By Franz Kruger BBC, Johannesburg

Dr Anton Schepers was explaining how he was going to replace both knees of elderly Jeanette Bakos when he was handed a letter.

Joburg Gen has halted all non-emergency surgery

He read the note and then told her to go home: The hospital had ordered a halt to all non-emergency surgery in order to prevent a massive budget overrun.

Mrs Bakos recalled: "He said to me: 'Go back, pack up your things and go home.'

"I said but Professor, I'm having my operation tomorrow. He said: 'No, you can't, because the Johannesburg General hasn't got money'."

Johannesburg's two biggest public hospitals are Johannesburg Hospital, still often called the Joburg Gen after its former name; and Soweto's Chris Hani Baragwanath, a former military base known as Bara.

With almost half the financial year still to run, both are running far ahead of their budget. Health officials say the two institutions together are heading for overspending of around $25m.

What we are doing is letting the HIV disease process run, and we are only stepping in when it is towards the end, when there are complications Dr Rudo Mathivha Chris Hani Baragwanath hospital

In response, management at Johannesburg Hospital have stopped all but emergency procedures.

At Chris Hani Baragwanath, provincial health authorities stepped in and replaced the management team. There, too, non-emergency procedures are being scaled back.

'Unethical'

Dr Schepers, a specialist orthopaedic surgeon, says it is simply unethical to withhold treatment from patients. Joint replacements - his area of specialty - may be classed as elective, but it doesn't make them optional.

Mrs Bakos' knee operation was cancelled at a day's notice

He says his patients "battle to get from point A to point B, they are confined to the house in many instances. They continue to take pain killers and they are constantly uncomfortable.

"Many are sitting in wheelchairs or on crutches. They are often young people who have the potential to be economically active and now can't earn a living."

But critics charge the hospitals are overspending because they haven't been given enough money.

About two years ago, the value of South Africa's currency plummeted, causing huge increases in the cost of food, imported drugs and other medical supplies. The rand has since recovered, but prices haven't come down.

Also, there's been a huge increase in population in the Johannesburg area, putting additional strain on the two big teaching hospitals.

Aids burden

But the biggest strain comes from HIV and Aids. Dr Rudo Mathivha is head of intensive care at Chris Hani Baragwanath, said to be the biggest hospital in the southern hemisphere.

She says over half the patients who come in for treatment are HIV-positive, and they need expensive care.

Soweto's Chris Hani Baragwanath has drastically scaled back operations

She says: "What we are doing is letting the HIV disease process run, and we are only stepping in when it is towards the end, when there are complications.

"It often requires expensive medication. It may sometimes require intensive care admission, and putting a patient on life support. Those are very expensive therapies."

Despite these massive additional pressures, the hospitals have only been given slightly more finance.

Chris Hani Baragwanath's budget went up from R800.7 million (around $123 million) in 2002/03 to R803 million (about $123.5 million) in 2003/04.

But provincial health official Dr Gwen Ramokgopa says the budget was all the Gauteng province could afford.

"We can do with more money, but we must also use the money we are having in a more efficient way."

She says part of the problem is that patients are flooding into these huge tertiary institutions with minor ailments that could be treated at local clinics.

She says the public needs to be encouraged "to use appropriate facilities so that we reserve hospitals like Chris Hani Baragwanath for the more seriously ill patient".

Research papers

The elderly Mrs Bakos is one of those who can't be treated at a local clinic.

She faces many more months waiting for her knee replacement surgery. But now she says she's not sure she wants it any more.

"I think this is an omen, I don't want to have this operation any more. I just feel that I mustn't have it, that's all."

Dr Schepers' area of specialisation has been put on hold for the next few months.

When the next financial year starts, he says he'll have a huge backlog to clear. Meanwhile, he says ruefully, he will spend his time writing up research papers.