Causes and implications of the 2008/2009 Antiretroviral moratorium in the Free State province of South Africa

Abstract

In November 2008, a moratorium on initiating new patients onto antiretrovirals was enacted by the provincial Department of Health in the Free State. This paper examines the causes and implications of the Free State antiretroviral moratorium in the context of South Africa's provincial expansion of antiretroviral coverage. It argues that financial mismanagement, bureaucratic malfunctioning and a lack of monitoring and evaluation were the root causes of the moratorium. The more immediate causes are also discussed, primarily the change in financial delegations in November 2008, in which Provincial Treasury abruptly prevented health officials from further overspending. As the first official cessation of a provincial antiretroviral programme, the Free State moratorium provided a litmus test for government's reaction to a critical challenge in the provincial ART scale-up. Its therefore provides a valuable case study for the state's response to systematic and health infrastructural problems that have characterised the national roll-out since its inception.