BLOEMFONTEIN, 25 February 2009 (IRIN) - Last week, regulars at
the HIV treatment clinic at Pelonomi hospital, in Bloemfontein,
capital of South Africa's Free State Province, would have told
you that the clinic has never been this quiet.
Ever since the provincial government stopped initiating new
patients on antiretroviral (ARV) drugs, the buzzing treatment
literacy classes for people about to start taking ARVs had shrunk
in size, while some existing patients stopped coming to check
whether their drugs were in stock.
A provincial moratorium barring new patients from getting ARV
medicine has been in place since November 2008, after massive
overspending and a failure to apply for emergency funding in time
became apparent. According to the AIDS Law Project, about 15,000
people in Free State are waiting to start ARV treatment.
The province has also discontinued CD4 monitoring [which measures
the strength of the immune system], health workers have stopped
referring patients in need of ARVs, there has been a fatal
interruption in the treatment of hundreds who have been on ARVs
for years, and the province is failing to meet the treatment
needs of many children.
The HIV Clinicians Society conservatively estimates that about 30
people per day have died in the province due to their inability
to access treatment.
AIDS lobby group Treatment Action Campaign (TAC) said this week
it was receiving complaints from doctors and activists in Free
State who said they still did not have access to drugs, despite
assurances from the government on 13 February that the moratorium
had been lifted.
"People think that they are going to die"
A small group of pregnant women sit in the waiting area at
Pelonomi, taking a break from their treatment literacy class on a
Wednesday morning; conversation is muted, and there are hardly
any staff about. Although the moratorium was lifted the previous
week, the drugs have not yet arrived at the clinic, one of the
largest ARV treatment sites in the province.
Sello Mokhalipi works for the Treatment Action Campaign in Free
State and conducts drug-readiness training for new patients at
Pelonomi hospital, but since the moratorium his classes have
virtually stopped; people who completed drug readiness training
in August last year are still on the waiting list for medication.
"It makes me feel bad when people come here and find that there
are no drugs; they come back to me and say, 'What are we supposed
to do with no drugs? Should we wait and develop resistance?'"
In January, Mokhalipi, who gets his own medication from Pelonomi,
was forced to buy a month's supply of Lamivudine (also known as
3TC) - a component of all first-line ARV regimens - from a
pharmacy because the clinic had run out of stock.
"Most people think that they are going to die if this goes on.
People are frustrated, depressed and confused; they don't know
who to turn to when they are told there are no drugs and have to
go home empty-handed."
Stella Mothata thought her six-year old nephew, Thapelo, was
going to die. When she went to Pelonomi clinic on 10 February to
collect his next batch of ARVs, she was told to come three days
later; but three days later, the drugs were still not there and
she was told to come back the following week.
Thapelo had already gone for a week without medicine and Mothata
was becoming frantic. "I asked them if they could give him
something for the weekend, but they said, 'There is nothing we
can do'," she told IRIN/PlusNews.
A desperate Mothata then called Trudie Harrison, director of the
Anglican Church's Mosamaria AIDS Ministry, and asked for help.
Harrison arranged for her to purchase the drugs at a local
pharmacy, but when Thapelo started taking the ARVs he became
sick. "He can't eat, when he eats he vomits and this morning he
woke up with a rash on his face," she said.
"They say it's pneumonia, but he woke up feeling better today, so
I took him to school. But the teacher sent him back because the
rash has become too bad - they say he can't open his eyes."
Mothata, who receives her own treatment from a donor-funded
private organization in Bloemfontein, is finding out whether they
will also treat Thapelo, as she has lost faith in the government.
But health officials insist that by March the treatment programme
will be replenished and will have "bounced back".
According to Portia Shai-Mhatu, senior manager in the Free
State's HIV/AIDS directorate, medical depots have been told to
speed up deliveries of drugs, while drug manufacturers have
agreed to fast-track the province's orders.
What went wrong?
As the health department tries to pick up the pieces, questions
about how this could have happened remain unanswered. The TAC has
accused the Free State's health department of "gross financial
mismanagement" but national health officials have put the crisis
down to "severe financial pressures" in the province.
"We can't prove that it was mismanagement, but I do ask myself
what has gone wrong?" wondered Trudie Harrison at the Mosamaria
The official answer is that a funding shortfall of R63 million
(US$6,300,000), higher numbers of patients on treatment, and the
introduction of more expensive dual therapy for prevention of
mother-to-child transmission, led to the shortages.
The health department budgeted for an anticipated 27,000 people
on treatment by the end of March 2009, but has now estimated that
35,000 people will be accessing treatment by then.
"By September  already, we realised that we were in a
crisis ... we thought the most sensible thing was to give
existing patients treatment. It would be very wrong and very
fatal to initiate treatment one month, and then the next month
there are no drugs," said Sylvia Khokho, executive manager of
strategic health programmes in the province.
"All this time we were hoping for money, but the crisis was
worsening. We were looking everywhere and taking money [from
other programmes] and pushing it to ARVs," she added. Shai-Mhatu
commented: "Without being defensive, it's clear that the Free
State health budget is too low."
With the exception of essential health services, the financial
crisis has also affected healthcare in other ways - hospital beds
have been slashed by more than 50 percent, according to the AIDS
Health budgets around the country have been pushed to the limit
by massive overspending, poor budgetary controls and the
implementation of a new salary structure for nurses.
KwaZulu-Natal Province has overspent its health budget by over a
billion rand (US$100 million) and media reports earlier in
February said doctors in the port city of Durban were complaining
that basic surgical supplies were unavailable at some of
KwaZulu-Natal's biggest hospitals.
National Health Minister Barbara Hogan has appointed a team of
experts to visit provinces and assess the over-expenditures and
the state of health services.
Although Finance Minister Trevor Manuel allocated additional
funding in his budget speech to roll out the new dual therapy
programme and expand ARV treatment, he also announced that new
systems were being designed to improve the national health
department's ability to monitor provincial expenditure.
"There is a broad consensus that public health services have been
insufficiently funded, but the problem is not simply inadequate
financial and human resources, it is also one of inefficient use
of resources," noted Adila Hassim, head of litigation and legal
services at the AIDS Law Project.
In an editorial in a local newspaper, Business Day, Hassim called
for parliamentary scrutiny of budget allocations and spending, as
well as for a way of ensuring that funds allocated to the
provinces would be spent on nationally determined priorities.
Whether it was mismanagement or inadequate funding, Harrison told
IRIN/PlusNews that the provincial health department had to take
responsibility for the lives lost.
"Where does the buck stop? It's people's lives we are talking
about, but there's no sense of accountability, they are just
blaming everyone else," she commented. "That is not good enough."