Important note: Information in this article was accurate in 2009. The state of the art may have changed since the publication date.
Sunday Times (Johannesburg) - March 31, 2009
When the new minister of health, Barbara Hogan, came into office late last year, there was a collective sigh of relief, especially when she pledged to focus her energy on fixing our dire public health system.
But has she been dealt an impossible hand? The South African Constitution talks about the "progressive realisation" of health rights within available resources. This means money, and lots of it. Health is an expensive business, and a lack of adequate financing has tragic consequences.
In November, Free State authorities suspended their HIV-Aids antiretroviral treatment programme due to a lack of funds. Antiretroviral medicines are highly effective in arresting the progression of HIV-Aids.
A conservatively estimated 30 people a day died in the Free State during the moratorium, with another 15000 adults now on waiting lists. The moratorium made little public health sense, as people who do not get antiretrovirals end up sick, requiring expensive hospitalisation and treatment, and costly burials. The money saved will easily be used up in extremely expensive in-patient care.
It has become increasingly clear that Free State health authorities issued multiple warnings that they were underfunded to the national health department and the treasury - both national and provincial - long before suspending their antiretroviral programme.
The programme experienced rapid growth, and Free State officials required far more money than previous years. This was not granted when the request was first made in April, and after repeated subsequent warnings. It was only after the moratorium was issued in November, immediately after Hogan came in to post, that money was found from a willing donor.
The department of health has deservedly borne the brunt of criticism surrounding the Free State decision. However, there are many role players in this tragedy, and it raises some difficult questions that have deep implications for health-care as a whole.
Firstly, how does the treasury make rationing decisions around antiretrovirals? South Africa has some of the best data on the HIV-Aids statistics in the world. It has some of the world's leading experts in HIV-Aids care.
We know how many people need antiretroviral care (just over 400000 new patients annually). Cabinet has formally approved the National Strategic Plan that sets this as a priority, and lists targets for treatment. Who from the treasury decided that the Free State didn't qualify?
The Free State is still treating less than half the people who require antiretrovirals in the province. Was there under-funding of the national programme, or were funds not distributed according to need?
If the treasury is forced to make health rationing decisions, who is assisting them? It is broadly accepted that the South African health system is underfunded. Rationing in health is essential to any public system, as healthcare is very expensive. We are unaware of a rationing discussion happening around any disease, let alone HIV-Aids, within the treasury.
How can the treasury support the "progressive realisation" of a cabinet-approved health intervention, when it does not make funds available? Our new and energetic minister had to approach US donors to hand over R20million, to save Free State lives.
SAA was granted over R1-billion from government coffers to keep it afloat. These tough decisions need explaining to avoid future band-aid solutions for predictable crises.
The second tough question: Where were the early warning systems on this moratorium, and where were those who should be shouting from the rooftops? It took civil society organisations like the HIV Clinicians Society, Aids Law Project and the Treatment Action Campaign to make a noise, to get information and alert the national department of health, who actually responded almost immediately to secure funding.
It took the media to keep the story alive, as local government officials kept promising that the drugs would soon appear in pharmacies, promises that were proved to be wrong as continued reports of patients being turned away reached us.
Why, after money was secured by the National Department, and expedited delivery times secured from pharmaceutical manufacturers and drugs ordered, did it take months for the antiretrovirals to finally arrive in the clinics?
Conspicuous by their absence were the politicians.
There appears to have been a severe breakdown in the relation-ship between the provincial departments of health and the treasury.
Why did the ANC not intervene when lives were at stake? Unions, nursing and doctor representatives like the South African Medical Association were silent.
The Human Rights Commission has yet to react. The Health Portfolio Committee is absent. Public health officials were missing in action. Why has so much of this oversight failed?
Minister Hogan has probably one of the hardest jobs to do in South Africa. She needs money and support to help us rebuild the credibility of a shattered public health system, not just in HIV-Aids, but for all illnesses. What happened in the Free State must never happen again.
Venter is a public sector HIV physician, heads the HIV Clinicians Society and is clinical director of the Reproductive Health and HIV Research Unit at Wits
090331
ST090305
Copyright © 2009 - The Sunday Times. Reproduction of this article (other than one copy for personal reference) must be cleared through the Sunday Times Permissions Desk.
AEGiS is a 501(c)3, not-for-profit, tax-exempt, educational corporation. AEGiS is made possible through unrestricted funding from the Elton John AIDS Foundation, National Library of Medicine, AIDS Walk of Orange County, and donations from users like you.
Always watch for outdated information. This article first appeared in 2009. This material is designed to support, not replace, the relationship that exists between you and your doctor.
AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.
Copyright ©1980, 2009. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .