What is Causing Drug Shortages in Uganda?

Uganda is having problems getting the right type of medicines to the right people at the right time. There are essential medicines out of stock, documented expiry of large quantities prior to utilization, unqualified personnel at the prescription/dispensing window, and self medication or medication unto others (child). What has been the consequence? Pain, increased or chronic ill health, under-doze or over-doze, treatment failure, emergence of drug resistance, socio-economic consequences, and in some cases, death. When essential medications are out of stock especially in remote villages where the communities do not have an alternative solution, then patients blame the health workers who in most cases have no control over the medicine supply chain. The Uganda National Minimum Health Care Package (UNMHCP) obliges the government to make essential drugs available to the population including drugs for TB, malaria and infectious diseases.

However, medicines are often out of stock and several factors are to blame including: the inadequate funding for Essential Medicines and Health Supplies (EMHS); bureaucy associated with procurement at the National Medical Stores (NMS); the hoarding of medicines by communities; problems at the district including the health worker shortage, lack of skills in medicines forecasting, under spending of the budget line for EMHS; and poor selection and quantification of medicines and lack of prioritization.

The health sector is under funded and medicines are no exception. Budgets FY 2004/05 and 2005/06, were 9.6% and 10.6% of the Uganda national budget respectively both less than Abuja Declaration by African Heads of State to spend 15% of the national budgets on health. Uganda spends US $ 7.84 per capita on health, yet to meet the UNMHCP, at least US$ 28, and 40 are needed when ARVs are included. Health Sector needs US $ 6.5-8 per capita to cover EMHS. In 2006/2007, only US $ 0.72 was availed by GOU: donors topped up to US $ 4.06 On a positive note in FY 2008/2009 60 billion allocated to procurement of ARVs and Arteminsin Based Combinations. With the population growth rate of 3.4% p.a, the medicines needs continue to grow especially among the 10,000,000 (UBS, 2008) people that live below the poverty line.

At a workshop on Health Sector Transparency and Accountability organized by Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda (www.aghauganda.org) which took place between 21-22 January 2009 for health sector leadership and civil society organizations working in health related activities in the Soroti district, it was revealed that co-Artem, fancida and chloroquine are no longer in stock in the district. As a result, malaria was being treated by quinine in many of the facilities.: “Quinine for children is not available, so we have to break the medicines so as to have the right dosage.” One official from Soroti district health office stated, “We received Tuberculosis (TB) medications which will be expiring in three months time.” He went on to say:

“Stock outs have also led to resistance among patients most especially the TB patients. They start the course of the treatment and some where in the course of treatment the drugs are out of stock causing resistance in the body.”

Some of the participants at the workshop blamed the communities for the drug stock-outs. It was reported that when a new supply of essential drugs arrives in the Health Centers, many community members flock to the unit to get drugs which they store for future use in case of stock-outs. Health workers are dispensing drugs to communities, without an accurate prescription. One healthwork

“Stock outs have created an over whelming turn up of patients at the hospitals when malaria drugs and pain killers like panadol arrive at the hospitals. When the drugs arrive, patients pour in at once to get their share of the drugs for storage due to the fear that the drugs are going to run out soon. The stock outs have made hospital work lag behind because then they can not run the hospital with out drugs.”

However, much of the blame for the drug stock-outs was placed on the bureaucracy of the National Medical Stores (NMS). NMS was set up in 1993 with the mandate to ensure the efficient procurement, storage, sale and marketing of quality medical drugs and other supplies. Districts can procure drugs either through the conditional grants from their Primary Health Care (PHC) or through District Medicines Credit Line System. In some cases, under spending of the PHC budget line for EMHS in some districts may cause drug shortages.

Through the credit line system, districts can procure essential drugs from NMS on credit, and funds will be paid directly to NMS from the Ministry of Health. However sometimes NMS may take 60 days instead of 30 to process and deliver an order to the district.

Delays in procurement of medicines are caused by among other things the procedural requirements under the Public Property and Disposal of Assets (PPDA) Act. At a capacity building workshop organized by the Medicines Transparency Alliance (MeTA) for civil society organizations, from April 26-30 2009, the General Manager (GM) of NMS, Mr. Moses Kamabare explained to the participants the problems caused by the PPDA law. Under this law which is the regulatory framework for procurement of public assets including medicines, the procurement process is governed by prolonged procedures requiring the approval of bids and contracts not only the GM, but also a Contracts Committee within a prescribed number of days. The process involves public advertising and approval of bidders hence the delays.

The NMS is now seemingly putting on a new image. Where orders have been delivered, NMS advertises the deliveries in the Newspaper. (See NEW VISION, April 28th 2009) In the past, drugs which have not been ordered are supplied to the districts in replacement of those which are out of stock. Where drugs are not available, NMS was required to issue a certificate of non-availability so that districts can procure the essential medicines from elsewhere especially the Joint Medical Stores (JMS). However, NMS in most cases failed to issue these certificates even when the drugs are out of stock making it difficult for the districts to order drugs from elsewhere hence the frequent stock-outs.

However, in some cases, district planners are to blame for the shortages. One health worker stated: “One of the major causes of the stock outs is poor management. The people in charge of procurement make the drug orders late.” Equally important is the shortage for human resources for dispensing medicines, and in some health workers lack skills in medicines forecasting.(AGHA, Promise Unmet, 2007). In a research carried out by Dr. Mshilla of Gulu Medical School in 2007, it was revealed that of all cadres of health workers, the shortage is greatest amongst pharmacists and dispensers.
A combination of things will eliminate stock-outs in Uganda:

1. Increased funding for the health sector particularly EMHS to meet the funding gap;
2. Increased support supervision to districts in areas of medicines quantification, forecasting and selection;
3. Amendment of the PPDA Law to reduce on the procedural requirements necessary for the procurement of medicines;
4. Sensitization of communities on the dangers of hoarding medicines;
5. Maintaining and increasing transparency in the drug procurement and supply mechanism at National Medical Stores;