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Medicine shortages: Urgent and systemised procurement process a dire need
View(s): 451- Stop-gap steps and glossing over scarcities will shake foundations of state health sector
By Kumudini Hettiarachchi
The family of a patient critically ill with rat fever (leptospirosis) admitted to a southern state hospital is requested to buy a life-saving injection as stocks are unavailable.
Another patient with a fractured thigh ball where it joins the hip after a fall, admitted to a state hospital in the suburbs of Colombo, is gently told to buy this device from outside.
Antibiotics or life-saving ‘miracle’ drugs, particularly ones which battle micro-organisms (bugs) which are resistant to medicines, are in short supply at state hospitals, the Sunday Times learns. This places the lives of patients struck down by death-causing sepsis in grave danger.
While hundreds of patients lamented the lack of medicines, numerous experts stressed that the current shortages being highlighted are just the tip of the ice berg.
“It is a very complex issue, shaking the very foundations of our fantastic state health system,” said a deeply-anguished senior doctor, underscoring that “Sri Lanka needs to get its medicine procurement methodology corrected right now, not tomorrow, not in six months or in five years”.
This methodology should be absolutely transparent, free of corruption and benefit the men, women and children, the poorest of the poor in this country, whom the state health sector is committed to serving and in which people have utmost trust”.
A valid view put forward – that the health authorities should take into serious considering without attempting to gloss over the medicine shortages – is how to expand and develop the health system that Sri Lanka “contracted” due to the COVID-19 pandemic and the economic crisis that followed.
“During that time there was no development of this vibrant system. Now we need to speed up the expansion and development, while stringently cutting out corruption and waste,” he said, referring to how the Health Ministry in collaboration with the professional medical associations/colleges had come up with a ‘Priority List’ of medicines.
That was a crisis situation, but now
Sri Lanka needs to re-visit it to open it out for innovative medical therapies etc., he added.
This is as numerous sources at state hospitals dotting the country confirmed that “samahara beheth nae (some medicines are not available),” with some hastening to explain that this is nothing new and has been happening over the years. Some medicines are out of stock, while others are used up. “So, we try to manage.”
To the question whether health authorities know how many patients would be dying or going into severe disease for lack of medicines, everyone was categorical that no such data were available.
“We manage by substituting,” was the common refrain, as some sources explained that sometimes they ask the families of patients to buy the medicines but if the medicines are very expensive, they try other medicines which are in stock.
The medicines for the state health sector are procured as follows:
n The State Pharmaceuticals Corporation (SPC) purchases all requirements of the state health sector. This is done by floating competitive worldwide tenders.
Known as ‘Stock Items’, a majority of medicines in this category are in the ‘Essential Medicine List’. These medicines are bought in bulk.
Once the tender process is done and the medicines are delivered to Sri Lanka, the Health Ministry’s Medical Supplies Division (MSD) stores and distributes the requirements of all state hospitals under the purview of the ministry. The regional MSDs do the same for state hospitals under the purview of the provincial authorities.
The SWASTHA software system launched in June 2023, linking the National Medicinal Regulatory Authority (NMRA), the SPC, the ministry and regional MSDs, hospitals and Medical Officer of Health (MOH) Offices, keeps track of stock availability.
- In a case where the MSD has no supplies of specific medicines, each Director of a hospital, on the request of Consultants, can resort to ‘Local Purchases’, under certain guidelines including the floating of tenders. Of course, there is an upper ceiling for such purchases, depending on the category into which the hospital falls.
- The Directors of hospitals, in special circumstances, meanwhile could also make a request to the MSD for limited procurement of a medicine under the ‘Named Patient Basis’ for specific individuals.
In Sri Lanka, there are 120 hospitals with specialists – ranging from national hospitals to specialised hospitals, teaching hospitals to district general hospitals and to base hospitals – and also 1,000 primary care hospitals which include divisional hospitals and primary medical care units. This is while there are 360 MOH units.
The criteria governing medicines that can be brought into Sri Lanka are: Registration with the National Medicines Regulatory Authority (NMRA) and being part of the MSD Formulary (an official list giving details of prescribable medicines) which covers the Priority List including crucial antibiotics.
Many pointed out that 80% of the diseases need only about 20% of the health budget, while 20% of diseases are using up a huge 80% of the budget.
“We need to streamline these processes,” an expert said, looking closely at the calling of tenders by the SPC, which process takes at least 8-10 months to complete. If for some reason, wilfully or not, the agent who has won a tender fails to supply the stocks, there would be a scarcity of medicines in the state health sector. Sometimes, it could be that the agent is bent on creating an artificial scarcity.
“Whatever punishments such as blacklisting meted out to the agent would not solve the immediate matter at hand – which is the scarcity of that drug, impacting on the health of the people,” he said, stressing the need for a watertight system to be in place.
With regard to Local Purchases, many said that some hospital Directors were dragging their feet, fearful that fingers would be pointed at them that they had resorted to irregular conduct. A lot of Directors are “scared” to do Local Purchases, it was alleged.
“The crux of the matter seems to be that many administrators are not ready to take responsibility and go ahead with Local Purchases while assuring accountability – so they keep checking and re-checking and the medicine shortage gets exacerbated, with patients suffering and the health system getting hobbled,” a source added.
| Buffer stock, answer to shortages, while boosting local pharma production under stringent oversight
While medicine shortages in state hospitals seem to be a perennial problem, many experts explained that over the years they have been “managing” and walking a tight rope. “In a country where we have so many qualified health personnel, why is it that we have not been able to solve these shortages by bringing in a good system,” asked one, explaining that usually the tender process is strict, as it should be to ward off corruption. One importer is awarded the tender and if something happens to that one importer’s supply chain, the whole stock is affected. His suggestion was that, even though it would take time, Sri Lanka should create a buffer or ‘safety’ stock, starting possibly with three months, then six months and finally a year for essential medicines. Of course, stringent spadework such as proper storage facilities, supply lines etc. should not only be set up but maintenance also ensured. Encouraging the boosting of local production of pharmaceuticals, health experts, however, issued strong words of caution. “The integrity of the local pharmaceutical companies should be thoroughly checked as also their past records. Thereafter, monitoring must be constant,” said a veteran in the health sector, going into detail about the fiascos Sri Lanka has faced in the past with “unscrupulous” local pharmaceutical industries. These local companies should adhere strictly to the three pillars of safety, efficacy and affordability, with absolutely no short-cuts, he added. | |
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