It has been said that the beginnings of a comprehensive response to HIV/AIDS in South Africa were outlined in the Health Policy of the African National Congress (ANC), prior to 1994 (DOH, 2004b1). “However, the implementation of AIDS policy in the first few years after 1994 has been characterized by a lack of progress and a breakdown of trust and co-operation, both within government and between government and NGOs” argues Schneider & Stein, 2001:724). In 2000, the South African government launched its five-year Strategic Plan for HIV, AIDS and Sexually Transmitted Illnesses (STI), which addressed four areas including “treatment and care”, which did not include anti-retroviral therapy (ART). It was only in November 2003 that the South African National Department of Health (DOH) announced its intention to roll-out anti-retrovirals (ARVs) in its Comprehensive HIV and AIDS Care, Management and Treatment Plan (DOH, 2003). The decision by the Government of South Africa to provide free ARVs came after much pressure from civil society groups, specifically the Treatment Action Campaign (TAC), and after the presentation of the findings of the “Joint Health and Treasury Task Team Charged With Examining Treatment Options to Supplement Comprehensive Care for HIV and AIDS2” (JHTTT) in 2003. Roll-out of the ARV programme has been slow, gaining momentum only towards the end of 2006, and very recently (March 2007), the DOH launched its new HIV/AIDS Plan, which has been hailed as comprehensive and progressive (Cullinan & Thom, 2007).
The HIV/AIDS policy development and implementation process in South Africa has been complex, highly political, and prolonged. Various analyses exist of the early HIV/AIDS policy development processes in South Africa (Nattrass, 2004. Schneider & Stein, 2001. Jones, 2005),
1.1. Purpose of this analysis
This paper uses the findings of the existing analyses and evaluations3 to inform a triangular policy analysis and stakeholder analysis of the implementation of the ART component of the 2003 Comprehensive HIV and AIDS Care, Management and Treatment Plan4 (CPHA hereafter). This paper seeks to retrospectively identify all the key players in the CPHA‟s development, their interest, influence, and degree of opposition or support for the policy. The paper also considers more prospectively (Varvasovszky & Brugha, 2000:338), the actors involved in its implementation, in order to identify the reasons for the delays and possible solutions. The analysis is placed within a rights-based framework, based on the belief that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”, as stated in the WHO Constitution (quoted in Green, 1999:8).
1.2. Theoretical framework of this analysis
In this paper, policy is broadly understood as those “decisions taken by those with responsibility for a given policy area” and more specifically, health policy incorporates all those “courses of action (and inaction) that affect the set of institutions, organisations, services and funding arrangements of the health system” (Buse, Mays, Walt, 2005:6).
1.2.1. Health policy development
There have been advancements in the theoretical frameworks seeking to understand the policy development process5. This case study of the South African CPHA‟s process shows that it cannot be viewed as a purely rational, linear process, as proposed by March & Simon (1958). Nor can the process be described as a muddled, incremental approach (Lindblom, 1959), since the ART component of the CPHA represents a new, large and radical programme for South Africa, demanding a massive commitment of will, finances and other infrastructural support. Perhaps the mixed-scanning approach to decision-making, as proposed by Etzioni (1967) offers a more realistic framework for the analysis of the CPHA, since it was the ANC‟s scanning of the political environment which highlighted the increasing public pressure to deliver ARVs, and underscored the fact that a fundamental decision was required. The bounded rational approach acknowledges the reality that while certain components of the South African government were trying to make rational choices, there were elements, or personalities, within government that appeared to be swayed by uncertainties and seemingly „irrational‟ opinions regarding ARVs.
1.2.2. Stakeholder Analysis
The basis for undertaking this stakeholder analysis is the understanding that the policy process is a complex one that is affected not only by the actual content (or topic and nature) of the policy, but also by the context and by the particular process of its development. Added to this are the influences of several actors, or stakeholders, and all these four aspects interact and affect each other. Walt and Gibson (1994) proposed the “health policy triangle” which incorporates all these aspects, and recognises their influence in the policy process, the stakeholders having a central role. Stakeholders might be defined as any individual, group or organisation which has interest in, influence over and/or is affected by the proposed policy. This paper seeks to utilise this approach (as described by Varvasovszky & Brugha, 2005) in understanding the development and implementation of the South African CPHA. Before doing so, let us examine briefly the HIV/AIDS situation in South Africa and the content of the CPHA.
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