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Damning City Press reports of a health system crumbling

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These three reports by Anna-Maria Lombard in City Press (14 February 2010) paint a damning picture of the South African public health system.

Medicine Stockouts - 3 stories from City Press

 

National Stockouts

South Africa’s already crippled state hospitals have run out of life-saving medicines.

A City Press investigation can reveal that bad planning, mismanagement and incompetence are leaving scores of patients without medicine to manage diseases like tuberculosis, hypertension, rabies, anaemia and malaria.

Virtually all the country’s provincial health departments have massively overspent in the past financial year. In some cases, suppliers have not been paid, while staff shortages across the country are wreaking havoc - especially on rural hospitals and clinics.

Worst hit seems to be the Eastern Cape where hospitals and clinics have run out of crucial medicines. A measles epidemic is ravaging the province while pharmacies are battling to get supplies of medication.

In Mpumalanga, clinics and hospitals don’t have rabies vaccine and malaria medicine. At least three patients have in the last two weeks died of rabies and six from malaria.

Supplies of folic acid and ferrous sulphate, or iron - essential for people living with HIV and pregnant women, have been out of stock for months. Clinics across the province have reported shortages of various antibiotics, tetanus, polio and hepatitis-B vaccines, needles, syringes, contraceptive injections and condoms, among many others.

In the Free State, some clinics have not only run out of basic medicines but have had their electricity cut due to non-payment of bills. A sister in charge of a clinic in the northern Free State says they had been told the health department is R33-million in debt and that all purchases have to be approved by the Provincial Treasury.

In Gauteng, the Democratic Alliance estimates that the Health Department owes drug and food suppliers more than R1-billion as the financial year winds down. Because of these delays, some service providers have held back on stock and doctors have to scramble for alternatives in order to treat patients.

“If institutions of international repute like Chris Hani Baragwanath and Charlotte Maxexe have stock-out problems, it points to much deeper, systemic problems,” says DA Health spokesperson Jack Bloom.

The Limpopo Health Department has overspent by around R90-million on its ARV budget. Hospital budgets have been cut to free up funds for ARVs. Even so, fewer than half of people who need ARVs currently have access to them.

In the Northwest and KwaZulu-Natal provinces, doctors say their problem wasn’t so much stock-outs but a dire shortage of doctors.

In one Northwest district, more than half of its doctors left by the end of last year and community service doctors didn’t arrive at the beginning of the year. As a result, no new HIV/Aids patients could be initiated on treatment.

The KZN health department has frozen all posts in all departments as a result of over-spending. A circular sent out by the Provincial Treasury in October said that due to the “anticipated high level of year-end over-expenditure”, province was embarking on a massive cost-cutting drive.
All appointments have been put on hold. The estimated over-expenditure is estimated at R1,5 billion.

The Eastern Cape’s two medicine depots have this week become the subject of a provincial investigation, admits health spokesperson Sizwe Kupelo.

Mthatha depot, which supplies medicines to remote clinics and hospitals, has not had a pharmacist to dispense supplies since the start of January. The depot had three pharmacists but their contracts weren’t renewed and they left in December without contingency plans in place. The depot manager is not a pharmacist and cannot order or prescribe scheduled medicines.

Drug shortages have ravaged the Eastern Cape for over a decade. The chairperson of the Rural Doctors Association, Dr Karl le Roux, says hospitals have learnt to pre-empt erratic drug supplies by ordering as many different versions of medicines as possible to prevents them from running out of a particular drug altogether.

But not even this pre-emptive strategy has worked this time. At the end of January, hospital pharmacies found their two-weekly order lists returned by the depot, with anything from 70 to 200 items marked “out of stock”.

A case in point is the Zithulele Hospital near Coffee Bay on the Wild Coast. The Mthatha depot could not supply 201 items on their list. Monique Lines who was Zithulele’s pharmacist till two weeks ago says she routinely reported stock shortages to the health department in Bisho, but it made no difference.

By the end of January, Zithulele had run out of polio and TB vaccine for children, cleaning solutions, gloves, gauze, oxygen, bandages and a vast range of antibiotics. TB medication has been on the stock-out list for months.

Zithulele had to appeal to the Rural Health Advocacy Project in Johannesburg to intervene. Project Manager Marije Versteeg has been seeking answers from the Province, without any success.

Zithulele will soon have to turn away new TB patients away, since there still isn’t medication at the depot. Patients have already been turned away from some feeder clinics. Without the drugs for second-line treatment, patients run the risk of developing deadly drug-resistant TB.

Medicine supply has always been erratic and by the Province’s own admission, the Health Department is R1,8-billion in debt. They’ve put all payments to suppliers on hold for this financial year.

But Eastern Cape Health Departmental spokesperson Sizwe Kupelo denies that there is a shortage of drugs. He says inadequate ordering at hospitals and “bad management” is to blame for the stock-outs.

Kupelo says an investigation has been launched into both the Mthatha and Port Elizabeth depots. “The Department wants to know which provincial manager was responsible for allowing the situation to deteriorate to this level. Maladministration will not be tolerated,” he says.

The provincial Health Department remains in such dire financial straits that they have invited National Treasury to send a rescue team to the province. With the team’s arrival this week, all delegations and mandates for spending were withdrawn and bid award committees disbanded. Work has begun to redesign the procurement system and overhaul its finances.

Mpumalanga Depot Disaster

Nellie Makwakwa fumbles with a tissue as her eyes brim with tears. It’s the thought of dying and leaving her children without care that frightens her. And she’s been told that she’s on the brink of a stroke if her blood pressure doesn’t come down.

The doctor at Tintswalo Hospital in Acornhoek in northern Mpumalanga had told that Nellie that her condition is life-threatening and that her chances of having a stroke, heart attack and kidney problems are great. And she’s only in her 30s. The doctor prescribed a drug called hydrochlorothizide. By taking the prescribed dosage, Nellie can lead a normal life.

But Tintswalo Hospital had no hypertension medicine, so Nellie travelled the sixty kilometres back to her local clinic, Hluvukani. The clinic said they didn’t have the pills either.

City Press accompanied Nellie to Hluvukani. The handful of nurses were run off their feet.

We met a number of patients outside the gate who had been sent home with “Out-of-Stock” written in the treatment books that they carry with them.

Peps Ndlovu is a big man in his sixties who is also hypertensive. He struggles with congestive heart failure and asthma and came to the clinic for an inhaler. The clinic was out of inhalers. He couldn’t get blood pressure medication or aspirin either. They were all “Out-of-Stock”, his treatment book told us.

The clinic was also out of most antibiotics, all painkillers, anti-inflammatories, anti-histamines, vitamins and iron and other essential supplements for people living with HIV.

We visited Tintswalo Hospital and learned from maternity nurses leaving for home that they were just about ready to go on strike. They had had days of no gloves in the labour room and no AZT to give mothers and babies to prevent HIV transmission during birth.

The story is the same at clinics and hospitals throughout Mpumalanga. Medicine procurement and distribution is in utter disarray.

The company that has the tender to buy, re-pack and distribute drugs for the Provincial Department of Health is Amalgamated Logistics. Their contract had however expired in May last year. It’s been renewed on a three-monthly basis, but in such a tenuous position, they’ve been unable to recruit more staff.

An insider in Mpumalanga’s medicines management chain told City Press that the Province is routinely behind on payment to suppliers and that suppliers in turn hold onto stock. This forces doctors to use more expensive ways to treat patients. One doctor had to give his anaemic patients blood transfusions, costing over R1000 each, because he couldn’t get them iron, at a few rand per packet.

The most damning evidence of poor management is the province’s R68-million medicine depot.

At the end of last year, Amalgamated Logistics was also told to pack up everything – equipment and stock – in their two provincial depots, and move to a beautiful, large, custom-built depot that was completed two years ago.

Yet today, the shiny new depot in Middelburg still stands largely empty, with grass growing knee-high and no sign of life.

The move, scheduled for the end of last year, never happened and Amalgamated had to duly unpack all their stock again.

Department of Health Communications Manager John Mlangeni disputes that the building has been empty for so long – the official opening was in September and the delay in moving was due to a lack of security.

He said this tender would be advertised “soon”, together with a tender for the actual move, and insisted that “we will soon be moving, we are just finalising logistics.”

In the meantime, the owner of the old depot in Middelburg, whose building is still being used by Amalgamated to run the Department’s depot, told City Press that the Department owes him R469,036.95 in unpaid rent since February last year.

Shortly before going to print, City Press received this exasperated sms from a doctor in the province: “I had a patient coming in with a stroke and found that for the previous three months every time she had come to hospital for treatment, her anti-hypertensive medication and aspirin had been out of stock. I wrote “the depot” as the underlying cause of death on her death certificate.”

Zithulele - Beacon of Hope

“The President and every government minister should spend a day with a rural doctor…just see what we do. See how sick people are and how they’re made to wait, and how little they complain.”

So says Dr Karl le Roux, Chairman of the Rural Doctors’ Association and principal medical officer at Zithulele Hospital. He says the quiet resignation with which their patients endure a lack of resources at the hospital is heart-breaking.

“Let them see how much patience and dignity patients have.”

The good news at Zithulele this week is that the measles outbreak may finally be subsiding. In the last week only 10 new cases were reported, compared to 40 two weeks before. A total of 260 cases have been treated since November.

Outbreaks may yet flare up in other areas. The Eastern Cape Department of Health says 9000 vaccines were brought in from elsewhere for mass vaccination campaign. But it won’t reach everyone.

The measles epidemic illustrates the problem with the Mthatha depot. Le Roux says they ordered vaccine when the first patient arrived in November.

“We needed to vaccinate all our kids in the paediatric ward. It’s recommended that staff get a booster dose in an epidemic. We ordered, but there was none at the depot.”

Four staff members got measles at the hospital. They believe at least three of these cases could have been prevented by a booster dose.

Le Roux says the problem is that they don’t have a good level of constant immunisation in the community. “If particularly kids haven’t been vaccinated, it spreads like wildfire. We’ve lost 3 patients, a child, pregnant mother and a young man. It’s been pretty hectic.”

Treating those very sick with measles at Zithulele was complicated by the stock-outs. “We don’t have simple stuff like paracetamol tablets and ibuprofen syrup. We’re admitting kids with temperatures of 40 degrees and we literally can’t give them anything. It’s very frustrating.”

“We want to provide high-quality health-care to this community. They’re desperately poor and from remote places, but that doesn’t mean they should get a second-rate service,” says le Roux.

But Le Roux feels the current lurching from crisis to crisis without underlying systems in place is unsustainable.

“We are relying on exceptional people to do exceptional things to keep our health system afloat. People who have stayed long-term in the public sector are remarkable people. They have taken so much crap and abuse, but they stay committed to their patients. Fighting with administrators, fighting with people who don’t understand them, being paid the same notch as when they started…all these issues…and they’re still there.”