Drug stock-outs: An open letter to the PM

The debate in Parliament about drug stocks demonstrated a typical case of “uncoordinated troop movement” with in Cabinet.

To resolve the matter, Deputy Speaker referred the matter to the prime minister with instruction that the ministries of Health and Finance ensure that Ugandans receive drugs. The debate about this particular stock-out, both in the media and Parliament, created the impression that it was a one-off.

Drug stock-outs are not a new phenomenon in the public health system in Uganda. In most lower health facilities, drugs last not more than a month after supply.  This is caused by a number of factors including the increasing number of health service users, which is not matched with the supply.

The budget available for procurement of essential medicines has for most times remained stagnant over the last years while the population has been increasing at an average of 3 percent. In the current financial year, Shs531 billion was allocated to National Medical Stores (NMS) to buy and distribute drugs and according to the National Budget Framework Paper for the 2023/24 financial year, it is projected that NMS will receive almost the same amount.

To be able to effectively forecast and plan for the medicines, the Ministry of Health together with NMS conducts an annual needs analysis and quantification report for public health facilities in Uganda.

This report provides up to date information on public health sector emergency medicines and health supplies, planning and health facility requirements in terms of actual pharmaceutical needs and funding gaps.

The report for 2020/21 demonstrated an increase in the funding gap for medicines from 13 percent in 2019/2020 to 15 percent in 2020/2021. In terms of level of care, health centre IIs are receiving only 38 percent of the drugs that they need to serve their patients, health centre IVs are receiving only 51 percent of the drugs they need, health centre IIs are receiving 68 percent of the drugs need. In case of Laboratory reagents Uganda requires an allocation of Shs65b but only Shs11b is available from government, leaving a funding gap of Shs54b.

Even with the resources at their disposal currently, the ability of NMS to procure and distribute drugs is affected by a number of macro-economic factors including foreign exchange losses, inflation, high population growth rates, among others.  NMS can buy and distribute as much drugs as the resources allocated to them can allow

To deal with the escalating costs of procuring and distributing medicines and health supplies, government needs to take a deliberate decision to migrate from a curative health system to a preventive health system.

A curative health system emphasises treatment as opposed to investing in disease prevention. Studies have demonstrated that a preventive health system is a more cost-effective health system as compared to a curative health system. Last week government launched the National Community Health Strategy and this is a step in the right direction. What we now need to do is to invest in its implementation.

There are also systemic supply chain challenges that contribute to persistent drug stock-outs. Currently there are two supply systems for medicines and health supplies; the pull-based system and the modified push system.

High level facilities (health centre IVs and above) are served on pull system where facilities place their medicines orders to NMS while health center II and III are served on a district kit system/modified push system. The district kit system has challenges in ensuring appropriate and equitable allocation of funds and this leads to difficulties in ensuring appropriate and equitable essential medicines and health supplies availability.

The kit system presupposes a one size fits all and as a result, the forecasting for the most part is not accurate.  It also leads to inaccurate planning for medicines and supplies leading to over and under planning in health facilities. This explains why some health facilities within the same district will have expired drugs while another has stock-outs.

While the drug supply should be demand driven, it also has components of the pull factor. Government needs to invest in supply chain of medicine including forecasting, delivery and management of medicines in health facilities. The medicines and health supplies delivery system should ensure regular and predictable supplies while at the same time reducing leakages through drug theft.

Mr Peter Eceruis the programmee coordinator-advocacy at Centre for Health Human Right and Development (CEHURD)