Will saying no to ARV donations end distribution problems?

Rejecting life-prolonging antiretroviral (ARV) medication seems like an odd thing to do in a country where only about half the people who need the drugs have access to them, but that is exactly what Uganda's National Medical Stores (NMS), the government's main supplier, has resolved to do to.



"In Uganda we have more drugs expiring than is acceptable because procurement is uncoordinated in the entire health sector," said Moses Kamabare, the general manager of the NMS. "In future we are going to cut out all drug donations unless they are fulfilling an identified gap; we shall encourage donors to coordinate with NMS through the Ministry of Health."



The local media have regularly raised the alarm over essential drugs expiring and having to be destroyed by the NMS.



The situation has been attributed to a rapid scale-up of ARV distribution that has not been matched by growth in the number of health facilities able to redistribute the drugs to people who need them, as well as problems with the supply chain.



"NMS has its own procurement plan, but someone sits in the Ministry of Health and just gets in touch with a donor without informing us," Kamabare said. "In most cases we have already procured these drugs - that causes them to expire."



Dr Zainabu Akol, head of the HIV programme in the Ministry of Health, noted that the country's ARV stocks would last through 2009, and said the ministry had already put some ARV donations from development partners on hold.



Reaction to the announcements about rejecting free ARVs has been mixed: civil society has generally been pleased that the government has decided to reorganise its ARV supply mechanisms, but some are questioning the wisdom of turning down drugs when half the people who need ARVs are still not receiving them.



Throwing the baby out with the bathwater?



"It would be very unfortunate if the step was taken to stop donors, yet a big number of people are not on treatment, especially the people in the rural areas," said Beatrice Were, a leading AIDS activist.



"[What] if we have people needing drugs after diagnosis and they are not available?" she asked. "Right now infection rates are going up - what will happen if we have many people in need of the drugs and they cannot get them?" Uganda has had a free ARV programme since 2003; to date, 106,000 people are accessing the drugs at about 300 sites nationwide.



"Before that step is taken we need to address the reality - that is, having our house organised to do the diagnosis and monitoring of those who are on treatment," Were said. "What we have is like a panic signal because we have had drugs expiring perpetually - that is why they are managing through panic."



The NMS also plans to improve its internal management processes, speeding up the distribution of drugs that have a shelf life of only three months left, and sharing information between dispensing sites to avoid running out or overstocking. Typically, a health facility with slow-moving drugs does not exchange information with one that has a high turnover of the same medicines.



Overhauling the supply system



"Items that are left with three months [to their expiry date] will be removed from our stock and distributed to big health facilities like government referral hospitals and organisations like the UPDF [Uganda People's Defence forces, the army] free of charge," said Kamabare.



NMS officials said information flow would be improved by opening a website to inform stakeholders about drug stocks with less than a year before expiry in the various districts.

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"At most we shall get drugs expiring worth less than 2 million shillings [US$1,000] annually, down from drugs worth 2.6 billion shillings [$1.3million] that were incinerated last year [2008], which had accumulated over three to five years," Kamabare noted.



During the last financial year, the government made its first ever contribution of 60 billion shillings ($30,000,000) to the fight against malaria and HIV/AIDS, which significantly boosted the procurement of drugs to treat the two diseases.



A new local manufacturer of ARVs and malaria medication, Quality Chemicals,  is also expected to boost the national supply. 



The government hopes to continue reducing dependence on donors in its health programmes; currently, the biggest suppliers of ARVs to Uganda are the US President's Emergency Plan for AIDS Relief, the Global Fund to fight AIDS, Tuberculosis and Malaria and the Clinton Foundation.



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