Why patients have no drugs at Uganda Cancer Institute

When Sunday Monitor visited the cancer institute on Tuesday, patients interviewed bemoaned the erratic supply of drugs. One such patient, who declined to be named, said: “We come to Mulago expecting to get free medication but most times, we have to go to private pharmacies. If you can’t afford, the doctors ask you to wait for the drugs. This takes months,”
Dr Orem blames the suffering of cancer patients largely on NMS.

“For over three financial years (2012/13, 2013/14, 2014/15) the viscristine 2mg has been at a price of Shs122,040 per vial, which is still astronomically high as compared to the international market price of $8.66 (Shs26,660) per vial. We started receiving the South Korean vincristine on February 12, 2015…. and this was priced at Shs122,040.

The following three supplies of the same brand of vincristine supplied on March 19, 2015, April 9, 2015, and May 4, 2015 were priced at Shs70,314. The South Korean vincristine 2mg is sold at Shs13,000 at retail price and Shs8,500 at distributor price,” Dr Orem complained to the NMS general manager, Mr Moses Kamabare about the inflated prices for cancer drug on July 7, 2015.

Mr Kamabare admitted the claims of over-pricing, but countered that it was a technical error by their system, which had been detected and was being rectified to credit UCI’s account.

On June 15, Dr Orem again wrote to NMS complaining about the same problem of inflated prices for cancer drugs supplied by the NMS.

“When going over invoice number 150601-011, delivered on June 2, 2015, my pharmacy team discovered that there was an outrageous pricing for the following items compared to the market price. This means that NMS is probably overcharging UCI at a mark-up above the stated 15 per cent or there is a fraud going on with the procurement system at NMS, which calls for a quick intervention,” Dr Orem told Mr Kamabare.
However, the problem has persisted.

Sources said the UCI and NMS battle over inflated prices for cancer drugs has stifled the working relationship between the two entities to the detriment of patients who cannot access treatment.

“We have raised the red flag since 2014, but some of these people (NMS) are too connected to the “powers that be” so much that no one can bring them to order,” a source at UCI said.
According to Dr Orem’s dossier, most of the cancer drugs supplied by NMS to the cancer institute, the investigation revealed, “were priced nearly five times higher than the cost of the same drugs from private suppliers.

This implies that the government spends more money on procuring drugs from its own agency than from private suppliers.

An analysis of the NMS price list compared to the market price for Pegylated liposomal Doxorubicin indicates the NMS charged UCI Shs2,892,672 for 25 units of the drug as opposed to Sh377,000 in private pharmacies, making an excess pricing of Shs2.5m.

The UCI names a long list of cancer drugs from NMS whose prices are about five times higher than the rates on the local and international market.

However, Mr Kamabare insisted: “No money ends up in over pricing because when our system makes and detects the error, we credit their account.”

Ordinarily, NMS, which buys in bulk would have its drugs at lower pricing at 15 per cent below the market price. For example, for drug zoladex 3.6mg/Goserelin 3.6mg, a 40 per cent discount is given if you buy 120 pieces and above, which would reduce the price from Shs318,900 to Shs191,340.

How it started
The UCI and Uganda Heart Institute have been seeking to do their own drug procurement without relying on NMS. They say they deal in highly specialised drugs, so they need to deal directly with the manufacturer.

Direct dealing with the manufacturer has more benefits such as enabling the cancer institute participate in drug trials (entitling patients to free medication), the manufacturer meeting compensation in case of damage caused by drugs and paying for incineration of drugs, the burden currently placed on UCI which spends at least Shs150m annually for the disposal.

In 2015/16, UCI drug procurement budget was Shs12.5 billion, with anti-cancer drugs taking Shs9.3 billion (about 17 per cent of the total budget), but the Ministry of Finance released only Shs7 billion and NMS only bought drugs worth 51 per cent of the planned budget and monies it received from government.

In some cases, no drug was delivered at all.
A cost analysis of NMS supplies compared to the UCI annual budget indicates NMS spent Shs4.8 billion (arising from inflated prices) out of an expected Shs2.8 billion (had market rates been followed), causing a loss of Shs1.9 billion. Comparing NMS pricing to the market price, the cancer institute would save close to Shs2 billion on cancer drugs if they made their own procurement.

Late and non-delivery
Documents seen by this newspaper also reveal NMS’ failure to supply drugs on time and sometimes no supply happens at all. For instance, for Doxorubicin drug, out of 450 units expected by UCI monthly, there was no supply in September 2015, February, May and June this year. The same is true with Fluorouracil in September 2015, January, February, March, April, May and June 2016.

This means that for all these months, the patients on these drugs either had to go without treatment or had to buy from private pharmacies. Those who could not afford drugs from private pharmacies either died or their conditions deteriorated.

For instance, there was no supply for six months. The emergency created allowed NMS to purchase five times the required amount of drugs at inflated prices and justifying the same as an emergency measure to fix the gaps. But this caused avoidable wastage.

However, Mr Kamabare said: “Whenever we fail to supply drugs, UCI knows why. We have engaged them and the National Drug Authority. We have advertised and failed to get a supplier for quality cancer drugs. Cancer drugs have to be of high quality, sometimes the delay is occasioned when UCI rejects or the drug is not registered.”

Some breast cancer patients interviewed for this investigation, said they take a combinational treatment model and the erratic drug supply complicates their situation.

For instance, a pharmacist at the facility explained that to treat breast cancer, a combination of Fluorouracil, Cyclophosphamide and Doxorubicin 50mg is used. For 2015/16, out of 20 Cyclophosphamide 1000mg expected per month from NMS, there was no supply from July to November. The drug was delivered in December. From January to date, the same drug was not supplied, disrupting the treatment.

“Only 40 per cent of the institute’s anti-cancer needs have been met in the financial year 2015/16, indicating that the probability of a cancer patient finding a cancer drug at the institute is less than 50 per cent, making it impossible for UCI to efficiently manage simple cases on the basic treatment,” the UCI dossier reads in part.

Quality queries
NMS has since 2014 been accused of supplying, “substandard drugs that compromise the clinical outcome of patients.
The UCI said NMS provided cycloohosphamide 1,000mg from South Korea that couldn’t fully reconstitute. The bleomycin 15 IU from the same company couldn’t be fully withdrawn from the vial, causing under-dosing, while docetaxel supplied in 2014/15 had poor physical qualities.

The UCI says at one point in 2014, a patient reacted abnormally to a drug, compelling UCI doctors to contact the manufacturer and to their shock, the company said it had never supplied such drugs to Uganda and the last supply was to Turkey. In essence, NMS had probably bought the medicine from the black market.

“We also have evidence of substandard drugs with an authorised documentation, which is illegal as per the National Drug Policy and Authority Act 1993, because you didn’t stick to the guidelines developed for the purpose,” Dr Orem indicted NMS.
Mr Kamabare did not dispute Dr Orem’s statement, but argued that sometimes UCI specifies drugs whose price is far higher than the budget can afford and they have to stick to lower quality drugs to remain within the budget and avoid exhausting the monies on few high quality drugs.

Covert fights?
Sources at the Ministry of Health said NMS had put up a spirited fight against Section 4(g) of the UCI Bill, which allows the cancer institute to procure its own medicine. This, the UCI director said, “is our only hope now because it means we can procure our own drugs and end this back and forth.”
The Bill is now awaiting the President’s signature, but sources said NMS officials, working with some highly placed officials in the ministry, are lobbying the President not to sign the law or at least expunge this particular section.
Mr Kamabare said in reply to this claim, “The Bill doesn’t take away our procurement function in as much as it makes procurement one of the functions of UCI. I will ask the minister to interpret the law in that respect.”

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