Update on Free State antiretroviral therapy shortages

Last week it came to light that the Free State was experiencing critical, life-threatening shortages of ARVs and had therefore called for a stop to the ART roll-out. To read TAC's original statement on the issue please click here. The Manager of the province’s ART programme, Dr. Mvula Tshabalala, instructed provincial healthcare workers to stop initiating new patients on ART with the exception of pregnant women.

The reasons for these ART shortages were alleged financial mismanagement within the provincial Health Department. TAC has since received some clarity on these issues from representatives of the Free State Department of Health as well as from a range of stakeholders who are currently monitoring the situation. The findings have important implications for the national roll-out as a whole.

According to the information that we have received:

• At the beginning of the financial year 08/09, the Free State had approximately 20 000 people on ART and expected to enroll a further 10 000 patients over the course of the year. However, the cost of the roll-out in the province was based solely on the price for regimen 1a and therefore did not cover the costs of other, more expensive ARV regimens.
• However, as the figure for regimen 1a alone was R 2,200 per year, the Free State needed R44 million to cover the cost of existing patients, and a further R12 million to cover new patients, bringing the cost of regimen 1a to approximately R56 million. The Free State was only allocated about R36 million to cover the roll-out for this year. The result is that the money was quickly exhausted.
• In addition to this, the Free State introduced dual therapy for PMTCT but no additional funding was allocated to cover the costs associated with the introduction of AZT into the province's PMTCT regimen

A number of our sources claim that the primary reason for the current financial shortfall in the Free State is that the National Department of Health has grossly underfunded the ART programme for 2008/9. The sum of R300 million for essential bridging funding required by provinces was promised by the National Department of Health. However, it was inequitably distributed between provinces, with only four provinces receiving the essential bridging funding they needed to meet the costs of the expanding ART roll-out.

The Free State was one of the five provinces left without bridging funding. As a result of the lack of funding, the Free State has stopped initiating new patients on ARVs. If the current budgeting deficits remain, the Free State Department of Health claims that their stocks of ARVs will only last until January. Unless these critical shortages are addressed, Free State health officials argue that they will not be able to start new patients on ART until April.

The critical questions to address are:

1. From where do these budgeting shortfalls emerge? Treasury, the Department of Health, or province health administration itself?
2. What can be done to ensure that bridging budgets are allocated from the Department of Health so that provincial Health Departments are able to access additional funds when shortages arise?
3. Why are other ART regimens, in addition to 1a, not being included and adequately costed?
4. Why is dual therapy for PMTCT not being included and adequately costed?
5. Why were some provinces allocated funds to address budgeting shortfalls and others not?