TUBERCULOSIS: SOUTH AFRICA: Government debt delays treatment

JOHANNESBURG, 3 August 2010 (PLUSNEWS) - Drugs to treat HIV and tuberculosis (TB) are not reaching patients in South Africa's Eastern Cape Province because the local health department has not paid its suppliers, according to a civil society watchdog [http://www.psam.org.za/newsitem.php?nid=1367]. Hospitals and clinics in the Eastern Cape have struggled since March to maintain stocks of medicines, including antiretrovirals (ARV), as unpaid service providers have had to stop supplying them or face financial ruin. Daygan Eagar, a health researcher at the Public Service Accountability Monitor (PSAM), an independent South African monitoring and research institute, said years of underfunding in the context of rising operational costs meant the provincial health department had steadily accrued debt. Unbudgeted payouts to health workers - such as the Occupational Service Dispensation, a national retention strategy that pays salary increases to health workers, and back pay to health workers who were underpaid while working in the province's former Transkei and Ciskei homelands under the Apartheid government - were among the biggest burdens on the department's budget. As in South Africa's other eight provinces, HIV-related programming in the Eastern Cape is partly funded by national conditional grants that can only be spent on HIV/AIDS. This has helped safeguard ARV supplies, but has not completely prevented disruptions. Provincial health department spokesperson Sizwe Kupelo denied that the recurring drug shortages have been due to unpaid bills and attributed the interruptions to the inability of suppliers to meet demand, and poor drug stock management by facilities. However, the department recently appealed to the provincial treasury for a USD$230 million budget top-up, which is expected to go towards clearing debt. A national study in 2008 put Eastern Cape's HIV prevalence at 9 percent - slightly lower than the national average - but the province has one of the highest TB burdens in the country, and one of the worst TB cure rates [http://www.mrc.ac.za/pressreleases/2009/sanat.pdf]. Charity steps in The Keiskamma Trust, an NGO based about 250 km from Port Elizabeth, Eastern Cape's largest city, dispenses government-supplied ARVs at its Umtha Welanga Treatment Centre, but the drug supply crisis has forced it to step into the funding gap. The organization typically spends only about $175 on medicines monthly, but since March it has spent $8,200 on supplying ARVs and TB drugs to its treatment centre, as well as to a number of rural clinics in the surrounding area that have also not been receiving drugs from government depots. The trust's managing director, Annette Woudstra, said the emergency expenditure had wiped out the charity's entire annual drug budget, and approaching donors to fill the void had been difficult. "It makes donors quite uneasy to know that government cannot provide these medicines," she commented. She was unsure whether the charity would be able to claim the money back from government. Clinic go without Dr Jenny Nash, a government doctor who divides her time between the five rural clinics that received TB drugs as a result of Keiskamma's intervention, said the clinics were still battling to get stocks of other medicines, including cotrimoxazole, an antibiotic commonly used to prevent opportunistic infections in people living with HIV. "Patients come to the clinics and the nurses write 'O.S.' [out of stock] next to the item you've prescribed," Nash told IRIN/PlusNews. "From a patient's point of view, it must seem a bit of a joke - it doesn't really encourage them to take drug [adherence] seriously." She said patients often struggled to pay for transport to the clinics to fetch their drugs, only to find that the money had been wasted. In rural areas, where doctors and nurses are hard to recruit and even harder to retain, drug stock-outs are also bad for staff morale. "I spend all this time writing [prescriptions for] all these medicines, and then I spend the next three pages writing out instructions to the [pharmacists] saying, 'if you don't have this drug, give this and this'," said Nash. Not unusual The situation in Eastern Cape is reminiscent of the ARV shortages in Free State Province in 2008 and 2009, which led to no new patients being started on ARV treatment for several months [http://www.plusnews.org/report.aspx?ReportId=85906]. While the national health department has promised that these kinds of treatment shortages would not be allowed to happen again, PSAM's Eagan said disruptions in ARV supplies were more common than many people realized."We've had cases of this in the Eastern Cape before," he told IRIN/PlusNews. The problem was not just about lack of money, but about the way the money was managed [http://www.psam.org.za/newsitem.php?nid=1368]. "The Eastern Cape has seen substantial increases for funding of its HIV and AIDS programming, but problems in the rest of the system have meant that facilities are going without drugs for weeks, and patients are going without treatment."