Malawi: Of essential drug stock-outs, gluttony and garbage in, garbage out

Foreword:

“As many of my colleagues in here may remember, this drug shortage was foreseen during a stakeholders meeting in October last year. But when one raised this, was perceived as an opposition agent and no action could be taken then http://www.zodiakmalawi.com/index.php?option=com_content&view=article&id=6396:acute-drug-shortage-state-neglegence-to-blame&catid=42:banner-stories&Itemid=102 .”

“It’s a shame and we can do better. For us who run the health service on the front line, it’s very painful. It was total negligence on behalf of government to reach this situation where there was no back up for any fall up,” Dr Ronald Mataya from Kamuzu Central Hospital, civic educating President Dr. Joyce Banda http://www.bnltimes.com/index.php/daily-times/headlines/national/13680-remove-agents-doctors-tells-jb .

One of my teacher’s favourite maxims was: ‘failing to prepare is preparing to fail’. As a youth, I never liked the connotations of this adage.

The President responding to issues during the meeting with doctors and health officials on drug crisis

The President responding to issues during the meeting with doctors and health officials on drug crisis

Today, I guess President Dr. Joyce Banda and Peoples Party (PP) would not http://www.bnltimes.com/index.php/daily-times/headlines/national/13650-medical-stores-runs-out-of-drugs want to hear this axiom either – in the light of the alarming and seemingly unforeseen shortage of essential drugs.President Dr. Joyce Banda and her team would find this axiom revolting because unlike other fiascos that this government has ‘successfully’ incriminated the former Democratic Progressive Party (DPP) government on, no-one but her administration is answerable for the current drug crisis.

The 2012/13 budget, 100% PP’s baby:

For a start, President Dr. Joyce Banda did not inherit the 2012/13 budget. And, it is essentially in this budget that the government should have factored enough funds, lacking which, a timely appeal to the ‘almighty’ donors should have been made – before the situation got out of hand.

Having failed to do this the Dr. Joyce Banda administration succeeded in its preparations to fail the nation.

Vague policies on government plans and budgets:

This article essentially revolves around two documents, viz.:

Reviewing the key note address which ought to have been the fountain of all good things, and looking at the budget preparation, compilation and approval process in retrospect; reveals that our parliamentarians equally share the blame for passing an inherently flawed budget.

It is for this reason that the nation is eagerly waiting to see how they will absolve themselves at the forthcoming Mid-term Review session

But still, this does not clear the executive for the fiasco because our parliamentarians’ policy analysis skills have never, to my knowledge, been commended.

Excerpts from the State of the Nation Address and Budget Statement 2012/13:

On Public Health (page 17):

“A healthy nation is essential for the development of a country. As such, Government continues to put a lot of effort in improving the health sector. In 2011/2012 fiscal year, a Health Sector Strategic Plan for 2011-2016 was developed and is now being implemented. Strategic focus areas include: human resource development and retention; strengthening supply chain management for essential drugs and medical supplies; and construction, rehabilitation and maintenance of health infrastructure.

…Mr. Speaker, Sir, in 2012/2013 fiscal year, Government plans to:-

  • construct 11 health centres and      140 staff houses in difficult-to-reach areas popularly known as Umoyo      houses;
  • rehabilitate Kasungu and      Chitipa hospitals and 23 laboratories throughout the country; and
  • establish a Public Health      Institute to strengthen governance and stewardship of the health sector.”

As can be seen, save for the reference to previous year’s “strengthening supply chain management for essential drugs and medical supplies”, the State of the Nation address delivered on Friday 18th May 2012 in Lilongwe, was devoid of concrete commitments to procure medicines in 2012/13 http://wiseonefromtheeast.blog.com/?attachment_id=373 .

It is therefore not surprising to learn that when a patriotic doctor raised the issued way back in October 2011, he was deemed to be an opposition agent trying to spoil the party and the plea was not even considered.

This oversight was partially (but not wholly) addressed in the Budget Statement presented on Friday 8th June 2012 by the Minister of Finance. The budget statement, on page 41, specifically committed http://wiseonefromtheeast.blog.com/?attachment_id=374:

  • K1.6 billion for purchase of drugs for central and referral      hospitals, and
  • K3.4 billion for district hospitals and health centres;

hence, a total of K5.0 billion worth of drugs for Malawi’s 14 million people, translating into a nominal provision of K357 per person.

Dividing this by 365 days, shows that each of Malawian had, on average, a provision of 98 tambala per day to buy medicine.

Which is not bad at all for a country infested with malaria parasite carrying mosquitoes; where the majority of the people share drinking water with wild animals and where HIV prevalence is a matter of concern.

As to:

  • how many aspirins 98 tambala can buy,
  • how many pills for malaria treatment 98 tambala can purchase,
  • how many doses of antibiotics 98 tambala could procure, and
  • how many sachets of Thanzi ORS 98 tambala can fetch,

I will leave to you to calculate.

But that is it: 98 tambala per day per person is what is in the national budget 2012/13 and we are now being told that this crisis was incubated by DPP.

If the crisis was indeed manufactured by the DPP, what was the president alluding to when she said:

In 2011/2012 fiscal year, a Health Sector Strategic Plan for 2011-2016 was developed and is now being implemented. Strategic focus areas include: human resource development and retention; strengthening supply chain management for essential drugs and medical supplies; and construction, rehabilitation and maintenance of health infrastructure?

The DPP, it appears from the State of the Nation Address, had put in place some sort of framework, and all that the PP needed to do was to pay attention to the detail. And this, coming from someone – like me – who was not exactly mesmerized by DPP’s policies, President Dr. Joyce Banda should have another think!

On Agriculture and food security:

Moving on, flipping the pages of the State of the Nation Address back to page 9, the president, made a strong commitment to maintain the FISP programme:

“In the 2012/2013 fiscal year, Government will implement the FISP for the eighth time at the same cost of K500 per 50kg bag of fertilizer and improved maize and legume seed. The number of beneficiaries will increase from 1.4 million to 1.5 million. Government will, as a matter of priority and urgency, explore the possibility of expanding access to farm inputs by introducing credit facilities for farm inputs to resource-poor farmers to complement FISP.

Government will streamline the implementation of the FISP to save on operational costs and will allow more private sector participation. Government believes that this will help reduce corruption and waste.”

The minister of finance, on chapter or paragraph 88 of the Budget Statement, page35, quantified the allocations, which were later quietly increased, according to a local paper. The original allocations were:

  • K40.6 billion for the procurement of fertilizers for 1.5      million farming families, and
  • K7.6 billion for the procurement of seeds for distribution.

The total initial budgetary allocation was therefore K48.2billion for roughly 1.5 million families, which translates on average to K32,133 per family; and assuming an average family size of 4.4 as per the 2008 Population and Housing Census Preliminary Report issued by the NSO in September 2008 http://unstats.un.org/unsd/demographic/sources/census/2010_PHC/Malawi/Malawi_Report.pdf , this converts to K7,303 per head.

Worth noting is the fact that: judging by the “sand-blending of fertilizer” common-place this season, there were no substantial improvements in delivery of the FISP programme operationally or transparency-wise.

To bear testimony to this fact, even the Malawi News Agency (Mana) http://www.manaonline.gov.mw/index.php/editorial/item/1375-farm-input-subsidy-programme-fisp-the-moral-question, a government mouth-piece, lamented the chaos.

Making sense of the nonsense:

There are several premises that one can expound on. The first is the evident disproportional allocation of resources: K48.2 billion for 1.5 million families’ FISP inputs vs. K5 billion worth of drugs for the entire nation, the vulnerable 1.5 million families inclusive!

The second is that it is difficult to appreciate the logic of bestowing K7,303 per head to our citizenry, in a badly managed and corruption-infested subsidy programme IF we will happily see them die of malaria, diarrhoea and pneumonia at KCH. If this makes sense to anyone, I obviously need help.

But the problem is that am using normal lens to look at the rationale. Let us, for a moment, borrow spectacles tinted with greed and it all fits together like a stamp and a letter.

When one thinks like a person bent on corruption the reasoning that influenced the allocation of K48.2 billion to FISP vs. 98 tambala per head begins to make sense.

The “logic” becomes clear because FISP is not only a fertile ground for cronyism and corruption but in the past, rewarded late president Mutharika with accolades and votes.

So there you have it: if a means to secure votes while simultaneously fattening some top dogs’ bank accounts offered itself, why would anyone bother drugs which though equally corruption-infested, donors have means of by-passing the government via by doing their own procurement?

In addition to the fact that the 2012/13 budget was crafted with self-enrichment in mind at the expense of national welfare, and that it was based on contradictory policies: e.g. giving fertilizer and seeds to people who may not live to reap what they sow due to drug shortages in hospitals; there are two other factors worth mentioning.

These are:

  1. Lack of realistic forecasting mainly due to under-estimation of      the adverse impact of the ill-advised floatation http://wiseonefromtheeast.blog.com/2013/01/16/january-17-lest-we-forget-a-chronicle-of-imf%e2%80%99s-policy-failures-%e2%80%93-the-case-of-malawi-an-aggravated-famine-and-chronic-and-severe-shortage-of-teachers/      of the Kwacha. A floated currency means that Government can no longer      accurately forecast and budget because it is difficult to foretell with      accuracy where market forces will place the Kwacha. If anyone was      wondering why President Joyce Banda’s predecessor was adamant on      devaluation – despite his not having a mint to print US$ – there you have      it. Imagine IF he had floated the Kwacha and among other things, drugs had      disappeared from hospitals, do you want to guess who would be agitating to      march?
  1. The obstinate flaw that haunts our leaders: aiming low.      Explaining this: If her predecessor was able to guarantee the availability      of nsima; one would have expected President Joyce Banda to aim a little      higher. Expressing this metaphorically, she should have aimed to put eggs,      milk, meat and honey on Malawians’ plates – to go with the nsima!

But, no, then she would not be a Malawian. The local Malawian breed has to aim low and be reminded by doctors that drugs have run out and people are dying. Talking of the doctors’ petition http://www.nyasatimes.com/2013/01/28/malawi-doctors-want-president-banda-to-intervene-on-drug-shortage-in-hospitals/ who, by the way, is the current minister of health? What is he or she paid for? Either this character should go, or President Joyce Banda has become hard of hearing – if the minister made mention of this crisis.

Underlying dynamics:

While there are several underlying factors, I will focus on the political miscues that President Joyce Banda made on assuming the high office. And, the first is that the president ignored the concept of What-You-See-Is-What-You-Get (WYSIWYG).

If the many people she retained from her predecessor’s cabinet and government failed to help him and Malawi, how could she expect something different of them?

This is her headache now because the elders, when coining the adage kamba amanyera amene wamtola knew what they were talking about.

Again, garbage in, garbage out (GIGO) seems to be another concept the president is unaware of. Although, closely related to the first, in this context it applies more to the budgeting process.

If her own policy statement (the state of the nation address) was just a sales pitch, intended to hoodwink the west that among other things, she would repeal gay laws, she should blame no-one for ending up with a budget that is not working.

If you input garbage into a system; you should naturally expect the system to churn out garbage. And this is exactly what this mess is all about.

Suggestions:

It is a badly kept secret that politicians from the ruling party benefit from the FISP more than the poor, and this explains the overnight millionaires in town. Unfortunately for the PP and its team, I think the long-term cost will outweigh the temporal benefits.

And again, having prepared to fail, President Dr Joyce Banda and her Peoples Party, should not cry foul in 2014 when voters exact their pound of flesh. My suggestions for the 2013/14 Budget are very simple.

President Dr Joyce Banda should see to it that the lot that had a hand in influencing the self-serving policy that landed her with the 2012/13 user-unfriendly budget (going by the blown state house budget) and homicidal budget (going by the unprecedented appeal by KCH medical personnel) are nowhere near the 2013/14 budgeting process.

Does President Joyce Banda need another crisis between now and 2014 as Malawi edges closer to the Tripartite Elections?

If the answer is “Yes”, then I would urge her to retain the incompetent bunch, if the answer is “No” then the ball is in her court.

Final word:

I have one final word for the policy-makers, and indeed the president.

Please do not be cheated that the day you will fall sick, circumstances, resources and time; will allow for your quick evacuation to the well-resourced hospitals of South Africa.

I could argue – if I were in the mood – that when push comes to shove, a well-stocked KCH or Queen Elizabeth Central Hospital, is just as critical to the poorest as to the president.

But rather than proceed on this line, permit me to empathize, in my own way, with the people needlessly suffering, one way or another, from a preventable drug crisis. The dead deserved better and indeed Malawi deserves better.

“I called the meeting this afternoon because since I became president in April I found a drug shortage problem in the country. I recently reshuffled my cabinet to remove the Vice President (from Health Ministry) so that there should be a minister who is fully concentrating on the affairs of the ministry,” said Preside Joyce Banda this week http://www.bnltimes.com/index.php/daily-times/headlines/national/13680-remove-agents-doctors-tells-jb , on return from a trip to South Korea and Ethiopia.

My take on this belated and lame statement: So what? This is far too little and too late Ma’am President Dr. Joyce Banda, people are eagerly counting down to May 2014!

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