Preparing for the Future of HIV/AIDS in Africa A Shared Responsibility (2011) / Chapter Skim
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6 Strategies to Ensure Ethical Decision-Making Capacity for HIV/AIDS: Policy and Programming in Africa
6 Strategies to Ensure Ethical Decision-Making Capacity for HIV/AIDS: Policy and Programming in Africa
Pages 148-170
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From page 148... ...
If global donor resources remain constrained and the predicted burden of HIV/AIDS in Africa over the next decade ensues, difficult questions will inevi tably arise regarding how to prioritize access to treatment ethically and equitably; the answers to these questions will have profound ethical implications. This chapter examines these ethical issues, focusing on options for building ethical decision-making capacity in Africa as a complement to the discussion of strate gies to build capacity for prevention, treatment, and care in Chapter 5.
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From page 149... ...
The subsequent section examines how an ethical decision-making capacity for HIV/AIDS policy and programming can be developed in Africa. EXISTING PRINCIPLES FOR ETHICAL DECISIONS IN HEALTH CARE This section examines in turn the levels of decision making in the allocation of health resources; key moral imperatives; the concept of equal moral status; and international covenants, codes, and declarations on ethics.
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From page 150... ...
. Key Moral Imperatives The committee identified two key imperatives it believes should guide ethical decision making: (1)
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At any of the three levels of decision making, when people whose needs exceed available resources have approximately the same clinical status or risk exposure, medical criteria alone are insufficient to guide resource allocation decisions, as will often be the case with needs for HIV/AIDS prevention, treatment, and care. In these situations, compliance with the WMA's directive that choices must be based on medical criteria and made without discrimination (Williams, 2009; WMA, 2005)
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Each patient has an equal claim to fair decisionmaking procedures on the part of physicians, and each member of society has an equal claim to just treatment by institutions and the state. Equal moral status is recognized in the Universal Declaration of Human Rights (UDHR)
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Because the key moral impera tives identified by the committee presuppose the equal moral status of individuals, the committee's recommendations for building ethical decision-making capacity reflect the importance of upholding this value under challenging circumstances. International Covenants, Codes, and Declarations on Ethics A variety of organizations in the international community have promulgated principles for ethical decision making in health care.
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From page 154... ...
The dire state of health care and the failing health systems in many African countries, however, raise questions about whether the aid provided has been effective and how much African leaders have done to help their own societies. The African Union, the Southern African Development Community (SADC)
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Is it because Africa lacks the requisite capacity, or is it because African leaders fail to deliver on their promises for improved health services? Most likely, both of these reasons apply.
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From page 156... ...
UNAIDS found that governments are already taking actions to sustain HIV/AIDS responses. These actions include: • rying to mobilize additional funding by pursuing advocacy with develop t ment partners, developing a national trust fund or solidarity fund for HIV/ AIDS, and exploring greater use of user fees and/or health insurance to pay for ART; • utting budgets and expenditures and/or rationalizing interventions and c reducing inefficiencies by seeking technical efficiencies in the HIV/AIDS response, merging agencies or other institutional reforms to reduce costs, cutting spending in areas deemed unnecessary or ineffective and imposing stricter rules on operational spending, creating a centralized national pro curement system for antiretroviral drugs and prevention commodities and improving drug supply chain management, and strengthening fiduciary systems; and • ethinking strategic plans by integrating HIV/AIDS into broader national r planning, developing a strategy for the health system that takes account of the impact of the crisis, and revising existing national AIDS strategies and annual action plans and their costs to reflect the impact of the crisis.
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From page 157... ...
Key areas of inquiry include procedural justice in specific African contexts; which responsible parties are involved in decision-making processes and what capacities they require for ethically informed decisions; capacity building to support ethical decision making; programs in ethics and human rights currently offered in Africa; an "all-of-government" approach to health in the form of interministerial committees; and the inclusion of socially disadvantaged groups in HIV/AIDS prevention, treatment, and care efforts. Procedural Justice in Specific African Contexts The principle of the equal moral status of individuals requires that policy makers avoid arbitrary or capricious distinctions that discriminate against individuals and groups.
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From page 158... ...
. Youngkong and colleagues reviewed 18 empirical studies of priority setting for health interventions in developing countries, including South Africa, Tan zania, Burkina Faso, Ghana, and Uganda (Youngkong et al., 2009)
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Its purpose is to challenge unjust decisions concerning the allocation of health resources through the civil society sector. Most well known is a successful constitutional challenge before the South African Constitutional Court, which required the government to grant greater access to treatment for the prevention of mother-to-child HIV transmission (Heywood, 2003)
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. Responsible Parties and Required Capacities Taking a long-term perspective on the pursuit of procedural justice is warranted in light of the complex political and institutional components of real-world priority setting.
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These committees would carefully review, modify, and approve treatment and care protocols for persons with HIV/AIDS. Capacity Building to Support Ethical Decision Making Several key questions arise regarding capacity building for institutions, groups, and individuals to support effective leadership and participation in the sorts of decision-making processes that would help realize conditions of pro cedural justice.
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From page 162... ...
The following core competencies are required by HPCSA to qualify health care practitioners: • how respect for patients and colleagues without prejudice, with an S understanding and an appreciation of their diversities of background and opportunity, language, and culture. • trive to improve patient care, reduce inequalities in health care delivery, S and optimize the use of health care resources in our society.
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From page 163... ...
Some of the fundamental requisites for meeting basic survival needs are well-functioning health systems, essential medicines and vaccines, clean air, clean water, diet and nutrition, sanitation, sewage, and pest control, which can go a long way toward alleviating poverty. However, social, economic, cultural, and behavioral determinants (e.g., living and working conditions, mental health, spiritual wellbeing, physical environment, personal health practices, capacity, culture, and discriminatory practices)
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From page 164... ...
Accordingly, in the committee's judgment, building ethical decision-making capacity requires multisectoral and multidisciplinary collaboration. National governments should consider incorporating professionals with training in ethics into interministerial committees that address all issues affecting the public's health, analogous to the South African Ministerial Council on Innovation now being considered.
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From page 165... ...
Recommendation 6-2: Donors and governments should support civil society organizations where they exist and help develop them in other places over time. As a first step, the focus should be on procedural justice.
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REFERENCES Advisory Group on Civil Society and Aid Effectiveness.
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2003. Preventing mother-to-child HIV transmission in South Africa: Background, strategies and outcomes of the Treatment Action Campaign's case against the Minister of Health.
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2010. Civil society.
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From page 169... ...
3. States should review and reform public health laws to ensure that they adequately address public health issues raised by HIV/AIDS, that their provisions applicable to casually transmitted diseases are not inappro priately applied to HIV/AIDS and that they are consistent with interna tional human rights obligations.
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From page 170... ...
12. States should cooperate through all relevant programs and agencies of the United Nations system, including the Joint United Nations Pro gramme on HIV/AIDS, to share knowledge and experience concerning HIV-related human rights issues and should ensure effective mecha nisms to protect human rights in the context of HIV/AIDS at the inter national level.
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