Kampala — THE perennial shortage of drugs in health centres around the country may be the result of an unreliable disbursement system and over-pricing by the National Medical Stores, an investigation by Sunday Monitor shows.

Public health centres are obligated to buy their drugs supplies from the NMS as a port of first call. Our investigations reveal that whereas health facilities duly follow the regulations, oftentimes the NMS, which charges above the market rate for a number of medicines, will instead issue what is known as a 'certificate of non-availability' even after receiving money from a health centre seeking the medicines.

This certificate is the document that permits the health unit to buy drugs from the Joint Medical Stores (JMS), a private organisation run jointly by the Catholic and Anglican churches.

Health centres pay NMS by bank draft and once their money is on the NMS account, it is never refunded to the health units to buy drugs from JMS when NMS says it has run out.

Sources who preferred to remain anonymous for fear of being victimised said the health centres, which largely depend on the government's periodic financial releases to buy drugs, are then left in a quandary. This is because they will not have money to pay JMS, which might have the unavailable drugs in stock, as their money is already 'tied' up at NMS.

One doctor who manages a Grade IV health centre - the health unit you find at county level - said that after depositing money with NMS and the drugs are unavailable, they are forced to wait for another government financial release in order to buy drugs at JMS. The Ministry of Health only releases this money every two or three months.

This implies that for the two or three months, patients at the public health centres are unable to enjoy government-subsidised treatment.

Money for drugs is released from the ministry in two ways: through a credit line sent direct to NMS and through the primary health care (PHC) grant for drugs which is sent directly to the districts.

For the PHC grant, 50 percent of it is spent on drugs and the rest on salaries.

For instance, one district with 22 health centres receives Shs230 million as PHC grant per year, Shs115 million of which is allocated to buying medicines. This already difficult situation, considering the cost of drugs and other supplies, is aggravated the moment money gets 'tied' up at NMS. The money which is tied up is not refunded but kept on the particular health centre's account at the NMS then when drugs become available they notify the health unit.

"We wonder why government allows NMS to retain money from health centres when they don't have supplies," another doctor said. "NMS is always suffering constant stock-outs."

Our investigations show that supplies frequently affected by stock-outs at NMS or those that are over-priced are essentials such as oral rehydration salts, septrin, flagyl (metronidazole), and anti-malarials like coartem and fancidar.

Irregular availability of drugs at NMS adversely affects the already limping health service delivery capacity, especially in the management of the pervasive malaria - one of the most common killer diseases in Uganda and on the African continent.

According to Dr J.B. Rwakimari, the head of malaria control at the Ministry of Health, 110,000 patients die of malaria annually.

"Ninety percent of the deaths are children below five years," he said.

Copies of price lists obtained by Sunday Monitor from both NMS and JMS indicate that the former charges higher rates. A tin containing 1,000 tablets of fancidar costs Shs31,000 at JMS but at NMS, it goes for Shs38,300.

Fancidar is the most commonly used drug in preventing malaria in pregnant women.

IV-cannulas (the butterfly-like needles used for putting children under five on intravenous treatment - drip) cost Shs350 each at JMS but Shs500 at NMS. A pack containing 50 such cannulas costs Shs17,000 at JMS but goes for Shs25,000 at NMS.

A tin containing 1,000 tablets of flagyl costs Shs5,900 at JMS but it goes for Shs8,191 at NMS. A tin containing 1,000 tablets of septrin costs Shs10,000 at JMS but fetches Shs13,000 for NMS.

While each sachet of oral salts costs Shs90 at JMS, the same goes for Shs109 at NMS.

"I thought everything was running smoothly," Minister Malinga said expressing surprise. "I was not aware that NMS charges more than other drug outlets. You go ahead and publish the story the way you have investigated it."

He, however, added: "Lately, there has been a shortage of drugs [for] which I didn't get a satisfactory explanation."

The only explanation NMS gave was that they were "carrying out something."

Dr Malinga also said he was not aware that NMS could in a way be held responsible for delays in delivery of drugs.

The Director of Health Services, Dr Sam Zaramba, said that if NMS charges more money for the same items "then there is a problem". He added: "Hospitals should only make payments against delivered goods." The principal pharmacist at Ministry of Health, Mr Martin Oteba, said that NMS was indeed charging "a little higher on selected items".

Mr Apollo Mwesigye, the general manager of NMS, could not clarify the cost difference between his organisation and other outlets such as JMS. "I wouldn't know the prices at JMS but ideally we are supposed to be cheaper than other drug outlets," he said adding: "I can't say our drugs are expensive or not expensive compared to JMS."

We could not reach NMS's head of procurement Nicholas Kyaterekera despite various attempts. Although a number of medical officers interviewed disclosed that NMS factors "transport costs" into its prices, Mr Mwesigye said "we don't factor transport on our drugs [costs]".

Ideally, Mr Mwesigye said, NMS is supposed to deliver drugs to all health units but some health centres "that urgently need the drugs collect them" but still pay a price with the transport cost included yet they will have used their own transport. It means that the health centres will have separately met the transportation costs yet the same cost was already factored into the drugs' price. NMS does not reduce the prices even if the health centres collect drugs which it is supposed to deliver to them.

When Sunday Monitor visited NMS headquarters in Entebbe, there were several ambulances belonging to various health units loading drugs. The evidently problematic system operated at NMS also extends to how they advise health units on availability of drugs and supplies. While Mr Mwesigye said that they usually give health units a proforma invoice showing which drugs NMS has in stock and their prices before the units make their orders, his assertion was disputed by our sources in various health units surveyed who insisted that even some items included on the said proforma invoices are usually out of stock.

The question health workers will now be asking themselves is: Is it possible that the present infant mortality rate that stands at 76 per 1,000 live births remains where it is partly due to unreliable drug supply over and above the fact that the government does not provide sufficient money? The same question could be posed for the mortality rate of 460 per every 100,000 (pregnant) women.