30 January 2013

South Africa: Deaths Likely Following Mthatha Depot Shambles

Scores of state patients living with HIV are in danger of dying after a myriad of problems saw the Mthatha Medical Deport unable to dispense antiretrovirals for a number of weeks.

In a hard hitting report, Emergency Intervention at Mthatha Depot – The hidden cost of inaction, Médecins Sans Frontières (MSF), the Rural Health Advocacy Project (RHAP), SECTION27 and the Treatment Action Campaign (TAC), document some of the universal reasons for the crisis that is crippling parts of the South Africa’s public health system.

“Reports of drug and medical supply shortages, staff shortages, corruption and the mismanagement of funds and healthcare facilities are familiar all over the country,” TAC General Secretary Vuyiseka Dubula says in the report’s introduction.

“The inevitable consequence of the collapse of the system is human loss: treatment interruptions that can lead to resistance and death, patients going without vital surgical procedures, and extended preventable – but unprevented – pain, illness and indignity,” Dubula adds.

She says that the bitter irony of the “likely death of scores of people as a result of ARV treatment interruption” following the problems at Mthatha Depot late last year in which the new National Strategic Plan was agreed, cannot go unnoticed.

The figures paint a bleak picture:

- A short survey conducted in the area estimates that at least 5 500 adults on antiretrovirals went for at least one day with any drugs while almost 600 children were sent home without treatment.

- A total of 34 facilities are still waiting for Tenofovir stock, a critical antiretroviral.

- It is calculated that at least 714 patients may have developed some form of drug resistance as a result of the supply disruption with between 20 and 80 patients likely to die.

- One in five facilities reported that they were completely unable to provide paediatric TB treatment, often for many months. This is likely to cause many deaths.

- It is estimated that the ARV treatment interruption will cost the province in excess of R1-million as patients will have to take the more expensive second-line treatment.

The recent breakdown in the delivery of services by the Mthatha Depot is viewed as a single, particularly severe episode that caused an immediate crisis in service delivery.

The report also reveals that the problems at the Depot go deeper than issues of labour disputes and flooding which precipitated the crisis. Inadequate human resource capacity, corruption, mismanagement and lack of oversight by the National and Provincial Departments of Health (despite knowledge of the extent of the problems) left Mthatha Depot vulnerable and the recent breakdown was predictable, as were its consequences.

Dubula adds that they had been left with the overwhelming impression that the health crisis in the Eastern Cape is one of management constraints, rather than a shortage of funds.

The Mthatha Depot serves over 300 medical facilities in the Northeastern third of the Eastern Cape, popularly known as the “old Transkei area”.

Last year the Depot alone held on average around R50-million of stock at any one time, issuing up to 9 000 items every month and received around 500 deliveries. More than 100 000 people living with HIV receive their antiretrovirals via this Depot.

The present crisis started in September last year with the national transport strike reducing orders delivered. A month later Depot staff went on a protracted strike, which ended a month later after intervention from the Provincial MEC. However, staff only returned to work on a “go-slow” and eventually 29 staff members were suspended in December. This left the Depot with 10 working employees, most of them contract staff.

The number of items issued to medical facilities fell from 9 000 to less than 2 000. This led to a shortage of among others antiretrovirals and TB drugs. It is also likely that many newly diagnosed or ill HIV-positive patients were not initiated on treatment during this time.

In an unprecedented move, MSF was authorised by the national health department to intervene and the humanitarian group in partnership with the TAC took over the Depot operations on December 7.

Unsurprisingly, they found a Depot unable to operate. The National Health Department also deployed three experienced pharmacists for one week.

By December 19 the backlog had been cleared and regular functioning commenced.

This means that within two weeks it was possible with a relatively small team and low financial investment (less than R220 000), to both halt the decline in service delivery to the hospitals and clinics and clear the backlog order.

The report warns that there is still concern that new patients waiting to initiate ARV therapy continue to be affected by unpredictable and erratic supply to the facilities. This is especially the case for HIV/TB co-infected children, who are still awaiting paediatric TB treatment and, consequently, cannot yet be initiated on ARV therapy.

MSF also found a large informal “store” with boxes of expired, but critical drugs, estimated to be worth millions of rands.

MSF is now handing all activities back to Eastern Cape health authorities. The TAC will mobilize 25 volunteers to assist in the handover.

To improve essential drug supply monitoring the RHAP, the Southern African HIV Clinicians’ Society, SECTION27, TAC and MSF plan to set up a drug stock-out monitoring system. The aim is to centralise reporting on supply ruptures from patients and health staff into a national database, to identify clinics requiring emergency supplies.

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