By Makanday Zambia Centre for Investigative Journalism
REPEATED shortages in the supply of essential drugs and other important medications and medical supplies over many years have reached almost epidemic proportions. They point to a systematic failure on the part of the health bureaucracy, reports Makanday Centre for Investigative Journalism.
As far back as 1977 doctors raised questions about deaths allegedly caused by shortages of essential medical supplies.
The ensuing report by the Kaunda-led government painted a bleak picture of the country’s ability to deal with drug stock-outs.
Amazingly, since then no significant progress has been made in addressing this problem, which must be compounded by an increase in population by close to 300 per cent since 1977. It may be fair comment to suggest that the issue may be going backwards.
There appear to be a number of administrative failures within the medical supply system. For example, the Ministry of Health still relies heavily on external donors for national drug needs, and this reliance is administratively confused.
The donors involved are in three categories – those who buy and provide in-kind assistance of drugs, those who bring money into the country and those who provide budgetary support to the health ministry.
Experts say this arrangement leads to coordination challenges across institutions that buy drugs. It can lead to over-supply of some drugs and shortages of others since September 2014 donors sometimes have to assume that certain drugs have been, or have not been, provided by others.
Shortages force emergency procurement by both the Ministry of Health and at times by cooperating partners themselves. On occasions donors end up supplying the country with drugs that are not even on the list of essential drugs.
Then, some donors give their funds directly to the Ministry of Health (MoH) while others channel it through the Ministry of Finance (MoF). The MoF then makes the funds available to the MoH for drug purchasing based on a disbursal schedule. This often leads to buying in fragmented quantities, some of which are too small to be floated by international tender.
Thus government pays a higher price for drugs that could have been procured cheaper if bulk procurement were carried out. Sources at the Ministry of Finance cite “poor accountability” as the reason for controlled and “staggered disbursal” of budgeted funds to the health ministry.
In addition, the Parliamentary Committee on Health noted a weakness in the distribution system of medicines and medical supplies in its 2013 report. The report revealed delays of up to 21 days in track dispatches to several health institutions. It also noted inadequacies in the number of fleets to cater for deliveries.
That committee, chaired by Dr Brian Chituwo MP, was of the view that the national medicine budget of K 590 million at the time was insufficient in view of an increased demand for medicines, medical supplies and a rising burden of disease. The committee was further concerned with the large sums of money spent on expired drugs, which it labelled as “wasteful expenditure”. It urged the MoH to improve the needs assessment at health centres so that the risk of medicines expiring on the shelf might be reduced.
Could a lack of money be another reason why the country experiences repeated shortages of drugs? The Minister of Health, Dr. Joseph Kasonde is categorical in his answer: “It isn’t the whole problem but if there is no money, there is no money, it doesn’t matter who is buying. So this kind of problem does arise of having no money…. it is also this disjointed service that is the problem, part of the problem not the whole.”
The events of 2009, that led to a shortage of antiretroviral (ARV) drugs reveal a murky side of the story, as opposed to one of administrative inefficiency. That year, the Global Fund, which currently supports treatment for about 500,000 of the nearly one million people living with HIV in Zambia, withdrew its wallet from the Ministry of Health. That was triggered by forensic audit findings by the Auditor General, after a tip-off from a whistleblower. It resulted in the Global Fund “turning off the tap for drugs”. The consequences have been far-reaching. Government was ordered to repay a staggering US$ 9 million to the Global Fund. A source at the Global Fund said over US$ 7 million has so far been paid by government.
That was not all, said the source. “From 2009 the Global Fund moved the MoH grants to UNDP (United Nations Development Programme) in order to minimise disruption in grant implementation.”
This case was just one part of a wider web of corruption affecting aid funds to the MoH and proof of high levels of dishonesty within the ministry. Other donors such as Sweden and the Netherlands, the two largest bilateral donors to the health sector, had earlier withheld funds on a much larger scale after finding evidence of embezzlement.
The Ministry’s history is not impressive when it comes to the handling of funds by its officials. Henry Kapoko, a former human resources manager and administration officer at the Ministry of Health in Lusaka, and Robert Kalimi, a director at Rojo Trading Limited, were in court over a payment that was allegedly made to Rojo Trading by the Ministry of Health in June 2008.
In 2013 Kapoko and his uncle were both acquitted on all seven charges of theft by public servant and money laundering involving about K370,000 of Ministry of Health funds due to what was termed “unsatisfactory investigations”.
In 2007, the court jailed former Permanent Secretary, Dr Kashiwa Bulaya for five years with hard labour on charges of abusing public office. Dr Bulaya was found guilty of helping himself to about K3 million of public funds meant to buy immune boosters for people living with HIV/AIDS. He served his sentence and was released in April 2012.
The responsibility of purchasing, storing and distributing drugs was initially the function of Medical Stores (MSL) when an Act of Parliament created it in 1976. Government at some point decided to take over the functions of procurement so that Medical Stores would concentrate on storage and distribution.
But this caused problems too and a decision has since been made to revert to the old system where MSL performs all functions.
Poor management at Medical Stores over many years led to spiraling debts in excess of US$ 1.3 million, inconsistent stock availability and low employee morale. Since 2004, Government has been working with Crown Agents, a British registered company, to transform MSL into a professionally run and financially sound institution to ensure reliable delivery of vital medicines.
Now, the Ministry of Health is trying to decentralise the functions of Medical Stores by opening distribution hubs in various regions.
“The key outcome of this new distribution model is not only to remove chronic shortages of drugs and medical supplies but to support districts in the management of these resources,” Dr. Kasonde said. But until all the regions have their distribution hubs, the close to 2,000 health facilities in the country continue to rely on the centralized system for their drugs and medical supplies.
Decentralisation of medical stores is hardly a new concept for Zambia. The 1977 report proposed establishment of provincial distribution centres which should cater for the needs of district hospitals and rural health centres.
Doctors who were growing increasingly frustrated at the time said “shortages of essential medical supplies have resulted in several deaths which would otherwise be prevented”.
Professor Chifumbe Chintu, at the time chairman of the Medical Association observed that the lack of drugs to dispense to patients made the public attribute “deaths to incompetence of doctors”.
Dr Kasonde points out that some of the challenges noted in the report by a board of inquiry more than 30 years ago are still haunting the health ministry. He said: “Our government has actually increased the amount (of money) on drugs over the last two years by three times. But there is also a management issue. When you receive those drugs how do you handle them so that people can receive them?
“That is our big task. It is even bigger than the task of getting money. It is management capacity, it is improving, but it is weak. We’re tackling it in terms of strengthening the management of pharmaceutical supply.”