6 March 2018

Uganda: Expired Drugs - Who Is to Blame?


Kampala — A Feb.12 Ministry of Health announcement that expired drugs to the tune of 1500 tons in stores at 6619 health facilities across the country would be incinerated has incensed many. Critics wonder how such a volume of drugs can expire in a country that suffers constant stock outs.

The previous month, Civil Society Organizations that advocate for people living with HIV had held a press briefing calling on government to provide people with Anti-retroviral drugs (ARVs) warning of a bigger danger of drug resistance.

Many patients were skipping their doses for they couldn't find these lifesaving drugs at their facilities. Those in need of ARVs were perhaps the loudest. But many people continue going to especially public health facilities only to be given prescriptions to buy drugs from private pharmacies. The ministry's announcement, therefore, has raised questions of why and what exact drugs were expiring in stores.

When asked, Moses Kamabare, the General Manager National Medical Stores (NMS), an entity that is mandated to procure and supply drugs to public health facilities across the country said they were not sure of what exact medicines had expired as they were yet to collect them from facilities.

"We are not sure," he said, "They might be supplies like syringes, gauze or gloves. Medicines expire because they have an expiry date. Everything that has an expiry date is prone to expire and we just can't have 100% consumption."

Apart from Kamabare, Dr. Diana Atwiine, the Permanent Secretary in the Ministry of Health, also said it is naturally expected that about 5% of pharmaceuticals in the distribution chain end up expired.

But, a report released in January from an internal audit - Statutory Internal Audit Report for the first quarter 2017/18 commissioned by Kampala City Council Authority (KCCA), pointed to what tends to lead to these sorts of problems.

The study found that most of the drugs that were expiring in health facilities managed by the authority had been delivered to them just a few months from their expiry dates.

Some of the medicines that were found expired included a HIV drug - Nevirapine syrup that had been supplied to Komamboga Health Facility in October 2016. Of the 810 bottles supplied, 599 bottles had expired before use by November 2016.

Also, according to the report, NMS had supplied 36 units of a laboratory reagent HumaCount to Kisugu Health Center III but only one unit was used and the rest expired a few months later.

While appearing on a TV talk show, Kamabare said this continues to happen across the country because facilities cannot anticipate with exactness what they will need and, therefore, rely on their best estimates from previous experiences.

"NMS respects the signature of the in-charge of the facility for every order that they place," Kamabare said, "We give them what they ask for and they use the raw data that is available to them to make orders."

He noted that there has been good progress with their forecasts that now the medicines they are incinerating are much lower quantities than they used to.

The country last incinerated medicines and medical supplies in 2012 and about 6000 tons were disposed of at Luwero industries in Nakasongola. The current 1200 to 1500 tons to be disposed according to Kamabare shows progress in making appropriate predictions.

But according to Dennis Juuko a Programs Director at a local NGO Center for Health Human Rights and Development (CEHURD), a situation where thousands of drugs expire, is alarming for a resource constrained country like Uganda. He says it shows a gap in planning and that healthcare managers are putting money in wrong priorities.

Juuko has also refused to accept excuses by officials that some of the drugs expire because they are donated by donors irrespective of what the country needs and can absorb. He says government needs to work with donors to identify areas most in need so that they can send medicines that will be put to use.

"It is true that NMS supplies depending on what health facilities are ordering but are these people doing the right quantifications? Do they have the capacity to forecast? Juuko wondered adding that sometimes orders are made without considering a facility's real absorption capacity.

But Kamabare explains that the issues surrounding the expiry of drugs are sometimes beyond their control. He, for instance, says at times drugs imported in the country especially to be used in medical camps are left over medicines that are about to expire. Although these have no harm, he says they raise a risk of the government spending on their incineration.

He notes that another challenge is that some new drugs have a shorter life span--made to be in use for six months--unlike others that are designed to expire in three years.

Because of the challenges of drug lifespan, the government last year released new guidelines requiring drug dealers and procurement agencies not to import drugs that have less than a year to expire such that it allows them a longer time to be used in the country.

NMS to launch forecasting tool

With such challenges, NMS has come up with more innovative ways of forecasting drug needs. Among the solutions, is an IT tool that they say will be in use this financial year. The tool will be used to retrieve data about a particular facility and its drug needs, in as short as just five minutes.

Although the tool won't solve all the challenges, Kamabare told the Independent its additional ammunition for it will increase visibility since it will be easy to see which facilities have excess and which ones have shortages because the medicines being supplied will be easily traced.

For now, critics and officials agree that having expired drugs in circulation poses a risk of public health hazards, pilferage, and re-labelling as a result of keeping such items in health facilities for long. Atwiine says expired pharmaceuticals are a growing concern in the country and she fears it can result into a risk to national security.


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