/ 21 June 2013

Eastern Cape drug depot in extremis

A coalition of health advocacy organisations has appealed to Health Minister Aaron Motsoaledi to put the Eastern Cape health ­department under national administration. 

It has also threatened to go to court "to look for solutions" if its advocacy efforts don't lead to significant improvements in the supply of antiretroviral (ARV) drugs, tuberculosis (TB) medication and essential medical supplies in the province, said Marije Versteeg of Wits University's Rural Health Advocacy Project. 

The Eastern Cape Health Crisis Action Coalition, consisting of the Rural Health Project, Section 27, the Treatment Action Campaign (TAC) and Médicins Sans Frontières (MSF), said there had been frequent ARV and TB drug stock-outs in the Eastern Cape.   

According to the coalition's report released at the sixth South African Aids conference, held in Durban this week, 28 of the 70 health 

facilities it surveyed in the Mthatha area ran out of HIV and TB treatment between March and May this year and at least a quarter of the facilities reported "ongoing stock-outs".

The 300 medical facilities in the area serve 100000 patients. The report said some hospitals and clinics received only 10% of the ARVs they had ordered from the Mthatha depot and the medicine generally arrived at clinics and hospitals only two months after it was ordered.

The findings are the result of a follow-up investigation of the coalition's investigation into what it termed the "management and drug supply crisis" at the Mthatha depot between September 2012 and January 2013. 

It found that 53% of facilities had run out of TB and HIV drugs. resulting in 5494 adults on ARVs going without treatment for at least a day and 561 children being sent home without HIV medicine. Research has shown that interruptions in HIV treatment can lead to patients becoming resistant to the drugs, which then stop protecting them. 

The investigation found that "714 people may have developed drug resistance to first-line [HIV] treatment as a result of the disruption in deliveries at Mthatha Depot … [resulting in an estimated] excess cost … [of] R1.1-million per year, for as long as those patients remain alive and on treatment".

Volunteer help
The report made recommendations to Eastern Cape health authorities on how to solve the problems, and a team of TAC and MSF volunteers helped to staff the depot in December 2012. "Five months later, the situation remains dire," the coalition announced this week. 

"Eastern Cape health department officials, including health MEC Sicelo Gqobana, deny [the facts] when they see the truth in front of them and ignore our efforts to engage with them, so the health minister should strongly consider placing the department under administration to get the job done," said Section 27's John Stephens.  

However, Eastern Cape health department spokesperson Sizwe Kupelo accused the coalition of "deliberately distorting information" and using the national conference to "mislead" the public. 

Kupelo said ARV drugs are available "in 98% of cases" and chronic medicines are available in 72% of cases: "As far as drugs are concerned, all of the health facilities in the area are running smoothly." 

Gilles van Cutsem of MSF said the coalition had offered to resupply the depot with temporary staff, but the department had not yet responded. 

"If we need help, we will take it," said Kupelo. "As we have no drug shortages, we don't need their help."

According to Van Cutsem, the depot has no manager and a staff of only 15 when there should be 40. This is the situation after 29 individuals were suspended in October last year after a wildcat strike. 

"After months the disciplinary process has still not been concluded and the workers are still all on full pay. But no one has replaced them," said Van Cutsem. 

Kupelo said this information was "removed from all truth". The depot had 57 staff members, including four pharmacists and a director, who would manage the facility and would begin work next week. He added: "A supply chain management system has also started and two deputy directors will be starting soon." 

The coalition's report said "disruptions at the depot exacerbate a chronic cycle of over-ordering by health facilities which is a result of poor stock keeping and, in some instances, appears radically out of step with actual levels of need".

While the facilities complain about undersupply by the depot, depot staff accuse hospitals and clinics of over-ordering, according to the report. It stated that the depot's management said that some orders were "far in excess" of what was actually needed and that they had to subsequently be adjusted to "conserve stocks". 

The coalition said: "Some facilities explain that they over-order in an effort to ensure that their patients have access to life-saving medication in anticipation of stock-outs and undersupply from the depot." 

Drugs expire
In some cases, the drugs expire before being dispensed, said the coalition. According to Van Cutsem, this happens because medicine is often not captured in the depot's system on arrival. 

"If the drugs aren't captured, they can't be distributed because they don't exist in the system," he said. "Although the capturing has improved somewhat since December, it's still far from perfect." 

Vyokazi Gonyaela of the TAC's Eastern Cape office said Goso Forest clinic in Lusikisiki told a mother with a two-year-old toddler with TB, halfway through her child's treatment, that it had run out of drugs. 

"After three months of treatment, [six months of TB drugs are normally required] the TAC had to urgently get hold of drugs for her daughter because the clinic had no medicine." 

"While the child ran a serious risk of developing multidrug-resistant TB, we're not sure what happened thereafter because the woman said she was too afraid to speak to us because the clinic had threatened to treat her badly," said Gonyaela.

In another case, a man who gets his ARVs from Mantlaleni clinic said: "Since 2008, the clinic has sent me home at least six times a year without drugs."

Motsoaledi said he could comment on the coalition's call only once he had studied the report. But he did voice extreme apprehension about the depot. 

"The Mthatha depot is by far the worst we have in the country," he said. "I've previously recommended that it be closed down. I still think it's the only thing to do as the problems are extremely deep rooted."

Motsoaledi said the ANC had adopted a resolution at December's Mangaung conference to "do away" with medicine depots. 

"We need to get hospitals and ­clinics to order drugs directly from suppliers. It's the same system that the private sector uses. However, in the case of the public sector, we can't rush into it. We need to make sure that the facilities have the capacity."

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Stop Stock-Outs to track supply nationally

Stop Stock-Outs is a civil ­society group consisting of Wits University's Rural Health Project, the Southern African HIV Clinicians' Society, Section 27, the Treatment Action Campaign (TAC) and Médicins Sans Frontières (MSF). It was launched this week at the sixth South African Aids conference in Durban. 

According to MSF's Gilles van Cutsem, the group will establish a network of patients and staff who will feed information about drug stocks into a national database. 

"That will give us a clear, real-time idea of where medicine has run out. This is to assist the national health department to understand the root causes of stock-outs, as their current system is not working," he said. 

While the conference's focus fell on shortages in the Eastern Cape, a report released by a group of health organisations, the Eastern Cape Health Crisis Action Coalition, pointed out that stock-outs are occurring across the country. 

The Rural Health Project said that in addition to HIV and tuberculosis drugs, public health facilities also regularly ran out of painkillers, diabetes and heart medication, antibiotics and ­surgical gloves.  

In addition: 

• The South African  HIV Clinicians Society receives frequent reports of ARV stock-outs in the Ekurhuleni region in Gauteng;

• The TAC has received reports from patients in Thokoza in Ekurhuleni who were given prescriptions to buy ARVs at Springbok Pharmacy in Alberton;

• The coalition said that in May clinics in Eshowe in KwaZulu-Natal ran out of the three-in-one ARV pill that the government had launched in April; and

• In April, Limpopo experienced stock-outs of the ARV Lamivudine at Messina Hospital.

François Venter of the HIV Clinicians Society said stock-outs seriously undermine drug adherence messages, particularly in the case of HIV.

 "We tell patients how important it is to take their ARVs at the same time every day, but then we have a system that can't supply them with enough drugs.