MINISTRY SPENDS E1BN ON MEDICAL DRUGS

MBABANE –The pharmaceutical space has proven to be one of the big industries in the country.

This has been evidenced by government’s expenditure in the acquisition of medicines for public health institutions.  
It has been found that government has spent over E1 billion in 2022 on the acquisition of medicines for emaSwati.
In the current financial year ending on March 31, 2023, government allocated E2.42 billion to the Ministry of Health. In the financial year beginning April 1, 2023, the Ministry of Health shall receive a budget amounting to E2.76 billion.

In a population of 1.2 million people, it meant, conservatively, each liSwati should access medicines valued at E833 per year. However, there are thousands of emaSwati who have medical aids. They seek treatment from private health institutions. For instance, SwaziMed, the biggest medical scheme in Eswatini, has over 40 000 members. It must be said that the E1 billion-expenditure on medical drugs is contained in the Forensic Investigation Proposal and Audit of Acquisition, Distribution and Management of Pharmaceuticals Report compiled by Pastor Timothy Sipho Matsebula.

It was tabled in Parliament last Friday by Neal Rijkenberg, the Minister of Finance. It is stated in the report that there was an increase in expenditure of E345 146 948.92 in the procurement of the medical drugs for the nation.
The procurement costs increased from E690 000 160.51 recorded in 2021 to E1 035 147 109.43 in 2022. There was also an obsolete stock of E18.3 million recorded in the financial years ending on March 31, 2019 to 2022. In this context, obsolete means out of date.

The pharmaceuticals were procured for public health institutions such as Mbabane Government Hospital, Pigg’s Peak Government Hospital, Hlatikhulu Government Hospital, Raleigh Fitkin Memorial Hospital, Mkhuzweni Health Centre, Nhlangano Health Centre, Siphofaneni Clinic, Siteki Public Health Unit, Horo Clinic, Ntfonjeni Clinic, Herefords Clinic and Maguga Clinic. Others are Mangweni Clinic, Hluthi Clinic, Nkwene Clinic, Zombodze Clinic, Jericho Clinic, Dvokolwako Health Centre and Ezulwini Satelite Clinic.

The auditor general (AG), Timothy Matsebula Revealed that pharmaceuticals amounting to E151.6 million were either missing or unaccounted for. In the financial years 2021 and 2022, the AG observed that there was missing stock of medicines and/or unaccounted for pharmaceuticals amounting to E18 793 823.99. He mentioned in his audit report that the Ministry of Health acknowledged the missing stock of medical drugs which amounted to E5 848 589.89 as reported in the Medical Drugs Trading Account for the financial year ended March 31, 2022. It was discovered that there was missing stock of E128 452.22 in the 2021 financial year.

Facilities

He also observed that, in the various health facilities visited, pharmaceuticals amounting E12 816 781.88 which were acquired during the financial years 2020/2021 and 2021/2022 were not accounted for. The audit discovered drugs valued at E9 308 963.02 for Mbabane Government Hospital were unaccounted for. The Pigg’s Peak Government Hospital did not account for pharmaceuticals valued at E2 283 688.91. Siphofaneni Clinic did not account for drugs amounting to E111 089.08 and Mpolonjeni Clinic had medical drugs valued at E45 990.19 unaccounted for.

“Pharmaceuticals were either not recorded in stock record cards or no stock cards to record the medicines maintained. Stock card balances and physical count balances were not tallying; and shortages in stock received,” reads the audit report. Over the two financial years (2020/2021 and 2021/2022), the audit report states that pharmaceuticals to the value of E7 730 237.26 were received and paid for by the Central Medical Stores (CMS) even though their life-span was shorter than 18 months.

The ag reported that there was no evidence or justification that supported the emergency or urgency of the medicine. Instead, there was only an attached document which authorised receipts of such medicine by the senior pharmacist.
The AG felt that this opened a risk of senior pharmacist agreeing with suppliers to accept medicine where there was no urgency. The office of the AG said the short-dated pharmaceuticals were purchased from Swazipharm and ASD Medical Supplies.

The audit report will be discussed by the Public Accounts Committee (PAC). However, the Times SUNDAY gave one of the companies an opportunity to respond. Nkosinathi Dlamini, the Sales & Marketing Manager at ASD Medical Supplies, said the company was never contacted by the auditors on the subject matter. He said the company did not receive them at its premises to check records and other relevant documents in the course of their audit.

Exercise.

Dlamini mentioned that ASD Medical Supplies was aware of the standard 18-month-shelf life for pharmaceuticals to be supplied and delivered at the CMS in accordance with valid contracts at any given point in time. Comments could not be sought from Swazipharm as they were out of office by the time attempts were made to get hold of management. The audit report exposed a situation in the Lubombo Regional Office where the principal pharmacist stored medicine in her office.

Some of the medicine expired while in her custody and the stock became obsolete, thus a loss to government, the AG lamented. “Further, stock cards were not maintained for the control and management of the movement of the medicines. There is no record which shows incoming and outgoing stock for easy tracing,” reads the report.
There was also a concern in Siteki as four entities were found to be sharing the same warehouse. The sharing entities were Good Shepherd Hospital, Lubombo Schools Health Unit, Siteki Police Stores Unit and Siteki Public Health Unit. The AG established that there was no custodian in the warehouse and no security measures, thus exposing the medicine to theft and misplacement.

Payment delays

AG Matsebula noted that it took a lengthy period for suppliers to receive payment after delivery to CMS. As a result, he raised a concern that suppliers were not aware how long they were going to wait to be finally paid for their supplies. They did not know how long it also took for a payment to be processed, since some invoices submitted late were paid earlier and vice versa. The audit investigation unearthed that there was no pharmacist or technician in all the visited clinics. The technician is necessary for the management and distribution of pharmaceuticals.

He observed in his audit query that the responsibility for the technician was given to the nurses who also attended to their nursing duties. The audit team found that the human resource available at the clinics was not equal to this task.
The problem discovered was that nurses were expected to attend to the patients, prescribe and finally dispense medicine to them.

It is stated that the objectives of the forensic audit and investigation were to assist the Government of the Kingdom of Eswatini and Ministry of Health to achieve the following –
l    Undertake a comprehensive investigation to establish the circumstances that led to the suspected irregularities on acquisition and distribution of medicines that covers 15 per cent of the population of 234 health facilities centers including CMS.

• Determine the circumstances that led to the contravention or transgression, as well as to identify any/all officials who contravened the relevant prescripts.
• Establish if indeed there were any irregularities, contravention, or non-compliance in the procurement process of the acquisition and distribution of medicines to public health facilities.
• Establish if the procurement process of tendering is adhered to and whether the procurement division or contract management appoints the supplier(s) with capacity to perform the supply and delivery of medicine in time.
• Identify and report any irregularities on the procurement of pharmaceuticals.  Determine any internal control weakness in inventory management of pharmaceuticals at CMS.
• Identify internal control weaknesses and systems on distribution of pharmaceuticals to health facilities.
• Establish the weakness of inventory management process in sample of 29 health facilities.
• Identify any irregularities and establish what were/are the circumstances that led to the occurrence of the suspected irregularities.

If these circumstances still exist, indicating what steps have been undertaken or what steps are to be undertaken to address the circumstances to ensure that such circumstances no longer exist.

Irregularities

Indicate what steps are being taken or would have been taken to address the suspected irregularities, and their expected outcome. It is also reported that the Ministry of Health was unable to meet the demand of the patients as CMS would, at times, deliver short supplies to the national health facilities. It is said that some pharmaceutical companies supplying CMS also made part deliveries, resulting in the health stores delivering short medicine to facilities. In a nutshell, the AG said his findings confirmed that there were indeed medical drug shortages in the country’s national health institutions.

He said the shortages resulted in patients having difficulty in accessing their medications. Affected by drug shortages, he reported that patients inevitably opted for privately owned pharmacies. Matsebula said patients had been complaining to health professionals about drug shortages as they had to be referred to other facilities to find alternative health care. According to the audit findings, patients were reportedly concerned and distressed by the current situation at the public health institutions.

“I have analysed and evaluated my findings against the responses of the controlling officer, made comparisons with global trends and came to a conclusion that medical drug shortages are a complex global phenomenon, which affects citizen’s economic and humanistic lives, particularly the quality of the lives of the citizens,” said the auditor general.
“However, the results of this report provide valuable insights into the impact drug shortages have on patients and on the lives of the citizens of Eswatini and has not extended to similar situations in other countries.”

He said he was concerned that the unavailability of basic medicines contributed to treatment delays. “… and if this problem is not resolved promptly, it may lead to a rise in diseases, complications, and increased treatment failures, all of which may increase the mortality rate in the country,” the AG said. He said alternative health care services, including those that were not licensed or regulated, increased the risk of increased mortality among citizens because of inappropriate alternatives.

These alternatives included substandard and counterfeit medicines from unlicensed and untrained health care providers. In such situations, the audit report indicated that patients tended to become victims of these health care providers. He reported that these alternative sources were usually recommended by friends/relatives or patients themselves who surfed the internet to explore other options for treatment. The auditor general said some of these alternatives did not come cheap to the patients.

Causes of drug shortages

He said his office tried to establish the causes of the problem of drug shortages. Without exonerating the possibility of misappropriation of the medical drugs along the medical supply chain system, he said the overall medical drug shortages in the country were mainly attributed to the following :

• Weak information management systems;
• Weak manual control environment;
• Cash flow constraints;
• Human resource shortages due to hiring freeze and fuel shortages.

 Matsebula said the consequences of medicine shortages were challenging, especially for the patients as there were risks associated with these medical drug shortages. He said the risks included the interruption of treatment for patients or wrong selection of alternative treatments, which might affect the quality of the lives of the citizens.
The country’s audit office said this situation demanded the introduction of risk-management strategies for medicine shortages in the national health institutions in accordance with international best practices. The audit also raised concern over government’s delay in paying the companies supplying medicals to the CMS.

Delayed payments

The audit office disclosed the total amount of E11 479 596.70. The owed companies included Swazi Oxygen, SwaziPharm and Mylan Laboratories. It is said that SwaziPharm was being owed E6 230 078. Government was also indebted to Mylan Laboratories for the sum of E4 346 419 and Swazi Oxygen was being owed E903 099.60.

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