In my work in the field, I am no longer surprised to see test stockouts, essential medicines stockouts, supply stockouts, broken or missing diagnostic machines, or patients who are afraid of healthcare workers. It is a complete tragedy, and as I work to help, I think of all the people who are sick or die because of failures of the healthcare system, who cannot tell anyone their stories. For those who do not work in the health system, or haven’t had an experience of health system failure, transparency and data on implementation is practically invisible – so there’s no public awareness of the issues.

So I was thrilled to see recent developments in accountability – the Stop the Stockouts campaign, and the creation of the Budget and Expenditure Monitoring Forum in South Africa.

Power to the People: Stop the Stockouts

Stop the Stock-outs , a multi-country Africa campaign, is using text messages sent by activists and members of the public to expose stock-outs of essential medicines at public health facilities and put pressure on governments to address the issue. It was launched in Kenya, Uganda, Malawi and Zambia by Health Action International (HAI) Africa. During Pill Check week in June, facilities were surveyed, and a map of stockouts was created. The image below incorporates July 2009 data. It was found that many government health facilities were routinely running out of, or just not stocking essential medicines to treat common diseases such as malaria, pneumonia, diarrhoea, HIV and tuberculosis (TB).

“We were finding availability levels in rural, lower-level health facilities of 40 or 50 percent for essential medicines,” said Christa Cepuch, a pharmacist at HAI Africa. Read more from IRIN here

Show me the Money: HIV Policy AND the Budget and Expenditure Monitoring Forum in South Africa

With a new government in South Africa as of May, there have been some very positive signs. Celia Dugger of The New York Times reported that the new health minister, Dr. Aaron Motsoaledi, had accepted the strong critique of South African HIV policy reported in this Lancet series: Health in South Africa. He is a brave man, and needs all of our support as he tackles the challenge of rebuilding the healthcare system.

Gap in Treatment Access and Re-estimating the Need

One of the most daunting challenges Dr. Motsoaledi faces is that less than 50% of people who need ARVs in South Africa have access to treatment. And this may be an understatement of the actual need. Why? The government uses the Actuarial Society of South Africa ASSA model to project need, but ASSA uses 10 years from seroconversion to the time of first AIDS definining illness, whereas research evidence now supports 7 years. Dr. Francois Venter and Dr. Pierre Barker created the HAART calculator which uses 7 year period to AIDS, and estimates a higher patient need for HAART at this point in the epidemic than that projected by the National Strategic Plan. So, the gap is even bigger than reported.

Budgeting Failures threaten HAART program

This week, the Treatment Action Campaign released a press release on the creation of the Budget and Expenditure Monitoring Forum. Read the IRIN report here.

The Forum plans to put pressure on the national departments of health and finance to provide better budgeting and oversight of health expenditure in the country’s nine provinces, and ensure that there are no further moratoriums on ARV treatment. Last year, the most visible of budget cut decisions was the moratorium on the initiation of patients onto HAART in the Free State from November 2008 through March 2009. The Southern African HIV Clinicians Society estimated that at least 30 lives a day were lost as a result of this decision.

Here’s an excerpt (with some editing by me) of the press release from TAC:

A further problem is that the quality of financial and programmatic information about the HAART and PMTCT programmes is poor. This makes it difficult to assess implementation progress and leaves civil society largely dependent on what we can find out from our own investigations and anecdotal reports. For example, there is no publicly available information of the volumes purchased against the antiretroviral tender. We have received a report that the volumes being purchased are substantially less than predicted. If this is correct, then the treatment target set in the HIV & AIDS and STI Strategic Plan for South African, 2007 – 2011 (NSP) is not being met.

The Minister of Health, Dr. Aaron Motsoaledi, has already confirmed that nationally, there is a billion rand shortfall ($135 million USD) in HIV programme budgets for the current financial year. We have received reports indicating that provinces are facing financial constraints which could lead to a cut-off or slow-down in putting patients onto HAART. This will lead to more avoidable deaths.

If I can get a .pdf of the TAC press release, I’ll post it.