The disturbing mystery of missing HIV/Aids drugs in Uganda

Angelo Izama


The news from around the country is not good; in some places

we are hearing of people with access to anti-retroviral

treatment succumbing to the Aids condition because

they do not have food to eat (healthy eating is an essential

factor in managing the condition), while in other places

HIV/Aids sufferers with food do not have access

to therapy partly because the high incidence of

infection, has outstripped the financial resources

currently available to make ARVs available.

However, in a few weeks, an agreement between

the Uganda government and a local drugs producer,

Quality Chemicals (QC) will be complete.

The agreement will specify what nature of life-saving

HIV/Aids drugs the company will provide for

the 300,000 or so Ugandans infected with

the HIV virus and require treatment.

It is what health managers and experts in

Uganda's checkered fight against the pandemic

hope the future will look like.

Locally procured medicines with Ugandan

taxpayer's money to replace a long, and some

say dangerous addiction to donor-funded procurement.

The government has set aside some

Shs60 billion to procure locally manufactured

ARV's from QC - a business with suspected

strong connections to the higher-ups of

the ruling National Resistance Movement party.

Until this point, the country's HIV/Aids response

plan has been "rented house" for donor countries

and NGO's providing virtually all Anti-Retroviral


This has bred a situation which some say

has made Uganda a hostage to the agenda set

by big Western-based pharmaceuticals who

benefit from the millions of dollars spent by

Western countries supporting

the treatment of Ugandan patients.

Regardless of the truth or not of such views- what

is factual is that there are major contradictions

in strategy - led by the concern that the national

response is tied too tightly to the rules

governing the money outsiders provide.

That's the part that the Ugandan authorities

have no control over.

A glance at the plethora of organisations

involved in HIV/Aids management and

the mangled distribution network for drugs

cannot qualify the success of treatment

programmes nationally.

It's to the broken health care system that

some point for most of the problems that

Uganda is facing.

One observer pointed out that in one district

like Kabale there are multiple organisations

all providing ARV's including The Aids Support

Organisation (TASO), the Joint Clinical Research

Centre and the Ministry of Health itself.

There could be more.

And this scenario is replicated around the country.

Ideally information about all patients and their

needs are tracked and fed into a nationally

coordinated plan but experts say

far from it – and despite the hype about

Uganda's successes in the past - there

are huge gaps in information – HIV/Aids treatment

is in a mess.

It's a statistical nightmare as many varied

figures are churned out and no consensus

exists on the correct number of patients,

infections and trends.

The Aids Information Centre (AIC) should know

but says it does not.

"MoH does not have a complete list or

general number of patients (although it claims

it does)" says Dr Raymond Byaruhanga

of the AIC who says most organisations

report centrally to the Ministry of Health.

With a reported rise in new infections, confirmed

two months ago with much alarm

by Uganda Aids Commission chief,

Dr Kihumuro Apuuli, there is also a moral and

medical dilemma as patients old and fresh

are suddenly left without drugs for months.

And it goes something like this.

In light of the financial crisis, accusations

of corruption such as the Global Fund saga,

money for Aids treatment is dwindling

leaving patients reeling as stock-outs are reported.

There are unconfirmed reports of deaths of patients

unable to get their regular dose at

government-mandated clinics, says Dr Byaruhanga.

"There are too many players and little coordination

between them," he says, adding that in fact

Uganda has no reliable numbers of

HIV-infected persons or those on treatment.

"We have poor statistics which means

we plan badly," he adds.

Fortunately, despite that poor planning

there are pockets TASO where patients

are guaranteed regular supply because

unlike other players it is in charge of its

entire chain including procurement of drugs.

"The solution is twofold.

Uganda can produce its own drugs and supply

to its patients or pay for treatment

of patients directly [as opposed to donor funds.]

I pay taxes why should I not get treated

by the government?" asks TASO director

Robert Ochai, who recognises the dependency

but says patients must come first.

TASO and other organisations reflect

the schisms in the patchwork of HIV/Aids treatment.

"The donors run a parallel process,"

explains a senior Ministry of Finance official

who tracks health care spending.

"Government has little control over what they do".

The official who could not be named because

they were not authorised to speak to the media

on the matter told Sunday Monitor that

the National Medical Stores – the official

drug repository - only distributes donor drugs

to accredited distribution centres.

This means that NMS can only distribute

what has been delivered to it and to whom

it is instructed to.

Currently, the body has Aids drugs to last

five months (this is matched to pre-existing

programmes not new ones) in stock.

"We receive ARVs on behalf of the government

and distribute them according to instructions

from the Ministry of Health.

Currently there are two Ministry of Health staff

at NMS helping in translating orders from

treatment centres and drawing up

allocation lists" said NMS publicist Hamis Kaheru

in an emailed response to Sunday Monitor.

"It is against those orders and allocation lists

that ARVs are picked and packed in our stores

and then delivered to treatment clinics.

Therefore it is true that we don't control

how much ARVs we stock and distribute.

However there are indications that this will

change soon because we have been informed

that NMS may start handling supplies from

Quality Chemical Industries Limited (QCIL)

for which government pays QCIL directly.

Therefore we shall be dealing with

QCIL directly" he adds.

The involvement of the Ministry of Health

suggests that the government has some say

in procurement and distribution but according

to Dr Byaruhanga there remains an unequal

relationship between the state and donors.

He argues that this explains the bizarre situation

where tonnes of drugs are procured

for non-existing patients which then expire

on NMS shelves.

He adds that donors still have a bigger say on

where to procure the drugs leading to delays

especially when there is disagreement

with government.

"For example PEPFAR (the American-funded Aids

support and treatment programme) objected

to procurement of drugs before including

from Quality Chemicals.

Where the donor pays,

he calls the tune" he said.

The head of planning at the MoH, Dr Francis Runumi,

in a phone interview on the sidelines of

a health conference in Kigali however

said the relationship between the ministry

and donors is governed by a Procurement

and Supply Plan (PSP) which acts as

an agreement of sorts as well as a roadmap.

It details the quantity and type of HIV/Aids drugs

that are required.

It's based upon this agreement

that procurement on a competitive basis is initiated.

Health officials say that a lot of Uganda's Aids

drugs are procured this way and suppliers

of both generic drugs like India's Cipla (a partner

in QC) and well known global pharmaceuticals

compete on even ground.

However, the PSP governs mainly procurement

out of the Global Fund for HIV/Aids,

Tuberculosis and Malaria.

Other organisations that procure for themselves

including PEPFAR which runs one of the biggest

budgets determine their own suppliers.

According to Lynne McDermott, the PEPFAR

communications officer based at

the American Embassy in Kampala - the programme

will continue to spend $280 million annually

on HIV/Aids through 2013.

"There are indeed problems with the supply

of ARV's in the national programme"

she acknowledges and adds that even

with PEPFAR's funding

"there is a gap between national treatment

needs and funds available to provide treatment".

PEPFAR funding accounts for the largest

percentage [61%] of off budget money

for health care in Uganda according

to an August 2008 study.

The US embassy notes that American money

alone is two thirds of HIV/Aids response in Uganda.

A major distortion in Ugandan government

spending on health care is precisely because

it is a minority stakeholder.

Of the close to $800 million planned for spending

on healthcare in the financial year 2009/10 half

is donor money.

It is however unclear if the government would

be better organised had its own funds

been sufficient.

Organisational weaknesses clearly

exacerbate the problem of making the best

use of the money available.

A study by the World Bank for example

found that nearly 90% of all drugs at NMS

did not reach their intended recipients - let alone

the leakages in the public health sector

blamed for the waste that goes on.

Former health minister Mike Mukula says

inconsistencies in the fight against HIV/Aids

is entrenching the disease.

"The way you make babies is the way

you get HIV.

Uganda's population is rising and the politics

of procurement must be put aside.

No single African country can meet

the bill of costs for treatment.

Aids should be de-politicised nationally

and internationally so that all hands

are on deck in this fight," he said.

After two decades in the trenches it will

take more than speeches to turn the page.

Link here

             J-L K.
Procurement Consultant
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