Barely days after high-level confirmation that the public health system in Malawi has only five percent of required essential drugs, indigenous medical suppliers say they have suspended supplying most public hospitals until their K1 billion (about $2.8 million) arrears are paid.

With the Central Medical Stores Trust (CMST) unable to procure public drugs over the past three years, mainly because it was undergoing reforms, most medical facilities have been relying on the indigenous suppliers and a donor-supported essential drug package for their needs.

The suppliers’ refusal to supply to referral and district hospitals is worsening the drug shortage crisis in government facilities.

On Tuesday, Minister of Health Catherine Gotani-Hara disclosed that public hospitals, especially district and referral facilities, have run out of 95 percent of essential drugs, but fell short of outlining specific measures for rectifying the situation.

The admission followed an ‘Open Letter to the President and the People of Malawi’ in which 15 doctors from Kamuzu Central Hospital (KCH) in Lilongwe pleaded with President Joyce Banda and the public to end the acute shortage of essential and basic medicines in the country to avoid needless deaths.

In an interview on Monday, Indigenous Medical and Surgical Suppliers (IMSS) chairperson Willy Chimbalanga confirmed that KCH is one of the facilities they have blacklisted.

“We are not supplying to certain hospitals where there are serious shortages because these hospitals owe us a lot of money and KCH is one of them,” said Chimbalanga.

KCH director Dr Noordeen Alide acknowledged that the hospital owes the indigenous suppliers, but did not specify the amount.

Said Alide: “Yes, we owe them a lot and we know it has impacted negatively on their capital because these are small-scale businesses. It is really a substantial amount.”

He said the problem is beyond KCH since it involves funding levels.

According to Alide, the hospital’s total annual drug funding is currently at K486 million (about $1.4 million), but in reality, that amount can only sustain the facility for three months.

He said according to computations by CMST, for three months, the country’s referral hospital needs $1 403 481.71.

“This amount is minus other essentials such as blood,” said Alide.

The hospital uses K15 million (about $41 666) quarterly to buy blood units for anaemic patients, he said.

He also said the hospital needs about K20 million (about $55 555) every three months to pay bills at Mwaiwathu Private Hospital in Blantyre where they refer some patients for specialist treatment.

Hospital checks have also shown that because the referral facility has not been able, since last year, to source donations from elsewhere, all health centres under the Lilongwe District Health Office have virtually shut down and now depend wholly on KCH.

This, apart from congesting wards, has also crowded the outpatients department (OPD) where long queues are the order of the day.

National crisis

A recent research study by the Overseas Development Institute (ODI) released this month found that, on average, 75 percent of such facilities, including health centres, are experiencing significant drugs stock-outs.

ODI also cites an Oxfam study as having found that only nine percent of local health facilities (54 out of 585) had the full Essential Health Package (EHP).

The study also says clinics are frequently out of basic antibiotics, HIV test kits and insecticide-treated nets while stocks of vaccines “run dangerously low”.

Local health facilities get their medicines from district health offices (DHOs) based at district hospitals.

DHOs buy the medical supplies from the indigenous suppliers.

Recently, the suppliers closed a pharmacy, laboratory and dispensary at Kasungu District Hospital for non-payment and now plan to close three more such facilities to force authorities to pay them, according to some members of the IMSS.

Kasungu Hospital only reopened after Banda intervened.

The hospitals facing closure, according to the suppliers, include Balaka, Salima and Nkhotakota; a threat that, if implemented, could spell doom for the poor in these areas, according to the districts’ health authorities.

But Chimbalanga could neither confirm nor deny the threat of the closures.

“We are yet to meet and map the way forward. But at the end of the day, action has to be taken because we have to make them pay us,” he said.

According to available statistics, if pharmacy, laboratory and dispensary facilities are closed for a full day at the four health facilities—including Kasungu—about 2 000 outpatients would be immediately affected and their lives put at risk.

For example, Balaka District Hospital alone attends to about 500 outpatients daily who wholly depend on the very services suppliers have targeted for closure.

At any given time, the hospital admits about 400 patients, according to Balaka district health officer (DHO) Owen Chikhwaza.

“If our pharmacy is closed for a day, a lot of lives will be at risk because ordering of drugs for the OPD is done on a daily basis; all admissions come through OPD and most of the life-saving drugs are administered at the OPD,” said Chikhwaza in an e-mail interview last week.

He said most people who come to the hospital cannot afford treatment in private pharmacies and clinics.

“Wards order drugs from the pharmacy three days in a week so if the closure fell on an ordering day it means over 300 lives will be at risk,” he said.

For the right diagnosis to be made, there is a need for a round-the-clock laboratory back-up.

Chikhwaza said without round-the-clock laboratory backup, a lot of malaria and anaemic children who would otherwise be saved could die; pregnant women and children requiring blood transfusion would risk losing their lives and the operating theatre would be closed.

At Kasungu District Hospital, where DHO Jarome Nkhambule said they attend to 736 patients—500 OPD and 256 admissions every day—hundreds of people were sent back without treatment when the suppliers sealed the facility.

The hospital did not register any deaths as a direct result of the closure.

Admission and OPD figures are almost similar at Salima and Nkhotakota district hospitals such that if suppliers closed the four facilities at once, 2 000 OPD lives would be at risk and close to 1 200 inpatients would suffer.

“The impact would be quite huge. Apart from OPD, in-patients also rely on daily orders from the same pharmacy,” said Nkhotakota DHO Wanangwa Chisenga whose hospital admits 300 inpatients and attends to 400 outpatients daily.

The only available options for Kasungu, Nkhotakota and Salima would be KCH which is not just more than 100km away but is in crisis.

Balaka would depend on Zomba, close to 80 kilometres away, and in no better shape itself to accept additional burden.

Ministry of Health spokesperson Henry Chimbali acknowledged the dangers that would come with closing of pharmacies in the district hospitals, but could not indicate when the creditors would be paid.

Said Chimbali: “By nature, the action of closing a pharmacy is paralysing the operations of the hospital because this is the last point of contact and most important to everyone who has gone to the hospital.

“Our stand remains the same—that district commissioners, in collaboration with the National Local Government Finance Committee [NLGFC], should take up the issue of the debt and this is the direction we are offering to the private suppliers.

“The debt at Kasungu, just as other DHOs, has accumulated over the years and it may have reached this level due to other pressures on the DHOs expenditure.”

NLGFC executive secretary Wezi Mjojo, in an e-mailed response, said her agency is only dealing with district hospital debts.

“Central hospitals still remain the mandate of the Ministry of Health. Further, as we clear the debts, the office of the Auditor General shall be asked to validate the amounts that are captured as arrears as per standard government requirement of certifying arrears before they are duly cleared as such,” she added.

Apart from the K1 billion owed to private suppliers, public hospitals also owe the CMST more than K3 billion in unpaid drug arrears.

Chimbali said in another interview that the ministry’s discussion with NLGFC is that they will mobilise resources to pay the debts for the eight DHOs that owe private suppliers.

He said: “The rest of the DHOs are working well with the private suppliers. What we know is that private suppliers are our long-term partners for the health sector and we will make every effort to sort out these problems and normalise our relationship. So, we expect them to continue working with our DHOs and CMST.”

It was reported on Thursday that the ministry has approached Treasury for an emergency package.