Public healthcare facilities in the North West have been plagued by chronic medicines stockouts for years. Now, as the province's health department is again taking the reins after four years under administration by the National Department of Health, there are some signs of improvement, although some people still return from healthcare facilities without the medicines they need.
The North West Department of Health was placed under administration in May 2018 in terms of Section 100 (1)(b) of the Constitution. The National Department of Health seconded Dr Jeanette Hunter to take charge in the province. In March this year, Minister of Cooperative Governance and Traditional Affairs Dr Nkosazana Dlamini-Zuma announced that relevant departments in the province would be taken out of administration in a phased manner. Then in July, the situation changed from a Section 100 (1)(b) intervention to a section 100 (1)(a) intervention, which means that the provincial department of health is again holding the reins, although they still have to report to the National Department of Health on certain key deliverables.
Despite some improvements in the four years under administration, medicine stockouts at some of the province's healthcare facilities continue for a variety of reasons - including budget shortfalls, delays in paying service providers, pending disciplinary cases of two senior pharmaceutical managers, and challenges in ordering, delivering, and maintaining medicine stock levels at hospitals and clinics.
Ritshidze, a community-led clinic monitoring project, in a report released in July, found that "26% of people interviewed (at clinics they monitored in the province) had left or knew someone who had left a facility without the medication that they needed in the last three months". The report flagged the North West as the worst performing of South Africa's nine provinces on medicine availability. The data was collected between April and May this year.
The province's health department rejected the report's findings in a statement. (Note that the percentages in the Ritshidze report cannot be directly compared to those provided by the department since they measure different things. Ritshidze measures what percentage of users report not getting the medicines they need, while we understand the department's figures to indicate the percentage of facilities that have the medicines in question in stock.)
Ritshidze also reports that just 17% of people living with HIV interviewed in the province said they were getting a three to six months ARV refill, compared to 49% in Mpumalanga, the province that is performing best on this indicator.
26% of people interviewed (at clinics they monitored in the province) had left or knew someone who had left a facility without the medication that they needed in the last three months - Ritshidze
"government doesn't have money"
Sixty-one-year-old Nkele Moerane depends on Dertig Clinic near Hammanskraal for her health needs. She says her hypertension medicine is often changed and recalls the clinic was out of pain medicine earlier this year.
"When we go to the clinic we often find that some medicines are short. When we ask the nurses why we are told that government does not have money to buy medicines," says Moerane. "In some instances, patients who are treated for a cold are told to go to the pharmacy to buy cough mixtures or use traditional medicines."
At the 13 sites regularly monitored by Ritshidze, an unacceptable 26% of people had left, or knew someone who left, a facility without the medication that they needed. The North West performed much worse than all other provinces on this indicator #NorthWestHealth @Stop_Stock_Outs pic.twitter.com/7gMTAobVA9
-- Ritshidze (@RitshidzeSA) July 21, 2022
Recurring budget problems
According to an exit (of administration) report drafted by Hunter and submitted to cabinet in July, the provincial health department every year runs out of budget for medicine and security.
"The pharmaceutical and security budget runs out in December and January of each financial year, resulting in a backlog of payments for orders and deliveries made (pharmaceuticals) and services provided (security) over the course of January, February, and March of each year," says Hunter.
This means that when the department receives its new budget in April, the backlogs for January, February, and March - combined with current payments - result in accruals. These accruals mean there is less money to fund priorities such as the filling of vacant posts and addressing medicine shortages.
When we go to the clinic we often find that some medicines are short. When we ask the nurses why we are told that government does not have money to buy medicines - Nkele Moerane
In his 2022/2023 budget speech, North West's Health MEC Madoda Sambatha said annual accruals still hover around the R1.2 billion mark. Though the North West Treasury has allocated an amount of R350 million to help finance the accruals, the challenges of insufficient budget allocations remain, he said.
When asked about plans in place to address these budget shortfalls, Foster Mohale, spokesperson for the National Department of Health, told Spotlight on 5 September that various stakeholders are in consultation to address the matter. "The [department] is in the process of setting up a meeting with National Treasury, Provincial Treasury, and the North West Department of Health to get the National Treasury to approve a once-off transfer into the pharmaceutical budget," he said.
Provincial health spokesperson, Tebogo Lekgethwane, told Spotlight this week that there have been initial discussions on the issue "that cannot be finalised in just one meeting". He said the aim is to get a financial injection in the coming adjustment budget.
For this financial year, the North West health department earmarked R1.8 billion for medicine and medical supplies.
Tomorrow we're back in the North West to launch the 2nd edition of our State of Health report! This year's report shows a mix of improvement/deterioration over the year, where the Dept. of Health committed to make change & what still needs fixing. Join us live!#NorthWestHealth pic.twitter.com/cF9cKrcz3v
-- Ritshidze (@RitshidzeSA) July 20, 2022
Suspensions and unpaid invoices
Health-e News previously reported that in 2020, a team from the provincial head office led by Hunter raided the offices of the Mmabatho Medical Depot. This raid uncovered unpaid invoices from 50 companies worth millions and some of the unpaid invoices dating back to 2014. One unpaid invoice that was found at the medical depot was for more than R16 million.
In the same year (2020), the Chief Director of Pharmaceutical Services and the Head of Pharmaceutical Services in the province were suspended. Their disciplinary cases are yet to be completed. When asked about the outcomes of the disciplinary cases, Lekgethwane told Spotlight that the case is "sub-judice and the department cannot divulge any details".
Lekgethwane insists that there have been improvements at the Mmabatho Medical Depot since the province was placed under administration. "This is evidenced by the upgraded accreditation by the South African Pharmacy Council from C to A - an indication that there are now fewer shortcomings. This accreditation upgrade also means that the unit can train pharmacy assistants," he said.
He said 19 suppliers that were on hold in April 2022 were all paid by the end of June 2022. This, he said, led to improved medicine availability in 81% of [public health facilities] at the end of the quarter.
Stock control problems
Hunter's close-out report also indicated that some pharmacists are not controlling stock evenly across facilities in their districts. This is evident when a certain medication will be out of stock at some facilities in one district, while other facilities will have an abundance of the same medication. In her report, Hunter said this issue is repeatedly raised with district managers, yet the problem continues to crop up periodically.
Spotlight asked Mohale if the department is offering any training to improve these shortcomings. He said that district pharmacists were orientated on how to manage stockouts. "This is not a matter of training. District managers, facility managers, and district pharmacists have repeatedly been oriented on how to manage and avoid medicine stockouts. There should be disciplinary action taken against facility managers or, where relevant, managers on other levels who do not take reasonable measures to ensure that the facility has stock of all essential medication," he said.
"The problem with medicine shortages across various facilities can be blamed on many factors," said a facility manager at a North West clinic, who asked not to be named for fear of reprisals (Healthcare workers in the province have previously been acted against for speaking to the media).
"Firstly, it lies with the issue that hospitals order medicines from the medical depot, then they are passed onto hospitals and then the hospitals send the medication to clinics," said the facility manager, adding that the delivery of medicines in North West is outsourced, so you will find that if a delivery truck belonging to a service provider has broken down, medicines will not be able to reach a hospital or clinic. This causes delays because the facility manager will now have to look for an alternative.
This is corroborated by EFF member of the provincial legislature and the party's provincial spokesperson for health, Kelebogile Kerileng, who says during oversight visits to clinics, some nurses said clinics order from district hospitals and the medication is sent to them. Only in case of emergencies can the clinic use its own transport to go fetch medication at the depot directly.
According to Lekgethwane, however, there is now a plan to improve the delivery times of medications. He says this involves "direct deliveries to hospitals while the medical depot will deliver directly to clinics".
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But in some cases, the problem seems to be poor planning at facilities rather than distribution problems. "In some instances, you will find that in most clinics, the person responsible for medicine stock control does not know their medicine utilisation, meaning how much of a particular medicine the facility needs and the quantity required to keep in stock for a certain period," said the facility manager.
Another concern raised by the facility manager is that suppliers do not always adhere to delivery schedules. This is often caused by international suppliers not having enough of a particular medicine in stock.
Solutions being implemented?
The line from the province remains however that the situation is in hand. When Spotlight asked Lekgethwane what plans are in place to ensure that the department does not run out of budget for medicines every year, he said, "Experts were appointed by both national and provincial treasuries to conduct a deep dive into pharmaceutical services at district level. We are currently implementing the recommendations from that report."
Lekgethwane says the department has made strides in addressing medicine shortages in public health facilities. "The overall provincial medicine availability has reached 81% as per the national essential list in the third quarter of 2021/2022 and that has been maintained until the end of March 2022. Availability of antiretroviral (ARVs) and vaccines for the extended programme on immunisation have been maintained above 92%, and tuberculosis (TB) medicines above 82% since the third quarter of the 2021/2022 financial year," he said.
But meanwhile, Kerileng says during an oversight visit last month at clinics around Mahikeng they still found medicine shortages. "During last month's oversight, we found that there were no infant vaccines at local health facilities as well as birth control injections (Depo-Provera). Every day we are receiving complaints from communities that they don't get medications from clinics to a point where they were instructed to buy from their own pockets at chemists," Kerileng said.
But Lekgethwane says that the province will experience shortages of specific items from time to time, especially when there is a national problem with that specific medicine. He urged the public to use the provincial health department's processes for lodging general complaints at clinics and hospitals when they experience medicine shortages.
