Chris Hani Baragwanath runs out of life-saving Adrenaline after health department switches suppliers

An about-turn to downgrade a long-standing supplier of Adrenaline™ to Gauteng’s public hospitals in favour of a relatively unknown company has left the province’s key hospitals running critically low on the life-saving drug and raised more red flags of tender processes.

On Monday, 14 August, the last ampoule of Adrenaline was used up at Chris Hani Baragwanath Academic Hospital (CHBAH), according to doctors. 

But frustrated staff have been raising the alarms of dwindling stocks from as far back as 8 May, with, they say, no intervention, no contingencies, no communication of a strategy forward, and outright blocks to activate emergency procurement processes as the stock-out crisis worsens. 

Adrenaline injections are used as a first-line drug in cardiac arrest cases for resuscitation. It’s also used as a medical treatment for life-threatening emergencies.

As of 1 June 2023, the hospital had ordered 54,960 units based on consumption, but had only received 18,270 units, meaning only a third of their order had been filled. The hospital uses between 8,000 and 12,000 units of Adrenaline a month.

A letter widely circulated this week set out the damning outline of multiple failings that led to this looming medical disaster. The letter, written by Dr Jacqui Brown, chairperson of the pharmacy and therapeutics committee at Chris Hani Baragwanath is dated 13 August 2023. It’s addressed to the hospital CEO, the acting CEO of the medical supplies depot and the head of the National Department of Health’s Affordable Medicines Directorate.

Brown writes that continued shortages have led to rationing of Adrenaline in the hospital as doctors and pharmacists have tried to reserve stock for the Intensive Care Unit. The hospital has also had to resort to alternative drugs, including noradrenalin, a more costly drug.

She stressed in her letter that noradrenalin is only approved for use in ICUs and coronary care units because of its “significant side effects”. Brown added that stocks of this drug too, had in the meantime, also become “depleted”.

“Despite all our efforts, we are still struggling to keep up with demand,” she wrote.

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. The current supplier is a company called Pharma-Q, which has failed to meet its contractual obligation.

It’s emerged that Adrenaline had previously been supplied, without glitches, according to Brown, by Germany-based multinational Fresenius, but its contract had been reduced to just 10% of their 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 and 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 efforts by the hospital 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 informed the hospital that it had been instructed to not give quotes to individual hospitals, ostensibly to ensure that 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 Chris Hani Baragwanath Academic Hospital, “together with 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 not meeting its manufacturing output.

“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 that 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. He said 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 National Department of Health. But the communications department at the department 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 has come to light among a growing culture of intimidation, harassment and victimisation of those who raise the alarm. In recent months, Bara has faced crises including 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.

Read more in Daily Maverick: Bara Hospital cancels surgeries after infrastructure department contractors fail to fix flood damage

Responding to questions on how the GDoH intends to make workplaces safe and protect those who speak out and raise the alarm, 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 and choosing to take a stand 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.” Daily Maverick did send this story to Pharma-Q and will add any further or additional comment should it be forthcoming. DM

UPDATE: Pharma-Q has responded to Daily Maverick’s questions after the publication of our article on Tuesday detailing months of dwindling stocks of Adrenaline at Chris Hani Baragwanath Academic Hospital in Johannesburg.  

The pharmaceutical manufacturing company Pharma-Q insists that the crisis of a shortage of Adrenaline from its failure to manufacture and supply it to Gauteng’s hospitals “lasted only 24 hours”. It deems the crisis over after it delivered “a full order of stock to Chris Hani Baragwanath [Academic] Hospital (CHBAH) by 9am, 16 August”.

This is despite a confirmed province-wide shortage of Adrenaline in Gauteng’s key public facilities for months, and staff at Chris Hani Baragwanath raising concerns of a looming disaster as far back as 8 May.

Chris Hani Baragwanath reported that it used its last ampoule of Adrenaline on 14 August. Leading up to that, the hospital had to ration stocks and use less suitable alternatives as a last-resort option for months.

Pharma-Q sticks to load shedding as its reason for failing to meet its contractual agreements to deliver Adrenaline. It says it only had backup power for “certain parts of its factory and only for a limited number of hours”. It says it began to be affected by load shedding in March and was unable to “manufacture a sterile batch in continuity for 6.5 hours straight”. 

However, it only approached the City of Johannesburg to enter into a “load curtailment agreement” in May and two generators it procured will only be installed in November.

It says when its contract to supply Adrenaline in 2021 was agreed on, “power cuts were not a daily reality”. The company has held several contracts with the National Department of Health since 2001. The contract for supplying 7.52 million ampoules of Adrenaline is worth R27-million. The national department oversees centrally facilitated contracts, so-called transversal contracts. 

During the height of load shedding, Pharma-Q imported batches of Adrenaline from India, where one of its shareholders, Micro Labs Group Ltd is based. It says that since 10 June, when its “load shedding curtailment” agreement with the City of Johannesburg came into effect, it has been able to “manufacture product consistently without any power interruptions”. 

By Pharma-Q’s own acounting, it has still taken more than two months to make a full delivery of Adrenaline to Chris Hani Baragwanath Academic Hospital. DM