Coartem stocks run out, 300 die daily

Mubatsi Asinja Habati | 09 Mar 2010
The Independent
Rachael Nalubega, 10, sits on her mother's lap near the entrance into one of the children's wards at Uganda's top medical facility, Mulago National Referral Hospital. Nalubega's eyes are motionless and unblinking. The crowded ward is enveloped in a nonstop noise of wailing children on rickety sickbeds.

Poor Nalubega is too weak to join in the wailing. An intravenous needle has been inserted into her little hand to allow liquid from a plastic bag hanging on the metallic frame of the sick bed to drip into one of her veins and possibly keep her alive. Her mother stares at her head, occasionally touching it gently. She is apparently desperate.

Nalubega's mother has moved from Gayaza, a rural suburb of the city to seek treatment for her only child. Nalubega is suffering from malaria, a killer disease that claims over 300 lives in Uganda every day. Most of these are pregnant mothers and children under the age of five.

A nurse enters the ward. Nalubega's mother rushes to her to inquire if she has brought some malaria drugs for her ailing daughter. The nurse shakes her head and addresses everyone in the ward.

"We are not having drugs like coartem, they are in short supply," the nurse, a young woman in her early 20s, says. "You will have to be a bit patient as we wait for the supply." The nurse leaves the ward and the wailing children and their hopeless caregivers.

This reporter was later told the hospital is using quinine; intravenously injected into the drip to give it to patients as an alternative to the Ministry of Health's recommended artemesinin-based combination therapies (ACTs) like Coartem.

Dr Richard Ndyomugenyi, manager of National Malaria Control Programme (NMCP) was quoted in the local press saying that the ministry resorts to quinine because of stock-outs. Intravenously injected quinine when not mixed in the right proportions, quinine can be lethal. Ministry of Health recommends artesunate or artemether injections because quinine compliance is difficult.

Uganda is facing stock-outs of essential drugs to treat malaria. Apparently, because of overreliance on donations for antimalarials like ACTs, it may not clear the apparent shortage of Coartem soon.

To avert the stock-outs Uganda needs Shs 110 billion for purchasing Coartem that can be supplied to all health centres in the country per year. In financial year 2009/10 budget, pharmaceutical supplies, which include medical drugs and supplies, were allocated Shs 300.9 billion, or 47% of the health sector allocation. This allocation comprises the Government drug credit line and ARVs budget under Ministry of Health (Shs 76 billion], as well as on budget donor funds from Global Fund for AIDS, TB and Malaria (US$ 93 million or Approx. Shs 180 billion). Under this budget, the country spends $0.93 per person on Essential Medicines and Health Supplies (EMHS). At the special World Health Organisation (WHO) price, a dose of Coartem costs US$2.4 for an adult and US$0.90 for the youngest age-group. This makes it impossible for the Government to afford Coartem without relying on donors. Coartem costs more at about Shs 15,000 (about US$7) in private clinics.

In August 2005, the Global Fund suspended grants worth US$367 million over mismanagement by the Project Management Unit where an audit found about US$1.6 million (Shs 3 billion) was stolen.

The Commission set by the government to investigate the theft found that up to 373 officials in government and civil society were involved. Less than 10, most of them low cadres have been prosecuted.

The Global Fund to Fight Aids, Tuberculosis and Malaria (GFTAM) has been pressuring the government to recover US$1.6 million of its grant money that was stolen in 2004.

The donors such as the Global Fund have not committed to supply Coartem since 2005 although the Ministry of Heath had presented a proposal soliciting funding to the Global Fund as early as 2004. The proposal was approved. Proposal approval does not mean releasing the money, there are other conditions to be met.

As a result, there have been occasional drug stock-outs of Coartem -a drug WHO recommended for first line malaria treatment in the country since 2007.

Dr Denis Rubahika Kinungu of the National Malaria Control Programme (NMCP) in the Ministry of Health says the conditions put by the Global Fund are now very tight and cannot be easily met.

Usually, the government looks at how much the donors have promised and tops it up. Dr Kinungu says the ACTs which are currently found in health units are entirely funded and procured by the Ugandan government.

"The government has a plan to increase the budget for malaria this year so that Coartem stock outs at the health units become history and even the excess Coartem would be distributed to the community through community drug distributors," he says.

Meanwhile, the country has resorted to using other ACTs like Duo-Cotecxin and ARCO from China in the first line treatment of uncomplicated malaria. Though some health analysts say these drugs may not be as effective as Coartem, the ministry insists it has tested their efficacy and found it okay.

There are fears that the country might be heading back to chloroquine and fansidar that had been phased out because resistance had developed among users, as well as new ACTs from China. Already some places like Lyantonde are receiving ACTs like ARCO made in China.

Dr Kinungu says this means the health workers who had been trained to administer Coartem must now be trained to administer this new malaria drug from China. The training is mainly for the less qualified health workers like those on village health teams.

Hamis Kaheru, the National Medical Stores' (NMS) spokesperson, declined to comment on whether NMS currently has Coartem to supply to health units. He said it is a policy matter handled by the ministry of health and their work is limited to distributing what is given to NMS.

Where there has been coartem or ACTs stock-outs, alternative drugs such as quinine, Sulfadoxine-pyrimethamine (SP) and Chloroquine (CQ) have been used. Yet CQ and SP were phased out due to perceived drug resistance that made malaria treatment more complicated. Kinungu says a considerable percentage of people still respond to CQ and SP where the resistance is not 100%.

Kinungu told The Independent that health workers are also adopting alternative strategies to combat malaria. The strategies include control measures like using insecticide treated mosquito nets, spraying with appropriate insecticide on the walls inside the houses (Indoor residual spraying- IRS), killing mosquito larvae could fight the disease. All these interventions are supported by health education, monitoring and evaluation and research. He said although there have been occasional Coartem stock-outs, there have been a reduction of malaria cases during the last financial year.

"This shows you that malaria control is done in an integrated manner not only by treatment."

Officials at the Ministry of Health say the year 2005 recorded the highest number of malaria cases in the country but the prevalence rates are now reducing because of increased use of mosquito nets, ACTs and indoor residual spraying. Ten million cases were reported in 2008.

About 7 million mosquito nets have been distributed countrywide. He attributes the increase in malaria cases in the financial 2007/2008 to the floods in the Teso region and the increase before 2006 was partly due to development of CQ resistance.

Analysts say now that because the Global Fund for TB, AIDS and Malaria has not been approved for round 9 and bearing in mind that government did not apply for round 8, the country might be headed for a drug crisis. The government needs to increase the budget allocation for EMHS next financial year. The government has also launched a campaign to arrest health workers who steal drugs from public health units. It is, however, hoped that perhaps when there is political accountability for those who mismanaged the Global Fund which included money for Malaria, Nalubuga's life and that of the other 300 who die daily will be saved if Coartem is made available in hospital pharmacies.

Click here to read about the March of Washingtons donation for antimalarial drugs to Soft Power Health in Uganda.