Sierra Leone - Three-year-old David bolts up from his feverish stooper as a needle pricks his thumb, producing a tiny bead of blood. He looks down horrified but is too exhausted to cry and falls back into his mother's lap as the blood is wiped away. Juane K. Nabieu, a community health officer in the district's main Peripheral Health Unit (PHU) drops the specimen of blood onto a strip. Within seconds two fine lines appear and David's mother Naomi Sam is told that her son has malaria.
Malaria is endemic in the country - it is one of the biggest killers of children. David is lucky. He is treated with the last batch of Artemisinin-based Combination Therapies (ACT) that Nabieu has just collected from the neighbouring district government drug storeroom. But poor record keeping, wastage and theft may be responsible for the loss of a quarter of vital aids drugs that have gone missing from the central government warehouse in Freetown, denying other children like three-year-old David the chance of survival.
The regular UNICEF stocktake found a preliminary figure of 25 percent of the aid was unaccounted for, UNICEF said in a statement on Jun. 14. The drugs are thought to include vital life-saving drugs like ACT. "An internal stock take report revealed the possible loss of drugs destined for government health clinics and that we asked the authorities to review... At present we are still looking into how much of the losses can be attributed to poor record keeping at health centres and district warehouses or to wastage due to improper storage or theft."
A UNICEF representative said that the internal stock take began at the end of 2010, and has just been completed. It reviewed stocks from the rural health posts across the country in a bottom-up check of drugs. It also follows reports from district hospitals across the country and PHUs about an ongoing shortage of ACT, vital in the treatment of malaria. At the Khailahun PHU there are only two more packets of ACT left - serving 156 PHUs. When the remaining doses run out, Nabieu, will refer his patients to the government district hospital.
"Most of the people who come here will not be able to afford the ACT sold privately - they rely on the free drugs," he says sitting behind a desk with an array of medicine bottles all lined up in front of him. "You can see we have many drugs, but the supply of fast moving essential ones like ACT always arrives in spurts - every month there is a shortage, and every month there will be people who suffer because of it." Sierra Leone's government took a massive step when it announced last April that health care for children under five and pregnant women would be free. The Free Health Care Initiative is 90 percent funded by international donors like UNICEF, the African Development Bank, UNFPA and the government of Sierra Leone.
In Khailahun district, drugs that were given as aid by the Global Fund and UNICEF are reported to be found in private drugs shops and sold by street market traders. "We have patients who come from neighbouring Liberia, which puts a strain on our resources, but the drugs in the local market may also be drugs that have come from Liberia or Guinea - the aid that comes into West Africa is generic and that makes it easy to sell anywhere," Nabieu explains. On the other side of Khailahun town, at the district hospital, things are no better. In the paediatric ward, tightly packed with mothers and babies all eerily quiet, nurse Alice Mansaray has a stack of paperwork and a new baby with complications from malaria to admit.
"Most children come to us with severe anaemia or convulsions - sometimes their mothers suppress their child's fever with paracetamol, when there are no free stocks of ACT in their PHUs, and they can't afford the private drugs. "When I run out of ACTs I send them to a private drug store. They have to go because they can't see their children die. We have seen more cases of malaria and more children with complications," she says as she holds up a strip of ACT. Though the government's hospital monitors say malaria cases have decreased compared to last year in Khailahun, there is no record kept of how many patients come back with complications. There is also no record of those who were entitled to free drugs, or who had to purchase them from the private sector because of the shortage of aid.
The Civil Society organisation, Health for All Coalition (HFAC), implemented a monitoring system, parallel to the government's. Alhassan Kamara at HFAC estimates that 45 to 50 percent of the aid that comes in disappears finding its way to the market - though no survey has been conducted to substantiate this. "Our monitors travel in drug delivery trucks. We insist community and district hospital representatives receive the consignment." This has reduced the "leakages" Kamara calls the thefts. "Transportation from district to the PHU needs to be strengthened. There is less transparency, and scope to sell on route."
This is not the first time such irregularities have been discovered in Sierra Leone. In 2008 a BBC report discovered UNICEF's malaria drugs in Kono (Eastern Province) were being re-sold in private pharmacies. "If there was such mass pilfering, the system would collapse," says Dr Amara Jambai, director of Disease Prevention and Control at the ministry of health and sanitation. "The community are very active and watch supplies very closely." Jambai admits that the capacity of the government is too weak to deliver the drugs to each PHU. "The cause of the shortage is not because there are thefts, but because demand is great, and the system is new."
The district hospitals in Khailahun, Pujehan in the South, and Bo in Central Sierra Leone, say that when they have approached Freetown for ACT, they still have supply issues. Pujehan hospital said they had not received a delivery since February - though they had a small supply remaining of ACT, other essentials like antibiotics and paracetamol had long been unavailable. Mahimbo Mdoe, UNICEF country representative says that UNICEF is due to take over the operation to run the logistics themselves. "We are hiring an international company to manage the central warehouse, and they will be responsible for doing a "milk-round" to all 1,200 PHU's across the country. "A year ago 80 percent of people didn't go to the doctors because of the cost. Sierra Leone is a fragile state. The numbers of people accessing the aid for the first time is an important step forward."
Meanwhile, Naomi Sam says that she could not have gone to the private drug store to buy the ACT that has just saved David's life if it were unavailable, because "I have no money," she says simply. She knows that coming to the PHU means that David will get free treatment. But, the 20 or so women with sick babies waiting outside may not be so lucky today.