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The Monitor (Kampala) | 21 June 2008

By Kakaire Ayoub Kirunda | Kampala

"I was disappointed recently when we took my mother to Mbale Hospital. The old woman was in so much pain, but before she was attended to, the doctor had to first write for us medicine on a small chit to go and buy so that they could treat her.

The nurses were not friendly at all. They treated us like their enemies. We were told to buy syringes and even the cheapest medicine like Panadol (paracetamol)."

Those were the contents of a letter that appeared in the Daily Monitor recently by someone calling herself Stella Wanyenze.

Medicines and health supplies constitute the second biggest expenditure for regional referral hospitals.

But some widely publicised theft cases and intermittent shortages make some members of the public think that medics could be stealing the medicines and selling them in their private drug shops and clinics.

Ms Betty Kibwota, the LC-V councillor of Pece Laroo Division in Gulu Municipality, is among those who say health workers are stealing medicines.

"Recently I intercepted six cartons of stolen drugs worth millions of shillings," she said. "The case is already in court. I hope justice will take its course."

The latest Annual Health Sector Performance Report also cites shortage of medicines in some hospitals.

"Availability of medicines was poorer than last year with six hospitals reporting a stock out of at least one indicator item in one or more quarters of the year compared to only one hospital reporting a stock out the previous year," reads the report in part.

So, why are there not enough drugs? Are health workers stealing the medicines meant to be offered free to the public?

Health economist Freddie Ssengooba of Makerere University School of Public Health says that while theft of medicines is a reality in health facilities, other factors also contribute to the shortage.

"I don't want to say where most of the drugs are stolen," he said. "Some are taken to the clinics of the health workers.

But some are being sold internally. A doctor prescribes the drug, it is not available, but if you do something [read pay a bribe], the drug becomes available. So [medicine] is virtually not available although it is there but regulated by informal payments or petty corruption."

According to Dr Ssengooba, research indicates that many losses happen at procurement level, not only with medicines but across the board.

Said the health economist: "Value for money is very poor. Sometimes donors say they are contributing $2 million to the drugs budget, but when you look at what comes you cannot claim that it is worth $2 million.

So, corruption is not only in government but even on the side of the donors particularly on drugs. "All donors do not want the drugs they give to be procured by government. Everyone wants to do the procurement so that they can buy from their people to control the process. This makes procurement a wasteful process."

Dr Ssengooba said some patients' attitude as well contributes to the shortage of drugs in the hospitals and other health centres. Some patients believe that they must always be given drugs every time they visit a health unit. And some health workers are more than willing to meet the demands of these ill-informed patients.

"Most of our health workers are working independently, and actually prescribing beyond their training," he said, citing as an example nurses who are not qualified to be prescribing certain drugs but do so because they are on their own.

"Any fever and they give an antibiotic, any pain and they give the strongest painkiller. So, in the end, because of the incompetence of the workforce, we are actually spending a lot on drugs."

But how much does the government spend on drugs for the nearly 30 million Ugandans?

Current statistics indicate that the per capita expenditure on drugs stands at $1.7 (about Shs2,890). Yet without including HIV drugs the ideal expenditure per capita should be $3.7 (about Shs6,290).

Reacting to the accusations in separate interviews, several hospital heads acknowledged the drug shortage, but none agreed that it was mainly due to theft by medics. They instead blamed under-funding for the problem.

"Generally the budget is not enough to buy all the quantities of drugs that we require in the hospital," said Dr Vincent Ojoome, the medical chief of Mbale Regional Referral Hospital.

"But we try as much as we can to provide the essential drugs [such as panadol and oral rehydration salts]. And the list is very wide. I have for the general hospital a list of 188 items and for the private [Masaba] wing, it would be the same but they have other specifics. The eye department also has specific drugs and they cost a lot of money."

Dr Ojoome said a lot of money is needed to provide for all the hospital's departments. "Now we get a release of about Shs26 million in a month, and this is meant to cater for the month's supply," he said.

"And then we also get a release of about Shs16 million in a four-month intercourse from the National Medical Stores [NMS]. But this can't cater for all that we need. So some items genuinely run out of stock."

To the west at the Fort Portal Regional Referral Hospital, acting medical superintendent Edward Nkurunziza offered a similar response.

"We are supposed to get the drugs from the National Medical Stores," he said. "But sometimes we place an order and NMS doesn't have those drugs, and by regulation we are not supposed to purchase drugs unless NMS has given us a certificate of non-availability.

And when we seek explanations, NMS says the Ministry of Finance doesn't give them money in time. Yet they tell us they don't have enough operational capital."

Although NMS General Manager Moses Kamabale acknowledges these problems, he says it is not his organisation's making, but a result of many other factors.

"The Public Procurement and Disposal of Public Assets Act is not friendly when it comes to the procurement of medicines," Mr Kamabale said.

"It delays the procurement process. The Act works in such a way that once any purchase involves over $35,000 there must be open bidding, the adverts have to be in the papers for a specified period of time. And as we do all this somewhere the stocks are running out."

But even after that, he said, NMS is also dependent on the chosen suppliers. "We do not manufacture drugs but depend on the manufacturers or suppliers. We do not control them and have to wait until they deliver."

Likewise, Mr Kamabale said, the mandatory analysis by the National Drug Authority of some pharmaceuticals such as antiretroviral drugs, anti-malarial and anti-tuberculosis drugs delays supplies to the health centres.

And that is not all. Even after getting the drugs, NMS' fleet of delivery trucks works in cycles, serving one region at a time, further delaying the process, said the NMS boss.

The other probable cause that Mr Kamabale cites is the inability of health units to quantify what they need. "Sometimes they underestimate their requirements."

And echoing cries of inadequate funding that were commonplace when accounting officers from all the regional referral hospitals appeared before the Public Accounts Committee of Parliament early this year, Mr Kamabale blamed under-funding for the problems dogging the NMS.

A closer look at our series has hinted at financing as one of the major causes to the problems that the hospitals are facing.

In our last article in the series, experts suggest some of the possible solutions to this and other problems plaguing the health sector.

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