Society Security, financial constraints, administrative inconsistencies weigh down vital pharma supply chain
March 23, 2024
Every day, Sidama Regional State’s Adare General Hospital is the setting for a flood of patients who swarm its premises in desperate search of medical attention. To a team of journalists visiting the hospital on March 13, 2024, the chaotic scenes were shocking, verging on theatrical. To its overworked health professionals, it was just another day on the frontlines of an ailing public health system.
The hospital’s large patient influx is partly due to its designation as a tuberculosis (TB) treatment center. In the last year alone, nearly a quarter million patients have been screened for TB at Adare General, according to Zenebe Turchie, the hospital’s director-general.
“Between 500 and 600 people have tested positive for simple, treatable TB every month for the last six months,” Zenebe told The Reporter.
Asnakech Tamene heads the hospital’s TB clinic – a small room in the hospital compound. In it were stacks of treatment kits, each designed to cover a six-month treatment regime for a single TB patient.
Asnakech held one of the kits in her hands as she described the problems stifling service provision at the clinic.
“The hospital has a very high TB case flow, but the resources we have are limited,” she said.
Access to medicines and medical equipment is among the most urgent and daunting hurdles facing Ethiopian healthcare. The clinic run by Asnakech is only one of thousands that are suffering from shortages while simultaneously having to contend with a surge in patient numbers as protracted conflict, drought, unemployment, and poverty take their toll.
The foreign currency crunch is a bottleneck on the supply of pharmaceuticals and medical equipment, but even the medicine that is imported is difficult to deliver to health centers in many parts of the country owing to security concerns. The prevalence of counterfeit medicines, illicit pharmaceuticals trade, and skyrocketing prices add to the healthcare crisis.
Heads of the Hawassa branch of the state-run Ethiopian Pharmaceutical Supply Service (EPSS) have stated that security issues in conflict-prone areas, unwarranted Woreda-level medicine re-rationing, debt, and federal pressure in debt collection are crippling their operations.
The Hawassa office is one of 19 run by the state pharma supplier, which warned last week that security hurdles are hampering federally-funded health programs to fight AIDS, TB, malaria, and conduct vaccination campaigns, as well as maternal and child care services.
Zemen Legesse, head of EPSS Hawassa, says no less than 131 health centers located outside of the Sidama regional hub are facing problems, while his office has managed to provide last-mile delivery services to 439 health facilities.
Henok Abrham, head of warehouse managements and storage administration, echoed the difficulties posed by protracted conflict, making last-mile delivery services in regions such as West Guji infeasible.
“Even carrying out the routine bimonthly delivery has become increasingly difficult. Right now, the only solution we have is working with zone officials. Sometimes they tell us not to go out there. When things get serious, they instruct us to wait for their say-so,” he said.
Henok says sometimes the only way to deliver critical pharmaceuticals to these areas is to wait for short windows of calm that come along every once in a while. In other cases, deliveries are escorted by police and woreda security officers.
Zemen disclosed his EPSS branch has been forced to request security escorts from the military, federal police, and regional police forces to make its life-saving deliveries.
“EPSS has been serving the people for the last 75 years without any political involvement whatsoever,” said Zemen. “Frankly speaking we had no interest in our vehicles getting escorted. Our outlook is that even those who blockade roads deserve access to medicine. Our work is like that of the Red Cross, and our vehicles should be treated as those of a humanitarian organization. But this isn’t what we’ve experienced. This is where we’re facing a challenge.”
He revealed there have been incidents where EPSS vehicles are commandeered and destroyed, including a recent one that saw one of only 19 refrigerated vaccine transport vehicles in the country burned to the ground.
“It would have been better if they’d burned down four or even five of our regular vehicles,” said Zemen. “[Burning] That one comes with a huge unquantifiable cost to human life.“
Henok told The Reporter about the lengths the EPSS staff must go to to deliver medicine in nearby Gelan.
“Between Keleltu and Tore is only a seven kilometer distance; it’s such a short trip,” he said. “But our delivery vehicles can’t make the trip alone. Security and police escort us in and out of the place.”
Henok says there are places where the Hawassa branch suppliers do not dare to enter without security.
“Some areas we simply can’t dare to defy the odds and try to enter,” Henok said. “In those places, we inform the woreda officials to send their people to come to the nearest rendezvous and take the medicines. We then hand over the supply and give them the fuel they need to get back.”
He disclosed one such place is a woreda located 30 kilometers from Bule Hora, which lies on the highway to Moyale. Henoke refrained from naming the woreda.
Zemen warns of the lasting effects the security problems will have on the healthcare system, citing TB as an example.
“Discontinued use of TB medication is very dangerous and sensitive. It has a massive impact on public health. A patient getting off TB medication could not only develop a multidrug resistant variant of the disease, but in time would also put everyone around at risk, creating a very complicated public health issue,” he cautioned.
But security and shortages are not the only concerns weighing down the EPSS Hawassa branch, as the capacity and effectiveness of the pharmaceutical supply chain on the woreda level continues to pose their own challenges.
Woredas are designated to receive and re-supply (to health centers) crucial medications and vaccines distributed by EPSS as part of various state-run health programs.
But, these woreda offices are neither furnished with the resources to oversee cold chain supply, nor do they have the necessary infrastructure to be able to carry out timely and efficient deliveries to the health centers who requested the supplies from EPSS in the first place, say experts at the EPSS Hawassa branch.
“The only work done in woredas is that of administration and management, all medical services are given at health centers. The working tradition of transporting and storing medications and vaccines in zones and woredas must be eliminated. It adds no value,” said Zemen.
He told The Reporter quality and safety shortfalls in vaccine distribution at the woreda level are exacerbating a new wave of pandemics.
“In the south, especially in Sidama, there is a fresh measles pandemic spreading,” said Zemen. “If we were to investigate why this is happening, one of the main contributing factors would definitely be the poor management of our cold chain system.”
Zemen also blames the shortcomings in woreda cold chain management for the recent surge in TB and malaria cases in areas that are under the purview of the EPSS Hawassa branch.
During a meeting on Thursday, participants from the branch repeatedly underscored the necessity of keeping vaccines at a temperature recommended by manufacturers to ensure effectiveness. They also decried the lack of crucial generators and refrigerators, alleging it has spoiled large numbers of vaccine doses.
“We take the medicines to these ill-equipped woredas and hand them out, with our support going as far as exchanging the ice packs we take with us with theirs, so that in the case of a power outage they would have a little more time, enabling them to maintain the medicine’s efficacy,” said Zemen. “However, vaccines are often spoiled or ineffective by the time they reach the public.”
He told The Reporter the improper handling of vaccines is part of the health crisis brewing in 131 health centers that depend on his branch for supply.
However, senior health officials in the region deny there are problems in cold chain supply management.
Endalkachew , director disease prevention at the Sidama Health Bureau, refutes the claims put forward by Zemen and his colleagues, saying his office has introduced failsafes to prevent the public health crises alluded to by EPSS officials.
He told The Reporter that all woredas are equipped with refrigerators that can maintain freezing temperatures for up to three days without power, and that some are also equipped with solar power systems.
“I don’t know whether what the EPSS branch says is true in other regions or not, but there aren’t any such incidents in Sidama,” said the Director.
He did, however, concede there is an alarming surge in TB transmission rates in the regional state, particularly in Gedeo, Guji, and Arsi Negele.
Bureau data shows TB detection rates in the region had grown from 72 percent in 2019, to 150 percent by the end of 2023.
Zemen also accused woreda health officers of enacting a re-reationing of medicine distribution without a mandate after taking delivery of supplies from EPSS.
Endalkachew refused to comment on the allegations.
Solomon Nigussie, deputy head of inbound logistics at EPSS, corroborated reports of re-allocation and rationing of medical supplies at woredas, leading to mix-ups and shortages at health centers who do not end up receiving their initial order requests from EPSS.
EPSS supplies last-mile delivery services to 70 percent of the 1,225 health centers that reports their storage and consumption data digitally, according to Solomon. However, the remainder depend on woredas for delivery.
EPSS supplies 430 kinds of medications, 73 of which are classified as critical and 166 as basic necessities. The list also includes 43 types of cancer medications. Many of these are imported from India and China.
EPSS relies on international donors for more than three-quarters of the funding needed to procure these medications, and costs for the remaining 23 percent are covered by a revolving state fund.
EPPS data indicates the supplier has more than 1.7 billion birr in outstanding receivables with health centers around the country. Its Hawassa branch alone has yet to receive payment for more than 180 million birr worth of medicines supplied to health centers in Hawassa, Negele Borena, and Arba Minch, in addition to dozens of other areas.
Zemen, head of the Hawassa branch, calls for an urgent revision of the EPSS establishment proclamation in order to build a new financing system for pharmaceutical supply, which he says is unsustainable.
“One of our most critical survival issues lies in the challenges we are now facing in our attempts to collect on the credit,” he said. “We’re placed into such tension as salary day approaches each month. We don’t have the money. It’s a wonder how we’re surviving,” Zemen told The Reporter.
Payroll and overtime expenses for the EPSS Hawassa branch clock in at 1.1 million birr a month.
EPSS officials say neither the federal government nor regional administrations are paying salaries, while officials at the Ministry of Health are reportedly instructing the supplier to continue distributing medicines to health centers that already owe it money.
“Even when we refuse, the Ministry forces us to provide additional medicines to those who do not pay us back, in an effort to make sure medicine shortages do not affect the public,” said Zemen. “But, if we keep going like this, sooner or later we might reach a point where we simply can’t buy any medicine or medical supplies because we can’t afford them.”
Zemen wants the federal government to cover the salaries of EPSS employees, and for the Ministry of Health to allow the agency to collect what it is owed from health centers. But, most of all, Zemen says he wants to see a revised proclamation that puts a strong medical supplies finance system in place.