October TheObserver; 54% of health facilities found with expired drugs
The expiry date on the container for the drug called chlorpromazine read August 2016. But by mid-October, the medicine was still sitting on a shelf at Kasangati health centre IV, arguaby ready to be prescribed to patients. Sitting beside the chlorpromazine containers were 13 other drugs, all on the shelves despite being well past their use- by dates.
These included; ethambutol (for treating tuberculosis), lumartem and coartem (for malaria), septrin for HIV patients, tetracycline eye ointment, HIV test kits, and red top vacutainer blood collection tubes.
And this was no isolated case, a recent investigation by The Observer spanning four districts revealed. At Kiswa health centre III on October 4, there was expired aluvia syrup for HIV/Aids-infected children below five years.
At Kyabazaala health centre III in Mukono district, which The Observer visited on September 22, there was expired niverapine syrup for babies exposed to HIV/ Aids, aluvia syrup for HIV-positive babies and lumartem for malaria.
This newspaper’s survey findings seem to confirm findings released by the Global Fund on Malaria, HIV/Aids and Tuberculosis on February 26, 2016. The Global Fund has disbursed $623 million to Uganda since 2002.
In a report prepared after a survey of 50 health facilities countrywide (40 public and 10 private facilities), the Global Fund said the usage of expired drugs is rampant in Uganda.
Marcela Rojo, the spokesperson of the Global Fund Geneva Office, told The Observer in an email: The Global Fund’s Office found expired health commodities in 54 per cent of the facilities visited, but the report did not weigh in on the magnitude of the problem in those health facilities or across the country.”
At the ministry of health, the assistant commissioner for Integrated Curative Services, Dr Jackson Amone, said the findings by the Global Fund pointed to a worrying trend.
“If 54 per cent of the health facilities were found with expired medicines, it means more than half of the health centres had expired drugs,” he said.
Uganda has a total of 4,496 registered health facilities serving its 34 million people. Of these, 157 are hospitals while 4,339 are health centres. So, how do these expired drugs end up in more than half of Uganda’s medical facilities?
NATIONAL MEDICAL STORES
The organisation mandated to ensure “continuous distribution of pharmaceutical products in a financially-viable and sustainable manner to meet the needs of public health services” in Uganda is the National Medical Stores (NMS).
Its public relations officer, Dan Atwijukire Kimosho, said that last year, the organisation supplied drugs worth Shs 1 trillion, of which government contributed Shs 220bn while the rest was from donors.
“I can’t tell how much has been lost in expired medicines since at some health centres we collect drugs which were not supplied by NMS after checking the batch numbers. To fight this, we are going to stop collecting expired drugs which have batch numbers that don’t belong to NMS,” Kimosho says.
However, the most recent value-for money audit on NMS by the Office of the Auditor General showed the tug of war within the organisation to maintain the legally-mandated buffer stock levels of four months while at the same time ensuring that they don’t overstock medicines.
“NMS stocks drugs without regard to buffer stock levels; as such, certain drugs are in excess of the one year’s requirement while others are under- stocked. There were huge stocks of expired drugs within the stores of NMS,” said the report, which was released in March 2010.
More than six years later, workers at the health facilities, which we visited during the two months of this investigation indicated that NMS has not yet found a lasting solution to the problem. Different sources at these health facilities said that NMS uses a “push system” of dumping unrequested medicines in a bid to avoid audit queries over expiries in their stores.
“Health centres can’t also redistribute these drugs to other centres since they don’t have the mandate. As a result, medicines end up accumulating and expire,” explained a medical officer at Kasangati health centre IV, who declined to be named for fear of retribution.
Global Fund’s Rojo propped up the health worker’s claim, saying their report had found that the expiry of health commodities before they could be used was partly a result of NMS supplying commodities that had not been ordered by the different health facilities. He added that some of the medicines purchased had short shelf lives.
The drugs inspector in Wakiso district, Ronald Sserufusa, told The Observer that some of the drugs, such as anti-retrovirals (ARVs), expire before use because international organisations donate more than can be used in short-time spans.
“The biggest percentage of expired drugs is ARVs because of big donations from non-governmental organisations. They donate HIV/Aids drugs that have less than six months to expire yet they all can’t be used in a short time,” he said.
The assistant commissioner in charge of the Pharmacy Department at the ministry of health, Morris Seru, says that in the case of ARVs, the periodic changes of HIV/ Aids treatment to match new scientific findings affect the government’s ability to utilise all the medicines it stock.
“When policies change, some regimens of ARVs drop from use yet they had stocked many and then expire,” he says. According to Sserufusa, the government’s own policy changes have affected the usage of other drugs. For instance, he estimated that the policy change on malaria treatment could have contributed to at least 50 per cent of accumulation of expired malaria drugs in health centres.
“Since 2014, when government introduced the new policy of first testing malaria before treatment using rapid diagnosis test (RDT), the number of patients with malaria decreased,” he said.
“With the test and treatment policy, very few people were detected with malaria, and a lot of malaria drugs like coartem, lonart, duocotexin and Palaxin which were stocked in health centres weren’t used, which increased the expiry of medicines.”
In addition, according to Sserufusa, the decision by the government to change the combination of malaria management from Fansidar and chloroquine (SP/CQX) to artemesinin combination therapy (ACT) also played a part.
The intention of the combination change was to circumvent the resistance to old drugs by malaria parasites but since ACT was introduced, the old combination expired in the stores.
The World Health Organisation’s health advisor, Joseph Mwoga, said drugs expire because government doesn’t allow health centre IIs and IIIs to request for drugs they prefer from NMS. Consequently, NMS decides the drugs to send to health facilities even when they are not wanted.
This assessment is shared by the auditor general, who says in his audit report, “Although NMS is mandated to supply drugs and medical supplies to all public health services, in a number of cases, NMS does not supply drugs and medical supplies to meet public health units’ needs as per their orders.”
Mwoga also faults the government over what he describes as poor procurement planning and coordination of the medicines and health supplies which enter the country.
“Different funding programmes and government are not well coordinated in ordering medicines from industries. Sometimes they order for similar medicines which reach at the same time in excess, creating over supply. Then NMS pushes them to health centres, and all can’t be used in a short time,” he said.
Poor storage of medicines in some health centres also contributes to the expiry of drugs. Some medicines are kept in stores that leak, and there is often a lack of refrigerators to protect sensitive medicines such as vaccines.
“Slow-moving medicines like psychiatric medicines also expire because most psychiatrists prefer going to Butabika mental hospital than health centres yet we always have drugs especially for follow- up cases. Eye drops also expire since few people take them,” Sserufusa explained.
A source added that the expiry of Vitamin A and family planning medicines could be due to routine health campaigns such as immunisation, for which considerable quantities of drugs are imported but sometimes not many people turn up.
Stephen Mungi, the councillor for Makerere III in Kawempe division, says some medical personnel hide particular medicines for emergencies that never occur. So, when NMS brings a new stock of drugs, the personnel keep the in a bid to get rid of the old stock first.
“Most patients also don’t check the expiry date of the medicines; so, they end up going home with expired drugs from such health facilities,” he says.
In 2010, the auditor general found that despite the requirement to destroy expired drugs every six months after write-off, there were expired drugs at both NMS premises and health centres countrywide which remain undestroyed for an average period of six years.
Indeed, a visit to health centres in Wakiso district confirmed this assessment. Since 2011, the expired medicines which NMS collected to date have never been destroyed.
“It is very risky to have expired drugs anywhere because people can re- package and circulate them,” said an official in Wakiso, who declined to be named. The public relations assistant in charge of Stakeholder management at NMS, Ester Bamukunda, said they are not mandated to destroy expired drugs. That responsibility, she said, belongs to the National Drug Authority (NDA).
When contacted, the NDA public relations officer, Fredrick Ssekyana, explained that expired drugs accumulate at health centres due to lack of funds to destroy them.
“It’s very expensive to destroy expired medicines yet hospitals have other pending issues,” he said.
Sekyana added that when they have the resources, they work with National Environment Management Authority (Nema) to destroy the medicines at Nakasongola military training school, which is the safe isolated place to destroy drugs without affecting the public.
“These drugs produce dangerous chemicals to the environment when we are burning them,” he said.
NMS’ Kimosho said some proprietors of pharmacies swap medicines that are due to expire with those at government health centres using their accomplices in order to avoid the relatively-high cost of destroying expired drugs.
Sekyana says private pharmacies which have expired drugs are charged Shs 100,000 for supervision per hour and Shs 2,457 per kilogram for the destruction of the drugs.
On August 26, the ministry of health issued a circular with guidelines for management of expired medicines. They included timely communication between NMS and health facilities, a ban on the delivery of medicines outside the officially- designated hours and implementing a system for the inter-facility transfers of excess medicines.
Dr Seru told The Observer that if implementation of the directives fails, the heads of health institutions at all levels will be held accountable.
“The implications that arise from expiries of medicine and health supplies at health facilities are that we are wasteful and don’t care about delivering quality health services to Ugandans yet there are limited resources,” Seru said.