Doctors at Chris Hani Baragwanath Hospital warned this week that the last ampoule of critically needed Fresenius Adrenaline had been used, apparently due to the downgrading of a long-standing supplier of Adrenaline™ to Gauteng’s public hospitals in favour of a relatively unknown company.
While the new supplier, Pharma-Q, blamed load shedding for its failure to meet its contractual obligations, hospital staff said they had been raising the alarms of dwindling stocks since 8 May, with no intervention, no contingencies, no communication of a strategy forward, and outright blocks to activate emergency procurement processes as the stock-out crisis worsens, reports Daily Maverick.
Adrenaline injections are used as a first-line drug in cardiac arrest cases for resuscitation, and as a medical treatment for life-threatening emergencies.
As of 1 June, the hospital had ordered 54 960 units based on consumption, but had only received 18 270 units. The hospital uses between 8 000 and 12 000 units of Adrenaline a month.
A letter this week outlined the multiple failings leading to this looming medical disaster. Written by Dr Jacqui Brown, chairperson of the pharmacy and therapeutics committee at Bara, it is dated 13 August 2023, and addressed to the hospital CEO, acting CEO of the medical supplies depot and head of the National Department of Health’s Affordable Medicines Directorate.
Brown wrote that continued shortages had led to rationing of Adrenaline in the hospital as doctors and pharmacists have tried to reserve stock for the ICU. They had also had to resort to alternative drugs, including the costlier noradrenalin.
She said noradrenalin is approved for use only in ICUs and coronary care units because of its “significant side effects”, and that stocks of this drug too, had since become “depleted”.
Switching suppliers
Her letter also referred to communication the hospital received from the medical supplies depot (MSD) that pointed to the crisis emanating from a change in Adrenaline suppliers.
Adrenaline had previously been supplied, without glitches, wrote Brown, by Germany-based multinational Fresenius, but its contract had been reduced to just 10% of its usual supply.
The 90% supplier bid went to Pharma-Q, a company based in Industria West in Johannesburg. Its active directors are listed as Kaamil Adam, Hussein Akbar Kalla, Nazir Adbul Kalla, Anthony Lesch, Anand Mehta, Dheerajmal Bastimal Siroya and Dilip Surana.
It lists its “product base” as eye and ear drops as well as creams and ointments.
Brown said hospital efforts to invoke the government’s “buy-out” procedures – essentially a way to allow for procurement under extraordinary circumstances – for Chris Hani Baragwanath, had been blocked.
This emerged when Fresenius representatives told the hospital it had been instructed to not give quotes to individual hospitals, ostensibly to ensure stock is diverted only to the MSD.
Other special circumstances procurement, including what’s called a Section 21 application, requires an out-of-stock letter from Pharma-Q, which hasn’t been forthcoming, and authorisation from the South African Health Products Regulatory Authority (Sahpra).
But Brown pointed out that Sahpra gives these approvals only if the medicines in question are not available in South Africa. This is not the case with Adrenaline, which is available here.
“Solutions: enforce the contractual obligations and if these companies are unable to supply, approach companies that are manufacturing adrenalin (sic) in the country to increase production,” Brown wrote.
‘No patients compromised’
Motalatale Modiba, head of communication for the Gauteng Department of Health (GDoH), confirmed the Adrenaline shortages at Bara, “and other health facilities in the province”, but said no patients had been compromised.
He acknowledged that Pharma-Q had not met its contractual obligations and said the company had blamed load shedding for this.
“Pharma-Q is struggling to cope with the demand, and is only supplying limited quantities … they say they have made provision for alternative power supply,” Modiba said.
Even though Bara used up its last ampoule of Adrenaline on 14 August, Modiba said the “majority of our facilities have one-month stockholding, instead of the usual two months”.
He said the MSD had received 20 000 vials of Adrenaline, 5 000 of which were issued to CHBAH, and that as of 15 August, the hospital had received a total of 9 000 vials.
Modiba directed the question of consequences and penalties for a breach of contract by Pharma-Q to the NDoH. But the communications department there directed Daily Maverick’s questions back to its provincial communications counterpart.
Exactly how Pharma-Q will be brought to account is still unanswered.
Continued crisis
The latest crisis at Bara tops a list of issues at the hospital, including intimidation, harassment and victimisation of those who raise the alarm.
In recent months, it has experienced a shortage of food for patients, interruption of waste removal services, and a lack of maintenance, leading to burst pipes flooding theatres. It is also without a permanent CEO.
Responding to how the GDoH intends to protect those who speak out, Modiba said: “Doctors are civil servants and are expected to comply with public services provisions. It would be incorrect to threaten workers (for) flagging issues that affect patient care, especially if those are raised in the correct platforms.”
The Progressive Health Forum (PHF), a network of doctors, health academics and health activists, said downplaying the intimidation of doctors who are speaking out is an outrage.
PHF spokesperson Dr Aslam Dasoo said: “Clinical staff face continued harassment by departmental officials and are threatened and intimidated for raising issues even through official channels.”
He said the latest crisis at CHBAH signalled “astounding dysfunction of the GDoH”.
“Reports that key academic hospitals are running dangerously low of stocks of Adrenaline is a new low for the GDoH. No hospital worthy of the name anywhere in the world is deprived of this essential drug.”
No comment had been received from Pharma-Q at the time of publication.
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