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The state of medicine in Zimbabwe’s hospitals

Second Report of the Portfolio Committee on Health and Child Care on the state of medicines and drugs supply in the public health institutions of Zimbabwe

Honourable Mathias Tongofa:  I move the motion standing in my name that this House takes note of the Second Report of the Portfolio Committee on Health and Child Care on the State of Medicines and Drugs Supply in the Public Health Institutions of Zimbabwe.

Thank you, Hon. Speaker.  Since the last quarter of 2018, Zimbabwe’s public health institutions have been experiencing severe shortages of medicines and drugs as well as other essential products. This has rendered the general public at the mercy of the private sector which introduced a three-tier pricing system. This is in the form of the United States of America Dollar (USD), Equivalent of the USD in Bond (RTGS$) and demand of a markup percentage on products purchased through EcoCash and Swipe. These demands are beyond the reach of an average citizen in Zimbabwe, let alone the poor and vulnerable population in the country.

This unbearable situation led to the public outcry over the acute shortages of medicines and essential drugs in the public health institutions in Zimbabwe and the price distortions of the medical products. Consequently, the Portfolio Committee on Health and Child Care was prompted to conduct an inquiry into the state of medicines supply in the public health institutions in Zimbabwe.

Objectives

The objectives of the enquiry were:

  1. To understand the medicines and drug supply chain in the county;
  2. To appreciate challenges being faced by the Ministry of Health and Child Care in the supply of medicines and drugs in public health institutions; and
  3. To recommend strategies that may enhance the provision of medicines and drugs in public health institutions.

Methodology

The Committee held oral evidence meetings with the various stakeholders and conducted fact-finding visits to the National Pharmaceutical Company of Zimbabwe (NATPHARM).

Oral Evidence Sessions

The representatives of the Pharmaceutical Society of Zimbabwe appeared before the Committee on the 5th of December 2018 to present on the state of medicines availability in Zimbabwe.

The Director-General for the Medicines Control Authority of Zimbabwe (MCAZ), Ms G. Mahlangu appeared before the Committee on the 5th of March 2019 to present on the institution’s mandate, role, function and operations in the supply of medicines and drugs in the country.

On the 10th of April 2019, the Minister of Health and Child Care, Dr Obadiah Moyo, briefed the Committee on the policy measures that the Ministry was taking to improve the supply of medicines in public health institutions and to address the price distortions in the market.

The Permanent Secretary for the Ministry of Home Affairs and Cultural Heritage, Mr M. Matshiya briefed the Committee on the 10th of April 2019 on the measures that the ministry has put in place to curb unlicensed trade of medicines on the streets.

Fact-Finding Visits

The Committee undertook two fact-finding visits to the National Pharmaceutical Company of Zimbabwe on 12th of February 2019 and on 11th of April, 2019. The objective of the first fact-finding visit was for the Committee to familiarise itself with the operations of Natpharm in terms of medicines and drug supply in the country. The second fact-finding visit was a verification exercise to confirm whether indeed, Natpharm had started receiving medicines as indicated, by the Minister of Health and Child Care on the 10th of April 2019.

The Committee Findings

State of Medicines Supply in the Public Health Institutions

As already alluded to in the introduction, since the last quarter of 2018, the country has been faced with a severe shortage of medicines across the board. However, the crisis has been more severe in the public than in private health institutions as the most essential medicines and drugs for chronic ailments such as hypertension and diabetes were out of stock. Consequently, senior doctors at Parirenyatwa Group of Hospitals have been on record protesting over shortages of medicines and supplies as the situation became dire, putting the lives of the patients at risk of preventable complications and deaths.

During the oral evidence meeting on the 10th of April 2019, the Minister of Health and Child Care confirmed that the public health institutions in the country were in a dire state. He further stated that shortages of medicines and drugs, among other medical supplies, were being experienced right from the primary healthcare level to the tertiary institutions.

State of the Pharmaceutical Industry

Key players in the industry are the manufacturing companies, importing wholesalers, distributors, National Pharmaceutical Company (Natpharm) and retailers. There are five main local pharmaceutical manufacturing companies namely: Varichem, Plus 5, CAPS, Datlabs and Pharmanova. Unfortunately, the current state of equipment and manufacturing processes has affected their ability to produce vital drugs and medicines in the country. At the time of the enquiry, capacity utilisation of the industry was, on average running below 40% primarily due to inadequate foreign currency allocations.

Regulatory Framework

The regulatory authority that oversees the pharmaceutical manufacturing industry is the Medicines Control Authority of Zimbabwe (MCAZ). MCAZ is responsible for pharmaceutical surveillance, licensing, enforcement, laboratory services, evaluation and registration activities for the sector. It was established through the Medicines and Allied Substances Control Act (Masca) (Chapter 15:03). Registration processes are rigorous and thorough for both imports and exports with the aim to ensure citizens are safeguarded against counterfeit and unsafe medicines.

In the quest for promoting local manufacturing of drugs and medicines, the MCAZ reduced lead time to process local applications from 11-20 months in 2016 to 3 months in 2017. Furthermore, local pharmacies are given priority review on their applications and are offered training on bio-equivalency and in some cases, bio-equivalency can be waived where necessary. However, the Pharmaceutical Society of Zimbabwe representatives recommended that the lead time be further reduced to below 3 months for local manufacturing companies to enable them to start producing most medicines currently being imported. They added that these should include critical lifesaving and chronic medicines. They also requested that registration guidelines for dossier purchase be put in place, exempting most requirements such as bio-equivalency studies and stability studies, so long as pharmaceutical equivalency is demonstrated.

Promotion of the Development of Traditional Medicines

The Committee was informed that Traditional Medical Practitioners seem not to be keen to register their medicines. However, it was stated that there is a regulation for complementary medicines which is being worked on, where these traditional medicines will fall under.  The Committee was further informed that in February 2019, the MCAZ licenced one Traditional Medicine Manufacturer under the Complementary Medicines Regulation and is located in Murehwa area.

Natpharm and Medicine Management

In 2014, the Portfolio Committee on Health and Child Care tabled a report on the State of Affairs in the Health Service Delivery System in Zimbabwe and revealed that:

Multi donor funds have provided support to the vital medicines and vital health services for the district health system. The programme supplies more than 75% of the country selected package of essential medicines. The programme excludes the five central hospitals, hence, the lack of essential drugs at the tertiary institutions… 98% of the drugs being distributed to various hospitals are donated by donors and do not seem to be purchased with morbidity patterns in mind and have very short shelf life plus or minus 3 months in most cases.

The result of the above-quoted scenario was that drugs were expiring at Rural Health Centres and District Hospitals whilst the Central Hospitals were in need of the same. The Report noted that this was due to lack of an effective redistribution system of the distributed drugs to reduce the quantities of drugs expiring. It recommended strengthening of the MoHCC’s monitoring system for effective drug management.

The Report also revealed that Natpharm had large quantities of expired drugs in its warehouse and recommended that it should sell excess stocks of drugs to private sectors and also donate to the schools, clinics, prisons and Mission hospitals to minimise expiries. Furthermore, the Report noted that Napharm, a quasi-government company mandated with procurement and distribution of drugs was incapacitated by lack of finance and strongly recommended for its recapitalization.

Five years later, the newly constituted Committee on Health and Child Care undertook a familiarisation visit to Natpharm on the 12th of February 2019. The Committee’s findings were disheartening in that Natpharm was still dogged by the above-mentioned problems. It still had huge piles of expired medicines and drugs in its warehouse and issues of its capitalisation have not yet been attended to.

During the familiarisation visit, the Committee vehemently expressed its disapproval on the proposed idea for Natpharm to establish retail pharmacies across the country, at a time when the public health institutions did not have medicines. The majority of our population cannot afford medicines from private pharmacies and rely predominantly on the public sector. Hence, the Committee proposed that the public health institutions be well stocked with medicines to improve on accessibility and affordability of the products to the general population. On the 10th of April 2019, during the oral evidence meeting, the Minister of Health and Child Care indicated that the Ministry had taken heed of the observation by the Committee. He further explained that the move to establish Natpharm retail pharmacies was to try and curtail the competition from the retailers who were charging in foreign currency, but, this has been overtaken by events and the proposal was dropped.

Unlicensed Selling of Medicines and Drugs

The Committee, greatly disturbed by the proliferation of the unlicensed selling of medicines and drugs in the country (black market), quizzed the MCAZ and the Ministry of Home Affairs and Cultural Heritage over the matter. In her presentation before the Committee on the 5th of March 2019, the Director General of MCAZ attributed the problem to the importation of undeclared medicines and leakages from the public health institutions. She informed the Committee that the MCAZ, in conjunction with the Ministry of Home Affairs and Cultural Heritage, carries out medicines and drug blitzes on the streets and at border posts. However, penalties are not punitive enough to deter the offenders.

Presenting oral evidence before the Committee on the 10th of April 2019, the Commissioner-General of Police, Mr T.G. Matanga, confirmed the assertions made by the MCAZ Director-General. He cited the arrest by the Police of three suspects who were caught in possession of huge consignment of medicines worth US$500 000 at a backyard warehouse in Waterfalls, a case which is still before the courts. He stated that part of this consignment belonged to the MoHCC.

The Committee was informed that although they carried out medicines and drug blitzes, the Police is inadequately equipped to combat such crimes. He stated that the Police had no vehicles and latest technology in combating crimes. He also stated that this was further worsened by the unattractive conditions of service and salaries of the police officers, resulting in demoralised officers. He also echoed the same sentiment regarding lack of punitive penalties to offenders, resulting in Police Officers being demotivated to follow upon such crimes.

Major Challenges

Four factors were presented as the major challenges that have led to the acute shortages of medicines and drugs in the country and these are:

  1. Lack of foreign currency to import medicines and drugs and raw materials for local production;
  2. Restrictive regulatory framework that affects the ability of the local manufacturers to produce vital drugs and medicines in the country;

iii. Lack of investment in technology and equipment (Obsolete equipment) in the pharmaceutical industry; and

  1. Lack of innovative research in the country owing to the current economic hardships.

Measures in place to improve supply of medicines in the public health institutions

The following are the measures the MoHCC had instituted to improve medicines and drug supply in the public health institutions as presented by the Minister of Health and Child Care during the oral evidence meeting on the 10th of April 2019:

Establishment of a Foreign Currency Allocation Committee (FCAC)

In 2018, RBZ was allocating foreign currency on its own, leading to diversion by the pharmaceutical industry buying non-essential drugs as RBZ would make allocations based on the request that came directly to them. In order to mitigate against the abuse of funds by the beneficiaries in the pharmaceutical industry and to ensure the funds are used to procure essential drugs, the MoHCC set up a Foreign Currency Allocation Committee. The Committee is chaired by the Principal Director Curative (MoHCC). Other members include: Director of Pharmacy Services (MoHCC); Natpharm (1); Pharmaceutical Wholesalers (2); Pharmacy Retail Association (2); Pharmacy Manufacturers (2); Pharmacy Association of Zimbabwe (2) and Finance Directorate. The Minister informed the Committee that since its inception in February, the FCAC has only received US$600 000 leaving a huge gap of financing required to meet the needs of the pharmaceutical industry, retailers and wholesalers. At the time of the oral evidence, the Minister indicated that Zimbabwe owes about US$50 million to the manufacturers outside the country.

Partner Engagement

The MoHCC has engaged partners such as the United Nations (UN) and entered into a swap arrangement. The Minister explained that this is, where, if Zimbabwe has invoices outside the country, instead of the partners to bring their foreign currency into the country, the Ministry requests them to pay for the invoices. He, however, stated that this arrangement is not always available as those monies are required for the general management and routine management of their missions in Zimbabwe.

Loan facility

The MoHCC, through the Ministry of Finance and Economic Development, has engaged funders who have foreign currency outside Zimbabwe on an arrangement that would see Zimbabwe repaying them over a lengthy period of time.

Tender requests in RTGS$

The MoHCC decided to have a blog and went to tender requesting for companies to submit in RTGS$. This approach worked because of positive responses from the prospective bidders. The Minister stated that the introduction of the inter-bank rate of 2. 5% helped them to be able to go to tender and request for quotations in RTGS$. As a result, the Ministry managed to secure RTGS$80 million worth of medicines. The first consignment of medicines worth RTGS$25 million was reported to have been delivered to Natpharm at the time of the oral evidence meeting.

The above-mentioned statements by the Minister prompted the Committee to undertake a second visit to Natpharm on the 11th of April 2019 with the objective to verify his assertions. To the satisfaction of the Committee, the medicines were, indeed, being delivered to Natpharm when it arrived at the premise on the 11th of April 2019. However, the Committee noted that this was a drop in the ocean considering the quantities of medicines and drugs the country requires in the public health institutions. The Minister also stated that although the RTGS$80 million facility would be upped to RTGS$190 million, the situation remains dire as the country’s medicines and drug reserves had run dry. He informed the Committee that Zimbabwe requires US$400 million annually to ensure adequate supply of medicines and drugs in her public health institutions.

Promotion of Local Pharmaceutical Manufacturing Industry

According to the Minister of Health and Child Care, Zimbabwe is currently buying 80% of her medicines and drugs from India. In order to reduce the import bill, the MoHCC is working on promoting the local pharmaceutical manufacturing industry. The Minister informed the Committee that it intends to revamp and re-capacitate the local manufacturing industry starting with CAPS and other manufacturing companies such as Datlabs, PLUS5, and Varichem among others. Since the pharmaceutical industry has representatives in the Foreign Currency Allocation Committee, the MoHCC would support them to get an allocation for them to buy raw materials. The Minister also indicated that the Ministry was in negotiation with Indian companies interested in revamping CAPS, but have challenges with its old equipment procured in the 1960s. To this end, the MoHCC, in conjunction with the Minister of Industry and Commerce, have already identified potential companies. The Minister further informed the Committee that the companies from the UAE have also expressed their interest to support Zimbabwe in the creation of pharmaceutical manufacturing plants.

Donations from Well-Wishers

Zimbabwe has kept her doors open for well-wishers to assist with donations in the health sector. To this end, well-wishers such as the United Nations mostly and others as well as the United Arab Emirates have been forthcoming during these trying times. These donor agencies have kept the health sector on its wheels.

Committee Observations and Recommendations

Observation

The Committee noted with concern that at the moment there is no concrete solution to address shortages of medicines in the public health institutions as pharmacies are either non-functional or are inadequately stocked due to inadequate foreign currency allocation towards the procurement of medicines and drugs as well as raw materials to produce the products.  In light of this, the Committee recommended the following:

Portfolio Committee on Health and Child Care Recommendation Number 1/2019

The Ministry of Finance and Economic Development, going forward, should prioritise regular disbursement of foreign currency to the health sector to ensure adequate and consistent medicines and drugs supply to the public institutions.

It is further recommended that the Ministry of Health and Child Care should ensure that pharmacies in public institutions are immediately resuscitated to ensure increased availability and affordable medicines and drugs for the generality of Zimbabweans.

Observation

The Committee noted that while the private sector benefits from the foreign currency allocation by the RBZ, it is disheartening to note that the bulk of the products they were bringing into the country were non-essential drugs. In light of this, the Committee recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 2/2019

The Government of Zimbabwe should immediately stop allocating foreign currency to the private sector and allow them to charge their own prices while it channels the foreign currency to Natpharm for the supply of medicines to public institutions to ensure availability of essential drugs in the country.

Observation

The Committee also noted that the existing regulatory framework and policies in the medicines manufacturing sector are not addressing the current demands for medical drugs in the country. Therefore, the Committee recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 3/2019

The Ministry of Health and Child Care should develop user-friendly regulatory framework and policies that promote, support and protect local pharmaceutical manufacturing industry by 31 December 2019.

Observation

The Committee noted that the promotion of the local pharmaceutical manufacturing industry seems to be skewed towards big players such as CAPS, Datlabs among others and recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 4/2019

The promotion of local pharmaceutical manufacturing industry immediately be expanded to encompass the small to medium enterprises in the sector.

Observation

The Committee noted that public health institutions are manned by unqualified personnel in violation of the requirements of the Medicines and Allied Substances Control Act (Chapter 15:03) and that where pharmacists are serving, the ratio of pharmacist to patient is currently unacceptable. The Committee, therefore, recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 6/2019

The Ministry of Finance and Economic Development should unfreeze by September 2019, the posts for pharmacists for the MoHCC to comply with the requirement of the Medicines and Allied Substances Act (Chapter 15:03).

Furthermore, the Ministry of Finance and Economic Development should provide concurrence for the review of the establishment of the posts of pharmacists by 31 December 2019 in order to address the ratio of pharmacist to patient at public institutions in line with the current demands.

Observation

The Committee noted with concern that despite the fact that a Report was tabled in this august House in 2015 during the 8th Parliament with the recommendation to prioritise capitalization of Natpharm, no action was taken in that regard. Therefore, the Committee recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 7/2019

The Ministry of Finance and Economic Development should immediately avail funds to expedite the capitalisation of NatPharm as per the MoHCC’s 2017-2020 Strategy in order to kick-start production of medicines and drugs by 31 November 2019.

Observation

The Committee is further concerned that not much has improved in terms of the drug management by Natpharm in line with the recommendations that were made in the report presented during the 8th Parliament. It also noted that there is unfair distribution of medicines and drugs with respect to Matebeleland North Province which gets its stock from Bulawayo. In light of this, the Committee recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 8/2019

The Ministry of Health and Child Care should put a mechanism in place to strengthen its monitoring system for effective drug management with regards to the redistribution system of the distributed medicines and drugs to reduce quantities of expiries by 31 October 2019.

The Committee further recommends that MoHCC decentralises the distribution points of medicines and drugs from Natpharm by ensuring that each province has its own Natpharm Depot in line with the dictates of devolution by the first quarter of 2020. This arrangement would improve on timeous deliveries of the products to the public health institutions as distances to transport medicines and drugs would be shortened.

Observation

The Committee noted with great concern the delays by the Ministry of Finance and Economic Development in the approval of board of survey for the destruction of expired medicines and drugs, leading to huge piles of the same at Natpharm. The Committee recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 9/2019

The Ministry of Finance and Economic Development expedite the approval of board of survey in order to have the expired drugs destroyed by 31 October 2019.

Observation

The Committee noted that the health service sector carries a very high-security risk as medicines and drugs find their way into the black market and recommend that:

Portfolio Committee on Health and Child Care Recommendation Number 10/2019

Public health institutions should immediately put in place their own strong internal security to curb against leakages of medicines and drugs.

Observation

The Committee noted that the black market is thriving as a result of shortages of medicines and drugs in the public health institutions coupled with exorbitant prices of the products in the private sector. The Committee further noted the inadequacies by the Police to deal with such crimes and their demotivation in light of lack of punitive measures. The Committee, therefore, recommends that:

Portfolio Committee on Health and Child Care Recommendation Number 11/2019

The Government of Zimbabwe, going forward should avail adequate foreign currency to Natpharm for procurement of medicines and drugs as well as raw materials to boost the local production. This would ensure that public health institutions are well stocked and eventually cripple the black market.

It is further recommended that the Police be adequately resourced to deal with such crimes and offenders be given deterrent penalties to curb illegal trade.

Conclusion

The evidence gathered by the Committee has revealed that the state of medicines and drugs supply in the public health institutions is disheartening as it is characterised by severe shortages of essential products from the primary to the tertiary levels of care. Based on these findings, the Committee urges the Government of Zimbabwe to prioritise the health sector and create an enabling environment that would promote the growth of the local pharmaceutical industry. I thank you.

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Daniel Chigundu

Daniel Chigundu is a male journalist in Zimbabwe and has been practising since September 2009. He used to the editor for The Business Connect (newspaper) in Harare, has his own news website Tourism Focus which is biased towards the tourism sector. Daniel is also working with Magamba Network on their project called Open Parliament where they do live coverage of Parliamentary activities on Twitter and Facebook. He is currently the secretary-general of the Zimbabwe Parliamentary Journalists Forum, is a member of Zimbabwe Small Broadcasters Association and a board member of Digital Communication Network. He holds a Diploma in Communication and Journalism from the Christian College of Southern Africa (CCOSA), a certificate in Youth leadership training from the Friedrich Ebert Stiftung (FES), a certificate in Citizen Journalism from Magamba Network and is currently a first-year student at Zimbabwe Open University studying for a Bachelor of Arts Honours in Ethics and Organisational Leadership.

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