Public hospitals grapple with medicine stockouts

Ms Chemurian Everlyn, a drug dispenser at Gulu Regional Referral Hospital, last week told the Deputy Inspector General of Government, Ms Patricia Achan, that late deliveries of essential medicines by the National Medical Stores (NMS) had resulted in serious setbacks in their operations.

“We have the delivery schedule for receiving drugs from NMS, but we don’t receive the items (drugs) requested as stipulated. When it is overdue, it makes things hard for us here,” Ms Chemurian told Ms Achan during a spot check at the facility, adding, “Sometimes we outsource from the lower units to bridge the gaps resulting from stockouts. We have always called as far as Lira and Arua referral hospitals and sometimes Mulago National Referral Hospital where we ask them for stocks of medicines, reagents and other supplies if they have them in excess.”

The Monitor understands that missing medical supplies that fashioned an acute drug stockout that rocked Gulu Regional Referral Hospital the past eight months has crippled a number of units. The most affected are the children’s ward, as well as the maternity and women’s unit. 

“There are units at the hospital that do not handle very big numbers of patients, and we run to them and retrieve certain items that are in most need and we take them to casualty, surgical, and maternity wards,” Ms Margaret Bazio, the officer-in-charge of the Nutrition Unit, who doubles as the acting Principal Nursing Officer at the hospital, disclosed, adding, “If you are in charge of a unit and have something excess, you are asked to donate it to those units that do not have it.”

Running on empty

We also understand that over the last one and half years, the spectre of a drug stockout has continued to hover above the hospital, thanks in no small part to a Shs1.3b annual budget that only covers just 25 percent of the facility’s needs. 

“Quite frequently, we don’t have enough medicines and health supplies. Sometimes people are told to buy [medical supplies for themselves],” Dr Peter Mukobi, the hospital director, conceded, adding, “Our actual needs are about Shs4b if we are to serve the numbers we deal with. On average, we serve about 200,000 patients every year, it is a very big number…”

NMS reportedly delivered drugs to the hospital in the first week of December. Dr Mukobi noted that while such supplies are done every two months, the stock usually depletes during the first fortnight of the first month.

“The items last for a maximum of three weeks and may even take a week or a longer period, but this is the reason why quite often we don’t have everything, even IV fluids, needles, and gloves, they get over in a very short while,” he revealed, adding that the stop-start nature of the supplies does not help matters.

This can be dangerous in multiple ways. For instance, at Moroto Regional Referral Hospital, the 2022/2023 end-of-year stock balances for essential medicines showed that expired drugs valued at Shs9.06m were being mixed up together with live medicines in the storage stands.

Because requested quantities of medical supplies were not being honoured by NMS, stocks of Losartan-H tablets, Amlodipine, gauze, blood transfusion sets, cannulas, examination gloves, jik, plaster, folic acid, etc. had run out from the facility.

Moroto is not an outlier. Mbale Regional Referral Hospital has also been struggling to dispense services to the population due to a drug stockout that resulted in a lack of several essential, vital and necessary drugs.  In 2023, expired drugs weighing 2.32 tonnes were returned from Mbale Regional Referral Hospital’s stores to NMS for destruction, according to its end-of-year stock balances for essential medicines.

NMS response 

On Monday, Ms Sheila Nduhukire, the NMS spokesperson, contested the narrative of undersupply, saying, in a statement, that “Gulu [Referral Hospital] has just received supplies that would last them three months without any stockout at all and so are Mubende, Lira and the rest.” She also further said health supplies the aforesaid facilities received cannot be exhausted in two months since they are combined cycles for four months.

Ms Nduhukire also noted that—while lower health facilities in Mbale and Moroto districts had not yet been supplied—“the lower health centres in Mbale and Moroto will receive their supplies in the course of this month.”

Audit query

The Essential Medicines and Health Supplies Manual 2012 requires an effective stock management system that ensures the right medicines of the right quality and quantities are available at the right place, at the right time, and at the right cost. However, Auditor General John Muwanga, in his 2023 audit report on the performance of NMS, observed that the national drug distributor was undersupplying health facilities and the supplies came late.

“NMS budgeted to procure drugs and medical supplies worth Shs185.91b for 3,254 health facilities across the country. Out of the 3,254 health facilities, a total of 3,183 health facilities had under deliveries of drugs and medicine supplies worth Shs26.4b,” Mr Muwanga disclosed, adding, “In addition, the deliveries were not following the cycles which meant delayed deliveries that caused disruptions in patient treatment. Under-delivery of expected supplies caused drug stockouts and treatment disruptions in the affected health facilities across the country.”

The hospital sampled during the audit, according to Mr Muwanga, reported drug stockouts for long periods. This significantly affected service delivery. Some of the significant drugs out of stock include Quetiapine, Fluanxol 20mg, Sevoflurane 100 percent v/v, Trifluoperazine tablets 5mg, Oral Morphine 250ml, 5mg/5ml among others.

“I noted under deliveries of ordered medicines and health supplies in all hospital samples worth Shs1.9b. Drug stockouts are not only detrimental to the lives of patients who need these drugs but also erode patients’ confidence in the public health care system, which may lead them to seek inappropriate and expensive alternative health care services elsewhere,” the Auditor General noted.

System overhaul

On Tuesday, Dr Charles Ayume, the chairperson of Parliament’s Committee on Health, said unless the Health and Finance ministries revise the appropriation amount designated to NMS, the challenge is likely to stay.

“The ministries of Finance and Health should find ways of ensuring there are funds for the logistics. We know there are medicines in their (NMS) warehouse. That is where the challenge has been, that the money for the logistics does not come on time, even if a driver volunteered, those who offload the drugs need to be instantly paid,” the lawmaker noted.

Dr Ayume said NMS needs to have a robust logistical system to enable it deliver its mandate.

“They do have the trucks, those refrigerated for cold chain cycle, but to run those trucks, you need fuel, drivers with their allowances and the loaders.”

Dr Ayume admitted that drug stockouts and late deliveries had become a common phenomenon despite its disastrous impact on the quality of life of the population across the country.

“The budget doesn’t fully capture the country’s (medical supply) needs. There are gaps here and there but our emphasis is that the little they can supply must come timely, medicine is a commodity that has a huge bearing on people’s lives unlike roads, etc.,” he said,

He added: “We have raised it severally in Parliament, and we have had meetings with NMS and they have made promises to rectify these issues, it makes us look quite shabby that we as a government cannot provide the population the health service yet the health care system is funded by their taxes.”

What triggers the stockouts

A 2022 research on health supply chain systems conducted by Ugandan researchers found that less than half (42 percent) of health facilities had computer hardware. The cross-sectional study was undertaken in 128 public and private-not-for-profit health facilities across 48 districts in the country.

Titled “Health supply chain system in Uganda: Assessment of status and of performance of health facilities”, the peer-reviewed study made some handy discoveries.

For instance, whereas up to 84 percent of the health facilities used a logistics management information System in some shape and form, only six percent of the aforesaid were electronic.

Back then, as many as 84 percent “of health facilities reported stockouts of essential medicines and health supplies in the past six months,” the study revealed. It added that 59 percent of the stockouts were caused by “a sudden increase in demand; 40 percent [by] delivery gaps/delayed deliveries; and 35 percent [by] “discrepancies in orders and deliveries.”

The researchers further noted thus: “Health facilities responded to stockouts through various means, including (75 percent) redistribution (43 percent) purchased from a distributor, and (30 percent) placing emergency orders.”

They proceeded to conclude thus: “The findings from this study show that the performance of health facilities in different supply chain processes and functions was defective. To improve the supply chain performance of health facilities, it is important to invest in infrastructure development, provide computer hardware and Internet connection and strengthen the capacity [of] key personnel.”

It added: “This is key for ensuring full functionality of the supply chain and availability of quality medicines and health supplies to the end-user.”

The research was carried in the Journal of Pharmaceutical Policy and Practice.