criteria:

• Does the system of rationing produce a high proportion of successfully treated patients?
• Is the cost per patient treated low?
• To what extent does the system of distributing treatment reduce the long-term effects of the HIV

epidemic on economic development? Queuing favours those whose time has the least economic value, say the authors.

• Do all medically eligible patients have equal access to treatment? Whilst ARV treatment for pregnant women favours the socially disadvantaged, it penalizes those who are not childbearing.
• Can the system be sustained? Can the poor continue to be targeted if donor support is withdrawn?

“Hard choices are unavoidable”, the authors say. They warn that at each decision making level, from international donors, though governments and local health services, there will be a temptation to use implicit systems of rationing rather than to make and enforce hard choices.

They conclude: “African governments can ration deliberately, on the basis of explicit criteria, or they can allow implicit rationing to prevail. Without analysis and debate about public policy, people will make arbitrary decisions about access to treatment, and implicit rationing will foster both inequity and inefficiency.“

“We believe that governments that make deliberate choices about rationing antiretroviral therapy, and then explain and defend those choices to their constituencies, are more likely to sustain economic development and social cohesion and secure a socially desirable return from the large investments now being made.”