Funding deficits and a seeming clash of egos have combined to wipe out stocks of family planning drugs and other implements in the country. At the centre of the stock-out is Health minister, Dr Jane Ruth Aceng and Uganda Health Marketing Group (UHMG).
Without prior notice early this month, Dr Aceng cancelled the contract of UHMG, which for the last five years, has been charged with the alternative distribution strategy of family planning commodities to private health facilities.
The Ministry of Health has instead signed a new contract with Joint Medical Stores (JMS) to handle alternative distribution.
Civil society organisations that work on reproductive health and family planning services in Uganda are up in arms because they say JMS, which they categorise as “a conservative church-based organisation”, has no history of handling and distributing family planning contraceptives apart from moon beads.
JMS is a private pharmaceutical store established in 1979 as a joint venture between Uganda Catholic Medical Bureau and Uganda Protestant Medical Bureau and in Uganda that serves at least 3000 medical facilities.
The family planning commodities that are currently out include Microgynon, Depo-provera, Emergency contraceptives, female condoms, implanon NXT, Jadelle, IUDs, and Sayana Press.
The National Media Store does not have any of these in stock until the government pays handling fees to release them from UHMG.
Genesis of the problem
The scarcity of contraceptives has especially hit upcountry public health centres. In the last two financial years, 2016/2017 and 2017/2018, the government did not procure family planning commodities. Instead, the $2.5m (about Shs10b) that was allocated for reproductive health in the health budget was spent on procuring Mama Kits for expecting mothers.
As a result, National Medical Stores (NMS), the government body that distributes contraceptives to public health facilities, ran out of stock in December 2017. It only has in stock male latex condoms and Misoprostol, a drug used in inducing labour (but more commonly known on the black market for inducing abortions). According to the Ministry of Health National Stock Status Report of family planning commodities released at the end of April 2018, NMS is totally stocked out.
According to a statement written by UFPC to the Speaker of Parliament in June, NMS does not have any hope of procuring any family planning commodities at the moment due to the long procurement processes. Efforts to talk to Mr Baker Yiga, the coordinator of UFPC, and Ms Joyce Tamale, the managing director of UHMG, were futile. Ms Tamale referred this reporter to Mr Yiga. The latter made an appointment with this reporter for an interview but never showed up. Repeated phone calls and SMS messages to his phone went unanswered.
When contacted by this newspaper on Friday afternoon, Ms Vivian Nakaliika, the spokesperson for the ministry of health, was unaware of the stock out.
“It is not so that there is a stock out. Some facilities upcountry have stock. Anyway, I am not aware about it but let me find out.”
Later, Ms Nakaliika told this reporter: “We are well stocked at the central level. However, right now management is discussing a new distribution strategy now that UHMG is pulling out. I do not want to speculate on who is attending the meeting apart from the minister and UHMG. But what is for sure is that the distribution strategy is going to change. The details will become clear in two days’ time.”
According to a Family Planning 2020 (FP2020) Progress Report, Momentum at the Midpoint, 2015-2016, released on November 1, 2016, the demand for family planning across Uganda is growing and contraceptive use is now common. In fact, the report notes, in the four years from 2012 to 2016, 613,000 women requested for a modern contraceptive method for the first time.
As a result, in 2016, the country is estimated to have averted 595,000 unintended pregnancies and prevented 1,000 maternal deaths through the use of modern contraceptives.
At the July 2017 London Summit on Family Planning, the government revised its targets to reduce unmet need for family planning to 10 per cent and to increase the modern contraceptive prevalence rate among all women to 50 per cent. Dr Aceng pledged, on behalf of the government, to allocate $5m to the purchase of contraceptives to mitigate an unmet need. The money was never allocated.
As NMS ran out of stock, it was picking commodities from UHMG to supply to health centres across the country. However, according to a highly placed source in Uganda Family Planning Consortium (UFPC), who asked to speak on condition of anonymity, by March 2018, UHMG had also run out of most products.
“What UHMG is left with is not enough to cover monthly consumption if the commodities are shared between NMS and UHMG for both the public and private facilities. However, the US donor agency USAID and the United Nations Population Fund (UNFPA) had purchased commodities for UHMG but those commodities are still in the pipeline because there are no funds to cater for the clearance and handling fees. These commodities could be used to bridge the stock gap until NMS can purchase its own products.”
USAID and UNFPA only purchase commodities from factories. According to a Memorandum of Understanding signed between the parties, government should clear the taxes on the purchased commodities, test them, and then pay the handling fees on the products UHMG stores in its warehouse.
The government has not met its end of the bargain over the years, and many times, the donors have been pressed to bail out the country by paying the clearing and handling fees. As of March 2018, the handling clearance and handling arrears had accumulated to Shs3.1b.
In the Financial Year 2016/2017, UFPC lobbied the ministries of health, finance, and the Parliamentary committees on budget and health to include the arrears in the 2017/1018 Budget. However, the Consortium was informed that the arrears were placed under unfunded priorities. In the 2018/1019 Budget, the arrears are not catered for.
This year, because USAID suspended funding to UHMG due to allegations of fraud, the latter does not have the Shs766m needed to clear and handle the contraceptives in its warehouse. Hence, the stock outs.
When the donors declined to be pressed into paying clearance for the commodities they had purchased, UFPC met with the Health minister in May 2018 to persuade her to pay the Shs3b arrears.
Our source in UPFC says when presented with the urgent need to pay the handling fees so that the contraceptives are released, Dr Aceng was unwilling because the item had not been budgeted for in the Financial Year 2017/2018. However, she committed to finding the money and her Permanent Secretary wrote to UFPC to that effect, although no specific timeline was given.
“We decided to seek the intervention of Parliament and persuade the Speaker for the need of a supplementary budget before the financial year ended to clear these commodities because some public health facilities have not received contraceptives for more than six months,” the source says.
The UPFC secretariat wrote a letter to the Speaker on May 19, 2018, a copy of which this newspaper has seen. The Speaker granted them audience on June 7, 2018 at 4pm. The meeting was attended by UFPC members, Dr Aceng, the chairperson of the Parliamentary Committee on Health, Dr Michael Bukenya, and the chairperson of the HIV committee.
The source adds: “Dr Aceng was not happy that UFPC had taken up the matter with the Speaker. She made it clear that she was not amused by the fact that civil society did not trust her. She committed that the ministry would use any savings from Financial Year 2017/2018 to clear UHMG’s arrears. However, to our surprise, she instead drafted a letter cancelling the agreement between the ministry and UHMG.”