Malawi is again experiencing a crisis in the delivery of essential medicines, with understaffed clinics and erratic drug supplies preventing many dangerously ill patients from accessing treatment.

Frequent drug shortages and stock-outs have plagued the country’s health system in recent years. According to a 2012 report by the UK charity Oxfam, only 9 percent of local health facilities (54 out of 585) had the full Essential Health Package list of drugs for treating 11 common diseases. Additionally, clinics were often out of basic antibiotics, HIV test kits and insecticide-treated mosquito nets, and in many facilities, stocks of vaccines were dangerously low. According to news reports, public hospitals had run out of 95 percent of essential medicines by the end of January.

In early February, President Joyce Banda met with health department officials and healthcare workers to address the crisis.

The situation was brought to light when doctors at Kamuzu Central Hospital in the capital, Lilongwe, wrote an open letter to Banda calling for an urgent solution to the shortages, which included lack of intravenous fluids, antibiotics, syringes and plasters.

“We have been struggling to provide these supplies using our private funding donated by friends and families, but we have come to realize that the situation, already dire, is not improving, and our current strategy is neither sufficient nor sustainable. In the meantime, we are experiencing the deaths of patients from treatable diseases (diarrhoea, pneumonia and malaria), which is heart-breaking. Talking to our colleagues, the situation is the same in all public hospitals,” the letter said.

Kamuzu Central Hospital administrator Naureed Alide said the doctors decided to write the open letter to the president only after exhausting all other avenues. “There has not been any positive response befitting the current situation,” he said.

What went wrong?

At the meeting, doctors blamed the centralized health delivery system, the devaluation of the kwacha – which, they said, has triggered inflation – and a lack of planning when purchasing drugs as key reasons behind the service problems.

President Banda’s move to devalue the kwacha by nearly 50 percent in May 2012 has triggered steep increases in the prices of basic goods and has pushed many Malawians deeper into poverty. However, drug shortages were a problem long before the currency was devalued.

Charles Mwansambo, principal secretary in the Ministry of Health, admitted that procuring drugs in Malawi is a “tedious and bureaucratic” process. “It takes a considerable, long time to reach the point where we have made a purchase of drugs,” he noted.

According to Mwansambo, the embattled Central Medical Stores – which supplies all government health facilities – made its last major purchase of medication in 2009; the drugs purchased were supposed to last two years. The large consignment was meant to allow time for the Central Medical Stores, then a government department, to transform into a trust in response to pressure from donors and activists.

But the move to become the Central Medical Stores Trust (CMS-T) has been fraught. “In theory, as a trust, the CMS-T is envisaged to work in a more business-like fashion, with better cost accounting measures to ensure it is self-financing and with greater independence. In practice, aspects of how the trust will be constituted remain undecided, and it does not yet appear to have the full confidence of key stakeholders,” said a recent report  by the UK’s Overseas Development International (ODI).

The newly formed CMS-T has inherited a debt of more than MK3 billion (US$8 million) owed by public health facilities, leaving the institution with no start-up capital. In addition, inadequate warehousing and storage facilities will have to be improved. The trust will also have to deal with “mountains of over-procured medicines and medical supplies such as plaster of Paris and envelopes for x-ray films”, noted Herbert Chandilanga, public relations officer for the CMS-T.

In the meantime, donors such as the Global Fund to fight AIDS, Tuberculosis and Malaria have bypassed the CMS-T, preferring to use a parallel system to purchase medication for their treatment programmes.

ODI warned, however, that parallel systems were unsustainable. “There is a danger that development partners (or other third parties) become locked into external procurement and provision of medicines indefinitely. Maintaining parallel systems can undermine incentives for change, and undermine the link between citizen and state, as people do not hold government responsible for service provision and leaders no longer feel responsible.”

Other reforms needed

The Central Medical Stores is not the only reason for the drug shortages. Lista Amon, programme manager for the UK Department for International Development (DFID) in Malawi, told IRIN that there was “insufficient funding for drugs. The formula used to calculate the drug budget merits further scrutiny as the price of drugs does not remain static.”

Amon suggests that there is a need to continue to ring-fence drugs within the health budget as well as to increase the drug budget.

Amon further recommends reforming the drug financing system; continuing reforms to Malawi’s drug procurement and distribution system, such as sub-contracting to private companies; and scaling-up measures to address accountability and transparency in the management of health commodities.

Malawi’s treasury has released $2 million, half of which will be used for emergency drug procurement. The other half will be used to help district and central hospitals settle outstanding debts with medical suppliers.