Last week, regulars at the HIV treatment clinic at Pelonomi hospital, in Bloemfontein, capital of South Africa's Free State Province, would have told you that the clinic has never been this quiet.
Ever since the provincial government stopped initiating new patients on antiretroviral (ARV) drugs, the buzzing treatment literacy classes for people about to start taking ARVs had shrunk in size, while some existing patients stopped coming to check whether their drugs were in stock.
A provincial moratorium barring new patients from getting ARV medicine has been in place since November 2008, after massive overspending and a failure to apply for emergency funding in time became apparent. According to the AIDS Law Project, about 15,000 people in Free State are waiting to start ARV treatment.
The province has also discontinued CD4 monitoring [which measures the strength of the immune system], health workers have stopped referring patients in need of ARVs, there has been a fatal interruption in the treatment of hundreds who have been on ARVs for years, and the province is failing to meet the treatment needs of many children.
The HIV Clinicians Society conservatively estimates that about 30 people per day have died in the province due to their inability to access treatment.
AIDS lobby group Treatment Action Campaign (TAC) said this week it was receiving complaints from doctors and activists in Free State who said they still did not have access to drugs, despite assurances from the government on 13 February that the moratorium had been lifted.
"People think that they are going to die"
A small group of pregnant women sit in the waiting area at Pelonomi, taking a break from their treatment literacy class on a Wednesday morning; conversation is muted, and there are hardly any staff about. Although the moratorium was lifted the previous week, the drugs have not yet arrived at the clinic, one of the largest ARV treatment sites in the province.
Sello Mokhalipi works for the Treatment Action Campaign in Free State and conducts drug-readiness training for new patients at Pelonomi hospital, but since the moratorium his classes have virtually stopped; people who completed drug readiness training in August last year are still on the waiting list for medication.
"It makes me feel bad when people come here and find that there are no drugs; they come back to me and say, 'What are we supposed to do with no drugs? Should we wait and develop resistance?'"
In January, Mokhalipi, who gets his own medication from Pelonomi, was forced to buy a month's supply of Lamivudine (also known as 3TC) - a component of all first-line ARV regimens - from a pharmacy because the clinic had run out of stock.
"Most people think that they are going to die if this goes on. People are frustrated, depressed and confused; they don't know who to turn to when they are told there are no drugs and have to go home empty-handed."
|I asked them if they could give him something for the weekend, but they said, 'There is nothing we can do'|
Stella Mothata thought her six-year old nephew, Thapelo, was going to die. When she went to Pelonomi clinic on 10 February to collect his next batch of ARVs, she was told to come three days later; but three days later, the drugs were still not there and she was told to come back the following week.
Thapelo had already gone for a week without medicine and Mothata was becoming frantic. "I asked them if they could give him something for the weekend, but they said, 'There is nothing we can do'," she told IRIN/PlusNews.
A desperate Mothata then called Trudie Harrison, director of the Anglican Church's Mosamaria AIDS Ministry, and asked for help. Harrison arranged for her to purchase the drugs at a local pharmacy, but when Thapelo started taking the ARVs he became sick. "He can't eat, when he eats he vomits and this morning he woke up with a rash on his face," she said.
"They say it's pneumonia, but he woke up feeling better today, so I took him to school. But the teacher sent him back because the rash has become too bad - they say he can't open his eyes."
Mothata, who receives her own treatment from a donor-funded private organization in Bloemfontein, is finding out whether they will also treat Thapelo, as she has lost faith in the government.
But health officials insist that by March the treatment programme will be replenished and will have "bounced back".
According to Portia Shai-Mhatu, senior manager in the Free State's HIV/AIDS directorate, medical depots have been told to speed up deliveries of drugs, while drug manufacturers have agreed to fast-track the province's orders.
What went wrong?
As the health department tries to pick up the pieces, questions about how this could have happened remain unanswered. The TAC has accused the Free State's health department of "gross financial mismanagement" but national health officials have put the crisis down to "severe financial pressures" in the province.
"We can't prove that it was mismanagement, but I do ask myself what has gone wrong?" wondered Trudie Harrison at the Mosamaria AIDS Ministry.
The official answer is that a funding shortfall of R63 million (US$6,300,000), higher numbers of patients on treatment, and the introduction of more expensive dual therapy for prevention of mother-to-child transmission, led to the shortages.
The health department budgeted for an anticipated 27,000 people on treatment by the end of March 2009, but has now estimated that 35,000 people will be accessing treatment by then.
"By September  already, we realised that we were in a crisis ... we thought the most sensible thing was to give existing patients treatment. It would be very wrong and very fatal to initiate treatment one month, and then the next month there are no drugs," said Sylvia Khokho, executive manager of strategic health programmes in the province.
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"All this time we were hoping for money, but the crisis was worsening. We were looking everywhere and taking money [from other programmes] and pushing it to ARVs," she added. Shai-Mhatu commented: "Without being defensive, it's clear that the Free State health budget is too low."
With the exception of essential health services, the financial crisis has also affected healthcare in other ways - hospital beds have been slashed by more than 50 percent, according to the AIDS Law Project.
Health budgets around the country have been pushed to the limit by massive overspending, poor budgetary controls and the implementation of a new salary structure for nurses.
KwaZulu-Natal Province has overspent its health budget by over a billion rand (US$100 million) and media reports earlier in February said doctors in the port city of Durban were complaining that basic surgical supplies were unavailable at some of KwaZulu-Natal's biggest hospitals.
National Health Minister Barbara Hogan has appointed a team of experts to visit provinces and assess the over-expenditures and the state of health services.
Although Finance Minister Trevor Manuel allocated additional funding in his budget speech to roll out the new dual therapy programme and expand ARV treatment, he also announced that new systems were being designed to improve the national health department's ability to monitor provincial expenditure.
"There is a broad consensus that public health services have been insufficiently funded, but the problem is not simply inadequate financial and human resources, it is also one of inefficient use of resources," noted Adila Hassim, head of litigation and legal services at the AIDS Law Project.
In an editorial in a local newspaper, Business Day, Hassim called for parliamentary scrutiny of budget allocations and spending, as well as for a way of ensuring that funds allocated to the provinces would be spent on nationally determined priorities.
Whether it was mismanagement or inadequate funding, Harrison told IRIN/PlusNews that the provincial health department had to take responsibility for the lives lost.
"Where does the buck stop? It's people's lives we are talking about, but there's no sense of accountability, they are just blaming everyone else," she commented. "That is not good enough."