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Health saga: Details emerge on Shs300b expired ARVs, test kits

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The Auditor General, Mr Edward Akol (3rd left), makes a presentation to legislators and parliamentary staff before handling over his audit report on Financial Year 2023/2024 to the Deputy Speaker of Parliament, Mr Thomas Tayebwa, (wearing yellow tie) at Parliament in Kampala on January 15. Photo | David Lubowa

Anew report by the Office of the Auditor General has raised eyebrows after unveiling the destruction of Antiretroviral drugs (ARVs), Covid-19 vaccines, and test kits worth Shs316 billion that had been declared “expired and non-viable”.

This value of the destroyed products (Shs316 billion) is huge when compared to the country’s annual budget for essential medicines and health supplies (EMHS) which is around Shs560 billion. The new report, which also unmasked drivers of poor service delivery in the hospitals, indicates that the value of the destroyed products in the 2024 audit year was an 860 percent increase from the products worth Shs33 billion destroyed in the previous financial year.

“This is wastage of government resources, which would otherwise have been utilised for other pressing needs,” reads the report presented by Auditor General Edward Akol to Parliament last Wednesday.

“The expiry of medicines leads to financial loss to government directly negatively impacting on service delivery as evidenced in the deficits in meeting the health facilities essential medicines and health supplies (EMHS) demands,” the report reads further.

In his recommendation, the Auditor General said they have advised the accounting officer of National Medical Stores (NMS) to appropriately budget for the EMHS in line with the demand to avoid overstocking of drugs and ensure adequate and timely distribution and delivery of drugs and health supplies to the respective health facilities.

Speaking to the Monitor at the weekend, Dr Robert Mutumba, the head of the Aids Control Programme at the Ministry of Health, said the ARVs were destroyed because a more effective medicine had been brought.

“The moment the new drugs are in the country, we are bound by ethical considerations that we cannot proceed giving the patients very inferior drugs. If it is your mother or father, would you allow the programme for purposes of money, to make them swallow the old stock?” he said, in defence of the move to destroy the drugs.

Mr Ian Nyamitoro, the supply chain management officer at the Health ministry, explained that the transition was approved by the government following evidence of increased drug resistance.

“We’ve been using a class of drugs called NNRTIS –Non-Nucleoside Reverse Transcriptase Inhibitors for about 10 years. And in 2019, we noticed that there was a lot of pre-treatment resistance to the drugs,” he explained.

“As per the World Health Organisation guidelines, when the population gets a pre-treatment resistance of about 10 percent, it is safe to introduce another new drug. Because it means even those that are getting on it, they are not benefiting from it because the virus is resistant to it."

“So based on that, we had to shift to another new drug that had come on board called Integrase inhibitors –so we have dolutegravir given its benefit that is shown in science to have a higher barrier to resistance meaning patients can keep on it for a longer time,” he added.

Uganda has close to 1.5 million people living with HIV and about 1.2 million are on Anti-retroviral therapy/treatment (ART) which is largely purchased by the US President’s Emergency Plan for Aids Relief (PEPFAR).

The money for the fight also comes from the Global Fund, the government of Uganda and other local and international partners. Gaps in planning for transition? Dr Mutumba said when the new medicine was being brought, there was some old stock. During the interview, both Dr Mutumba and Mr Nyamitoro said they could not immediately remember the exact volume of the destroyed ARVs.

“Usually at that point when this new medicine is coming in, there is some old stock, even when you plan it very well because then we have to make sure that there is already some stock that people are using before the other one gets in,” Dr Mutumba explained.

He added: “And this is usually what some of those people report as expiries. And we are going to continue. For us in the programme, each time we discover that there are new ART medicines, the latest, we normally sit down and discuss a transition and we ensure we don’t cause any crisis.”

Mr Nyamitoro also said the drugs destroyed were those that had already been delivered to different health facilities.

“So we manage the transition balancing between what is available in the country and what we're getting in on board for the new drug to ensure that the transition is smooth to minimise drugs that wouldn't be used,” he said.

Mr Nyamitoro added: “I know there were some residual stocks that remained within the system following the transition and these were mainly at a facility level, the ones at the centre, we try to control it.”

NDA speaks out Mr Abiaz Rwamwiri, the spokesperson of the National Drug Authority (NDA), also defended the move to destroy the drugs and vaccines, describing it as a way to protect public health.

Mr Rwamwiri said: “Drugs have shelf life, they expire and when they do, NDA supervises their safe destruction (there is a clear policy on how expired medical products should be collected and destroyed).”

“The medicines quoted here, the volumes were surged by 1: Covid-19 vaccines and testing kits (most of us didn’t take our doses)! ARVs that hadn’t actually expired but there was a change of dose formula and this was a global issue! When these products aren’t of use, NDA supervises their safe destruction as a way of protecting public health,” he added.

Some of the stolen antiretroviral drugs (ARVs) that were recovered by the National Drug Authority (NDA) in 2024. NDA officials said recovered medicines are also often destroyed because of compromised storage conditions. PHOTO | COURTESY OF NDA

The government purchased a lot of Covid-19 vaccines after the success of the global advocacy for increased access to developing (poor) countries. But when many of the procured vaccines started coming in in 2021, it didn’t take long for the country to start registering a general decline in severe Covid-19 infections which also affected willingness to go for vaccines.

This declining interest in vaccination was worsened by social media campaigns against Covid-19 vaccination by people who are opposed to most or some of the vaccines that have been scientifically proven to minimise the risk of severe disease or infections.

Although people are still getting Covid-19 infections, according to details from the scientists and the Ministry of Health, the country didn’t experience more severe waves of the disease at the level of the second wave in 2021 when hospitals were filled up.

Redundant medical equipment

The Auditor General also revealed that there was underutilisation and nonfunctional medical equipment in hospitals which affected access to services.  In line with this, Mr Akol also highlighted inadequate funding for the maintenance of medical equipment.

“Mulago National Referral Hospital has an Intensive Care Unit with a bed Capacity of 27 Beds but currently only 15 beds are occupied, which is 56 percent occupancy, due to lack of professional health care staff,” the report reads.

“In the other five hospitals of Butabika, Kiruddu, Kawempe, China Naguru, and Women Specialised Hospitals, various critical equipment are nonfunctional. In Entebbe, Kisenyi HCIV, Makerere University Kampala Hospital, Kasangati HCIV there were instances where ICU beds, patient monitors, and oxygen concentrators are not being utilised yet functional due to the absence of medical personnel,” the report reads further.

The underutilisation and non-functionality of medical equipment, Mr Akol noted, were attributed to the lack of enough trained personnel to run the complex equipment as well as inadequate space to fix the equipment.

“I advised the management of the respective hospitals to consider training staff in the operation of the various complex equipment and follow-up with the Ministry of Finance to provide funding to expand space to install the various equipment to enhance operational efficiency,” the report reads.

Shs18b needed for maintenance “I reviewed the approved budget and equipment maintenance plans and noted that the Health Infrastructure Department (HID) of the Ministry of Health requires approximately Shs20 billion for the maintenance of all medical equipment. However, only Shs1.8 billion was allocated in the budget,” Mr Akol observed.

He added: “Consequently, the department lacks the capacity to maintain all medical equipment, except for specialised equipment whose maintenance is embedded in the framework contracts with the respective service providers who originally supplied the machines.” The Ministry of Health did not secure extra funding for the maintenance of medical equipment delivered during the Covid-19 period, the report indicates. “This funding shortfall leads to the breakdown of medical equipment, negatively impacting the healthcare delivery system. The inability to maintain equipment reduces the availability and reliability of medical services, potentially compromising patient care and safety,” part of the report reads.

Other issues raised

The Auditor General also noted that there was underdistribution of medicines and medical supplies to health facilities in the country, hampering access to treatment among taxpayers. “The health facilities’ budgets for EMHS are run by the NMS and during the year the whole budget of Shs562.545 billion for the financial year was fully warranted.

However, the comparison of the EMHS delivered to the health facilities indicated that NMS distributed EMHS worth Shs503.398 billion,” the report reads.

This, the report indicates, led to an under distribution of Shs59.147 billion representing 89.5 percent performance.

In the 3,546 health facilities that the Auditor General said he assessed, it was noted that 342 facilities received fully their budgeted deliveries worth Shs239.582 billion, and 3,204 facilities received supplies below the budgeted amounts by Shs59.148 billion.

“Out of the 3,204 facilities that had under distributions, 177 facilities received less than 70 percent of their budget(s) by Shs33.756 billion. The under deliveries lead to stock-outs and hence affect health service delivery to the citizens,” the Auditor General added.

The Accounting Officer of NMS told the Auditor General that the “failure to deliver” the medicines was occasioned by gaps in the disbursement of money by the Ministry of Finance “to fund the distribution of the essential medicines and medical supplies.”

“Management of NMS was advised to always liaise with MoFPED to ensure timely availability of funds to enable full and timely distribution of EMHS to the health facilities to avoid wastage and expiry of the much-needed drugs,” the report reads in part.