The issue of medicines and medical supplies (pharmaceuticals) shortage in our beloved country does not need introduction any more as many of us are aware. With most of the population relying on the public health system for their health care need, the government in general takes much of the blame as it has the responsibility of ensuring that all our social needs including health care are met. Central Medical Stores (CMS) being the institution charged with the responsibility of providing pharmaceuticals to the public health facilities is also mostly blamed. Whilst agreeing to the fact that CMS currently is facing a huge burden to meet this daunting task, I would want us to think of going to the basics of our pharmaceuticals supply line and concentrate on the basics and see if they can be of assistance to alleviating this problem.
Just like any other commodity, the principle of demand versus supply also applies to pharmaceuticals. From the introduction, I would probably be right that the concentration has been on supply and less if any on the demand side. In our country, pharmaceutical utilization audits are non-existent as such the utilization of the scarce precious resource cannot be ascertained. All we know is that our country procured pharmaceuticals worth so much as a result.
Malawi as a country has got an Essential Medicines List (MEML) which was updated in 2009. This list has over 300 products in it classified according to: (i) level of use as H (health centre), D (district hospital) and C (central hospital); (ii) therapeutic priority as V (vital), E (essential) and N (non-essential); and (iii) procurement priority as A and B. In this list however, all non-essential medicines were removed. I do not have to go into the nifty gritty of these categorizations but I would want to mention that various combinations can be made like HVA, HEA, DVA, DVB, DEA, DEB, CVA, CVB, CEA, CEB etc. Thus from a supply point of view, the last categorization holds a very crucial key and thus I put some details to it.
This categorization specifies how CMS and the public health care facilities will procure pharmaceuticals. Class A-list items are those ones required for large numbers of patients or clients and this includes all health centre level medicines. These routinely will be procured and stored by CMS for distribution. Class B-list items are those generally required for a limited number of patients or clients. These are not routinely procured and stocked by CMS and annual estimates and advance payment from individual user units are supposed to be made to CMS for supply. Currently, the supply line policy gives responsibility to the user units to make ultimate decision as to which products to select and/or procure for their own use and as such the categorization made in the MEML is supposed to aid that process.
The policy makers anticipated the challenge of funding and hence proposed that where funds are limiting then priority should be given to VA (vital and A-list) items. The situation of late does not seem to suggest that this is being implemented to the later as there are very critical shortages of all classes of medicines. This raises many questions than answers and probably that is why much of the blame is pushed to these two entities. As a stop gap measure probably, government also allows District Health Offices and Central Hospitals to procure from private suppliers upon acquiring an approval of such. Whether this stop gap measure is benefitting Malawians at large is not the subject of discussion now.
Against this background I would want to suggest the following; firstly, CMS should prioritize the procurement of VA-items as a matter of urgency. This is a very basic issue in our supply policy and through its total implementation we will ensure that the health care need of most Malawians is met. Second, government should make a deliberate policy which will allow Central Hospitals procure C-level medicines on their own from private suppliers following current good procurement practices (cGPP) and applicable procurement laws and regulations of Malawi. This will also free some funds from CMS which can then be utilized to take the first suggestion. It is much easier to exercise control over the four central hospitals than to control all the district health offices and central hospitals as is the case currently. And in addition, medicines utilization audits should instituted and/or supported in our health facilities which will ascertain the appropriateness of medicine utilization thus ensuring transparency and accountability.
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