GAC’s Procurement, Distribution Audit Reveals How Liberia’s Health System Runs on Limited, Expired Drugs
MONROVIA – A performance audit on the Adequate Procurement and Distribution of Medical Suppliers/Drugs in Liberia for the fiscal years ended June 30, 2017, to June 30, 2019, tabled at the National Legislature on June 16, 2022, by the General Auditing Commission has revealed that the procurement and distribution of medical supplies by the Ministry of Health (MOH) is woefully inadequate to meet the medical needs of Liberia. According to the GAC report, the performance audit was motivated by consistent and persistent reports in FrontPageAfrica Newspaper and other local media about the lack of medical supplies /drugs in health facilities around the country.
Authorities at the MOH informed the GAC that the target set for Procurement and Distribution of Medical Supplies/Drugs has always been around Sixteen to Twenty Million United States Dollars yearly to address the national needs for medical supplies/drugs. For three fiscal years during the audit period, the Government of Liberia spent US$4,070,732 to purchase drugs/medical supplies.
Donor partners contributed a whooping US$29,765,932.95 for the purchase and distribution of medical supplies for the three fiscal years. This means that Liberia spent US$33,835,932.95 for the procurement and distribution of medical supplies, thereby resulting in a funding gap of US(60,000,000 – 33,835,932.95 ) US$26,164,067.05.
The GAC noted from the review of contract documents that procurement was not done in sixty days as stated in the contract documents. For example, the audit found that procurement of medical supplies/drugs should have been completed by March 2017, instead; there were two addenda made to extend the time of procurement. The original price of this contract was USD $745,486.66. The first Addendum was June 27, 2017 increasing the original price to USD $1,682,290.07 while the second addendum on October 27, 2017 increased by USD $358,330.00 totaling the expected payment for the contract to USD $2,040,620.07. All these addenda occurred while the contract was still in its implementation stage. Due to the late allotment of funds to the Ministry of Heath by the Government of Liberia, the procurement of these drugs & pharmaceutical products did not meet up with the earlier time frame slated in the contract; thereby causing medical facilities to go out of medical supplies/drugs. Meanwhile, the Ministry of Health did not provide contract documents for the procurement and distribution of medical supplies to the GAC for the fiscal years 2017/18 and 2018/2019, the report said.
The GAC review of documents further showed that 102 data clerks were trained and assigned in the counties at health facilities. However, during the field visit to the four counties in January 2020, auditors did not see any data clerk assigned in the counties, nor did they receive reports on these Data Clerks’ activities. The GAC findings further showed that those medical facilities were not capturing the actual usage of drugs supplied and dispensed on a timely basis which led to incorrect data during the reporting period on drugs supplied and dispensed.
The GAC interviews with 44 key players (CHOs, OICs, Dispensers, and Pharmacists) at health facilities in the four counties, showed that there were limited medical supplies/drugs at their facilities due to transportation problems, bad conditions, and funding constraints. During the site visitation, the GAC observed that essential drugs such as Amoxicillin, Penicillin, Mebendazole, Niclosamide, Paracetamol, Ibuprofen, Phenytoin, Metronidazole, Quinine, Artemether, Doxycycline, Folic Acid, Cestraxone, and Cripo that are greatly needed t in health facilities were in limited supply in facilities such as; Well Babyma, St. John, Owengrove in Grand Bassa County; C. H. Rennie, Gbaye Town facility, and Larkayta health center in Margibi County; Gonzipo medical center,Zordee, and Malama facility, Liberia Government Hospital and Dagweh Town facility in Bomi County.
Due to the absence of these medical supplies; doctors, pharmacists and nurses were constrained to make prescriptions for patients.
Empty shelves at health facilities store rooms in Bomi County, January 2020
GAC interviews conducted with key players namely; (OICs, Pharmacists, Dispensers, Directors and Ministers) at the Ministry of Health and other health facilities, revealed that the distribution of medical supplies should be done on a quarterly basis (every 3 months). However, the GAC reviewed waybills/supply logs of health facilities and noted that delivery of supplies was done in four to five months or beyond after previous distribution.
Additionally, during interviews conducted with thirty-four (34) key players by the GAC, twenty-one (21) stated their facilities received supplies on a quarterly basis. However, the GAC review of logs (Waybills & requisition forms); revealed that medical supplies were distributed and received after four to five months. Thirteen (13) stated they received supplies not on a quarterly basis, meaning after distribution, it takes a period of four to five months plus, before they are supplied by the Ministry of Health due to bad roads, logistic problems and funding constraints. This situation, the report stated led to the Ministry of Health not distributing drugs/supplies on a timely basis; leaving health facilities (Hospitals, Medical Centres and Clinics) constrained to let patients go without drugs.
The GAC audit revealed that verification during January 2020, that auditors identified expired drugs at Margibi County and Grand Bassa County Depots. In addition, from reports reviewed by the GAC, drugs such as AB Bott m. sample- 224 cartons – exp. April 6,2019, Acid phosphatase- 46 cartons –exp. April 19,2019, Prednsolone 5mg -5,376 cartons –exp. March 19,2019, Artemether injection 80mg -3,540 cartons- exp. April 19, 2019, PIMA CD4- 180 cartons expired March 1, 2019 were found at health facilities.
Central Medical Store June to July 2019 expired commodities report revealed that while distributing the 12th Round Last-Mile Drugs to Bomi County, they experienced expired drugs during the offloading of these supplies. In addition, the GAC identified expired drugs at Margibi County and Grand Bassa County Depots.
The existence of expired drugs at Central Medical Store and County depots is the result of not conducting an effective and timely comprehensive inventory and the First Expire, First Out (FEFO) principle at Central Medical Store (CMS), depots, and storerooms of health facilities, according to the report. Consequently, the GAC said medical supplies/drugs expired unknowingly to health facilities when it should have been used before the expiration date, causing loss of resources and inadequate medical supplies at health facilities.
Expired drugs at health facilities visited January 2020
The GAC review of medical supplies request logs and supply logs, noted that the quantity of medical supplies requested and received at health facilities through Central Medical Store were often not consistent. The report said there were instances in which quantities requested by health facilities were reduced by Central Medical Store during delivery as drugs commonly used were requested for but were not supplied and were instead replaced by drugs not requested due to what the Central Medicine Store had available at that time.
However, Requisition (SSRR) & Stock status reports, waybill & Internal Requisition and emergency Order Form(EOF), reviewed from facilities visited, indicated that medical supplies distributed at health facilities were not in line with the quantity and specification requested by health facilities due to limited quantity and specification available at the Central Medical Store/county depot. As a result, the GAC said facilities were out of needed medical supplies/drugs for days and months, therefore, medical practitioners gave prescriptions for unavailable drugs to patients to buy in drug stores until drugs are available for distribution.
In addition, interviews were conducted with 44 key players (three (3) County Health Officers (CHOs), twenty-one (21) Officer in Charge (OICs), four (4) Pharmacists, and nine (9) dispensers); 31 persons constituting 70% confirmed that supplies were not done in line with quantity and specification requested, while 13 persons constituting 30% said they received supplies in line with quantity and specification requested, the report added.
According to interviews conducted with key players at Ministry of Health head office “at the county level (County Health Officers, Officers In Charge, Dispensers and Pharmacists) the regional or county depots that served as extension of the Central Medical Store/National Drug Service have inappropriate storage facilities for medical supplies/drugs. This problem has led to the use of sub-storage, such as small rooms, and corridors. This situation is further worsened by the fact that there are interrupted power supplies in most facilities, and no county has adequate cold chain accommodation.
Dilapidated storage facilities; Sassa Town Clinic showing damaged and leaking roof while in Tubmanburg, Bomi County, the County Depot showed damaged Air condition and refrigerators. Jan 2020
During the site visit by the GAC, it was observed that facilities store rooms, depots and dispensaries are not in good condition to give medicine/drugs the right temperature. Some had windows and doors (string door) opened to warm air and heat due to a lack of consistent power supply, while others had a leaking roof which lead to the impotency and short lifespan of medical supplies/drugs.
Therefore, the GAC has recommended the following to the Ministry of Health to address the shortish of medical supplies/drugs in medical facilities and clinics around the country:
The Ministry of Health should ensure that the procurement of medical supplies is carried out on a quarterly basis as stated in the Ministry’s standard operating procedures (SOP) to meet the medical needs of the citizens.
The Government of Liberia should put in place a mechanism that will facilitate the timely provision of funds for the procurement and distribution of medical supplies.
The Ministry of Health should ensure that Data Clerks are assigned to health facilities to gather proper information on the quantification and specification of drugs received and dispensed. Official periodic reports on these activities should be presented to the relevant authorities and filed accordingly.
The Ministry of Health should ensure that personnel assigned at Central Medical Store are trained and qualified in the requirements of product identification, the detection and the avoidance of counterfeit/expired medical supplies/drugs entering the supply chain. Evidence of training should be documented and filed accordingly.
The Ministry of Health should ensure that drugs are made available on a quarterly basis to all health facilities.
Medical supplies/drugs should be transported in accordance with procedures such that:
• The identity of the product is not lost.
• The product does not contaminate and much not be contaminated by other products.
• Adequate precautions are taken against spillage, breakage, misappropriation, theft, and inappropriate environmental condition.
The Ministry of Health should ensure that regular (monthly or biannual) physical inventory (FEFO) is taken to avoid the distribution of expired drugs and records should show observations made during the inventory and, where applicable, proposals for corrective measures.
There should be an effective follow-up program to evaluate and monitor the inventory report and the records of any corrective actions taken.
Central Medical Store/county depots should ensure that Medical supplies/drugs distributed to health facilities are in line with health facilities’ requests.
The Ministry of Health should ensure that all storage at health facilities meet up with the required storage practices (be in a cold condition of 25 to 30 degree Celsius and should have refrigerated air conditioning unit with constant power supply).
Storage facilities should be of sufficient capacity to allow the orderly storage of the various categories of medical supplies/drugs namely essential and pragmatic drugs to be released earlier or later based on the expiration date.
The Ministry of Health should provide temperature monitors at all storage facilities especially in areas that are most likely to experience fluctuation of power supplied.
An assessment of national procurement and distribution system should be conducted to ensure proper coordination between the Government of Liberia and the donor community during procurement of essential and pragmatic drugs.
This process will facilitate the gathering of data by the authorities of the Ministry of Health on the quantification and specification of essential and pragmatic drugs that are needed in the various hospitals, Health Centers and clinics. During this process, the Ministry should take in to consideration the life span of the drugs to be procured, meaning drugs that are procured should be able to meet up with the distribution schedules (1st, 2nd and 3rd quarters) as indicated in the SOP.
The Ministry of Health and the donor community should give special attention to drugs that have short lifespan during procurement and distribution so that they will not expire while going through the different stages of the process as indicated in the Ministry’s response.
Approval of medical supplies/ drugs to be procured should be given on the category of products needed, the financial investment in the product, the procurement agent used by the donor, and the ensuing storage and distribution channels to streamline the medicines supply systems. This system may prevent partners and donors from over or under stating products support and the financial investment in the product donated to the country.
The authorities at the Central Medical Store should establish an automated inventory system that will automatically signal when a particular medical supply/drug is nearing expiration or has expired. This system should support the parking of the drugs in the order of FIRST EXPIRE FIRST OUT (FEFO), the report concluded.