“Gambling on Treatment”

Abstract

The broader challenges associated with service delivery in South Africa are often missing in analyses of access to public sector ARV programs. Most commonly, and as important as they inevitably are, access is being gauged according to human resource issues and also individual patient behavior and retention. This chapter therefore locates “access” within the institutional landscape itself to look at how the organizational culture conditions access for people living with AIDS. Not least, this is because ARV clinics have been newly established at a number of district hospitals. These new structures have to interact with broader hospital management and working practices. The bigger administrative picture therefore has a bearing upon how ARV clinics operate. And, on top of this already complex coexistence, is the fact that the ARV issue has been so politicized in South Africa. It is therefore pertinent to ask how such governance issues have shaped the availability and quality of hospital-based care and treatment. Above all, the role of people-living-with-AIDS’ own experiences at these institutions, their perceptions of access to AIDS-related services at Jubilee, the local hospital, inevitably has a bearing upon how they may seek ARV services. The chapter begins with the story of “T,” a person living with AIDS in the area, to illustrate how these issues are integral to unpacking the issue of “access” to ARVs.

… there are some institutions [like Jubilee] whereby you can’t even meet with management, you see. They will say, “no we don’t want to meet with you, we are the ones, we are the bosses here, you see.” Now, how are you going to deal with issues with such kind of management?

—COSATU, area representative¹