Activists are calling for the Gauteng health department to be placed in intensive care, with a strong dose of medicine required to nurse it back to health. According to activist organisation the Treatment Action Campaign (TAC), the province's health system is perpetually hobbled by drug and staff shortages, and broken equipment.
The TAC has received numerous reports of medicine being out of stock across the province, specifically of antiretrovirals (ARVs), epilepsy and blood pressure drugs.
"We started getting emails of shortages of efavirenz [an antiretroviral drug] in [City Clinic] in Germiston," said Steven Ngcobo, TAC Gauteng provincial co-ordinator. "The nurses say they order 1000 boxes but [only] get 200, and shortly after they have to place more orders." He said the complaints started in February this year.
The reports prompted the TAC to look into potential shortages at clinics across the province. They say that, for weeks now, nurses at Phenduka Clinic on the East Rand have been writing prescriptions for HIV patients and sending them to a pharmacy in town, where they are told to purchase their ARVs – drugs that should be provided for free.
A Phenduka patient, who asked not to be named, said when she visited the clinic in March to collect her treatment she was handed a prescription instead. "I was told there are no pills. The sister wrote a prescription for me to go buy them in Alberton for a couple of hundred rand. I don't even have that money."
According to the patient, she "had two pills left that day". She ended up asking her neighbour to share some of hers. "But she said I should go buy my own treatment because there wasn't enough."
Another patient, Khetukthula Hlongwane, said she was given a small supply of ARVs for 10 days, but only after pleading with the health workers. "The nurses treat us badly and shout at us for wanting this treatment and tell us to go and buy it. But where will I get that money? I am unemployed."
Department of Health vs. suppiers
The TAC said officials at the clinic claimed they had not received sufficient supplies and that depots were out of stock of some medicines. The TAC said it was being given the runaround by the provincial health department when it asked for information on why there are shortages.
Provincial health department spokesperson Simon Zwane said his department was not responsible for the recent hiccups in the system. Instead, he pointed a finger at the suppliers. "To address the issue, the MEC [Hope Papo] has contacted other companies to supply ARVs and meet the demand," he said. "Those companies have already begun distributing."
But suppliers have also pleaded innocence. Zolani Kunene, a representative for Adcock Ingram, said the 2013/2014 ARV tender award conditions allowed for a three-month lead time to supply initial orders. "All orders thereafter are subject to a six-week lead time. We are currently on course to meet our requirements."
Another supplier, Aspen Pharmacare, said it had not halted distribution either, and was un-aware of the problem.
The shortages are not the only challenges faced by the provincial department: it has encountered significant difficulties over the past few years, with matters coming to a head in 2012 when debt accruals led to the nonpayment of drug suppliers and broken equipment that remained unrepaired.
The province's woes are also not simply an unfortunate anomaly. As recently as October and November last year, the Eastern Cape and Limpopo experienced critical drug shortages of ARVs and TB medicines. In Mthatha in the Eastern Cape, strike action led to the suspension of three-quarters of the medical supply depot workforce, which caused delays in getting the ARVs to clinics.
There are also national problems. Last year's nationwide shortage of tenofovir, a key ARV drug, forced the national department to source the medicine from alternative manufacturers after the department said that two main producers, Sonke Pharmaceuticals and Aspen Pharmacare, could not keep up with the demand. The companies contended that the department did not order enough supplies, or order them on time. The department's newest ARV tender, to be implemented this month, will source ARVs from different suppliers in an effort to prevent future shortages.
National office of health standards compliance
Mark Heywood, the executive director of the social justice organisation Section27, said plans to establish a national office of health standards compliance, already under way, would also help to prevent shortages.
"At least you will have an independent statutory body that people could report to and those complaints will be investigated," he said. "The facility should have norms and standards so a person can assess what a clinic should be providing them with and what medicines a clinic should always have."
The nurse programme manager at The Southern African HIV Clinicians Society, Nonhlanhla Motlokoa, said another way of eliminating challenges would be to shorten the lengthy, multistep process required to get pills ordered and delivered. "There are too many levels … The medicine starts at the national depot, and from there it goes to the provincial depot, from there it goes to the hospital where it is pre-packed. In other instances you find that suppliers are not paid and they stop delivering the ARVs." Motlokoa said it would be better if medicine was delivered directly to facilities.
Regardless of the steps taken to fix the system, the TAC maintained a long-term, proactive approach is needed, rather than a series of short-term reactionary responses. "When we say there is nothing this side they will deliver and patch here, whereas the other areas [continue to be] without [medication]," the TAC's Gauteng chair Sibongile Tshabalala said of the provincial department. "We are unhappy about that. We want the health system to be normal everywhere."
Ayanda Yeni is a researcher at the M&G Health Journalism Centre. This story is produced with the support of the Open Society Foundation and is editorially independent of any sponsorship