In November 2008, a moratorium on initiating new patients onto antiretroviral (ARV) treatment was enacted by the Provincial Department of Health in the Free State province of South Africa. The moratorium, which was part of a series of cost curtailment measures, lasted for four months. During this time, an estimated thirty additional patients in the province died from AIDS each day. The moratorium contradicted national government’s commitment to scaling-up of ARV treatment to 80% of those in need by 2011. This article uses the health systems components outlined by Harries et al. as crucial to the delivery of quality care as a conceptual framework to assess the causal elements of the antiretroviral moratorium. It examines the factors that contributed to the moratorium, including poor financial management systems, human resource and equipment shortages, weak monitoring and evaluation systems, and bureaucratic malfunctioning. This article describes South Africa’s system of fiscal federalism and its impact on health budgeting. As the first official cessation of provincial roll-out, the moratorium served as a litmus test for government’s reaction to critical challenges in the expansion of the ARV treatment programme at both national and provincial levels. It therefore provides a valuable case study for the state’s response to some of the systematic
and health infrastructural problems that have characterised South Africa’s ARV roll-out since its inception.
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