The battle against cancer in Uganda remains grim as patients grapple with inflated prices of drugs.
The National Medical Stores (NMS) with support of top administration at the Ministry of Health continues to sell Uganda Cancer Institute (UCI) highly overpriced medicine which majority of the cancer patients can’t afford.
Uganda Cancer Institute boss Dr Jackson Orem recently expressed alarm at what he described as the “steady growth of the cancer malady in the population” with estimates showing about 800,000 cancer cases in Uganda.
In 2017, 300 new infections per 100,000 people were recorded compared to 270 per 100,000 in 2008.
This figure is expected to rise to 400 new infections per 100,000 people by 2020.
UCI further says eight of every ten children in Uganda diagnosed with cancer die.
A recent special investigation by the Auditor General indicates that unit prices charged by NMS on just a sample of 11 anti-cancer drugs in the financial year 2015/15 were “over and above the market price.”
The AG compared NMS prices with the retail market prices for the same type and brand of sampled anti-cancer drugs from two reputable pharmacies that are also prequalified suppliers to NMS.
The audit discovered that the “price of an anti-cancer Etoposide 100mg was inflated by over 419 percent and another anti-cancer, pamidronate 90mg was overpriced by 63 percent”, making it unaffordable to poor cancer patients in Uganda.
The special inquiry determined that the “overall loss calculated on the inflated process for “only 11 sampled drugs” amounted to Shs 794m.”
Officials estimate that the loss would have amounted to Shs 2.2bn if NMS had made 100 percent deliveries according to the procurement plan in just one year.
A review of the NMS Market Survey for 2015 revealed that the market price of Vincristine, which treats leukaemia, breast cancer and head and neck cancer, was Shs 33,595 per unit. But the comparison of this with the price charged by NMS revealed an over charge of Shs 88,445 per unit and a total overcharge of Shs 517m for 5,850 units supplied.
Further, analysis of the NMS price charged revealed a contradiction from the NMS’ explanation in that Vincristine supplied on February 12, 2015 batch number EO37139E was priced at Shs 122,040 – which price was charged for previous supplied units and on March 19, 2015, the price of Vincristine from the same batch number was later lowered to Shs 70,314 per unit.
This was further reduced to Shs 18,587 per unit in June 2015 in line with the retail price initially stated by UCI.
It is clear that “NMS has been overpricing the drug Vincristine since July, 2013 and there is a possibility of overpricing on other drugs and sundries,” the AG report date September 2016 observed.
The development has raised concerns about the commitment of the Health Minister Dr Ruth Aceng, her Permanent Secretary Diane Atwiine and NMS boss Moses Kamabare to quickly address the problem of high anti-cancer drugs for patients.
With majority Ugandans being poor, most of the patients can’t afford the drugs sold at high prices by NMS.
According to Innocent Atuhe, a Cancer Prevention and Care Advocate, failure to complete prescribed dosage when drugs are rationed with some patients getting half dosage is a common occurrence in public health facilities.
“This means that those that cannot afford to buy the rest of the dose from private pharmacies are most likely not to complete the dosage,” said Atuhe.
“This leads to poor treatment outcomes and poor quality of life of patients. To cancer patients, it means more pain and suffering.”
Dr Orem recently said at a function at UCI that lack of drugs was affecting the quality of care given to cancer patients who seek treatment at the facility.
The AG said in his findings that “huge price markups affect the quantities of drugs that would be supplied to UCI and in turn affects the effective treatment of patients.”
ChimpReports understands that a contracts Committee of NMS approved three-year framework contract for the supply of anticancer drugs in March 2015.
A comparison of the framework contract unit prices of sampled seven anticancer drugs with the actual unit prices charged by NMS for the same drugs revealed that significant markup of Shs 662m in prices was applied by NMS on supply of the drugs to UCI.
For example, Erlotinib (trade name Tarceva), a drug used to treat non-small cell lung cancer (NSCLC), pancreatic cancer and several other types of cancer was overpriced by Shs 11m per unit.
NMS supplied 20 units of Erlotinib to UCI, leading to a loss of Shs 220m.
This denied poor cancer patients access to the important drug which ordinarily costs Shs 1.2m.
Had UCI bought this anticancer drug at the prevailing price of Shs 1.2m per unit, the final cost met by the patient would have been lower by about 90 percent. This would mean increased accessibility, lower prices and more cancer patient lives saved.
Capecitabine (500mg tablets), which is a chemotherapy drug usually given to treat cancer of the colon, rectum, breast, stomach, pancreas and gullet goes for Shs 77,755 per unit.
However, NMS supplies Capecitabine to UCI at a staggering Shs 1.9m per unit, leading to a unit price variance of Shs 5.8m. NMS recently supplied 25 units of Capecitabine, leading to a loss of Shs 147m.
This means majority of the patients suffering from rectal, stomach, oesophageal and pancreatic cancers who are unable to buy Capecitabine from UCI had to try other means or die.
Additionally, Rituximab, which is used to treat non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukaemia (CLL), costs Shs 3.1m per unit. Yet, NMS supplies this drug at Shs 7.4m to UCI, implying a Shs 5.8m price variance per unit.
In simple terms, every unit of Rituximab, which is usually given on the first day of each cycle of chemotherapy treatment, is inflated by Shs 5.8m, making it almost impossible for majority poor Ugandan cancer patients to afford it.
Calcium folinate iv drug ordinarily costs Shs 11,000 per unit. However, NMS supplies this drug at Shs 92,000, leading to a price variance of Shs 81,186 per unit hence a loss of Shs 72m in overpricing.
For the common man, this means digging deeper in the pocket for Calcium folinate. The drug helps prevent side effects of treatment or overdose with the medicine methotrexate and similar medicines.
Calcium folinate also helps in combination with the medicine 5-flurouracil, for the treatment of certain forms of colon cancer (metastatic colorectal carcinoma).
As if this is not enough, Cisplatin, a chemotherapy drug used to treat testicular, ovarian, bladder, head and neck, and non-small cell lung cancer is inflated by NMS to Shs 107,514 from the known retail unit price of Shs 85,000. For 2,430 units supplied by NMS to UCI recently, Shs 54m was lost.
In its defence, NMS said it “conducts price surveys for drugs and sundries” it procures and “issues a report” on an annual basis.
However, the AG observed that the “unit prices eventually charged by NMS were above the prices quoted in its market surveys.”
The AG further observed that “unit prices charged by NMS of three anticancer drugs were compared to prices quoted by NMS in their annual price survey for 2016 and high variances were also noted.”
For example, NMS conducted its own price survey for L-Asparaginase, a chemotherapy drug used to treat acute lymphoblastic and established its retail unit price at Shs 30,022.
Interestingly, NMS charged UCI Shs 332,254 per unit of L-Asparaginase – marking a Shs 302,232 variance in price.
In short, NMS inflated the cost of this drug by over 100 percent.
By procuring 670 units of this drug alone from NMS, UCI lost a staggering Shs 202m.
More to this, Pamidronate, which is used to treat bone weakness or pain caused by myeloma or breast cancer that has spread to the bone (secondary bone cancer), ordinarily costs Shs 73,882 per unit. Yet, NMS sells this drug to UCI at Shs 203,785 per unit.
The AG observed that “overpricing of drugs results into reduction in the quantity of drugs that UCI receives from NMS thus negatively affecting service delivery.”
He said a detailed price analysis on all items supplied must be conducted regularly.
Atuhe says Uganda Cancer Institute uses highly specialized and very expensive drugs and therefore needs to deal directly with the cancer drug manufacturers.
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 disposal of expired drugs, the burden currently placed on UCI which spends at least Shs150m annually for the disposal.
According to the Uganda Cancer Institute Act which came into force on 12 January, 2017, the institute is an independent body. Section 4(b) of the act indicates that one of the functions of UCI is to procure medicines and supplies for treatment of cancer.
Section 5 of the Act maintains that the institute shall be independent in the performance of its functions and duties and exercise of its powers and shall not be subject to the direction or control of any person or authority except by the minister of health whose direction, if any, should be consistent in respect to the functions of the institute.
Inspite of this, procurement and supply of anti-cancer drugs are still being done by National Medical Stores, 7 months after the act coming into force.
This has resulted into shortages of the life-saving anti-cancer drugs and supplies with 2 billion meant for the procurement of the said drugs remaining unused as cancer patients suffer and die in unbearable pain in this country.
Technocrats at Uganda Cancer Institute have repeatedly made clear the fact that NMS lacks capacity to procure specialized cancer drugs.
The AG said in his asked for an explanation on the various prices of Vincristine 2mg that were supplied to UCI and a “detailed investigation on NMS prices charged made for all supplies to other institutions.”
ChimpReports understands that Kamabare was not subjected to any investigation.
The AG added: “Management of NMS should provide a satisfactory explanation on the discrepancies in process of sampled drugs. Failure to do so, they should be held liable for the above loss.”
NMS publicist Dan Kimosho said then that UCI “would consistently reject the items requesting for US-FDA approved items. NMS was left with no choice but to buy these items expensively.”
The AG called for a detailed investigation to analyse the “extent of the loss on all drugs and sundries supplied by NMS to all other government health institutions, due to over pricing.”
UCI said the AG’s result, “confirms to our findings as the institute had done an analysis of the 2014/15 and 2015/16 supplies especially for anti-cancers and found the prices to be astronomically high.”
UCI told the AG that, “Despite communicating to NMS, the trend has continued in the new financial year 2016/17.”
This would imply the new management at Health Ministry led by Aceng and Atwiine are yet to stop the alleged abuse of the resources.
Given the fact that NMS buys in bulk, it’s expected UCI would benefit from the economy of scale, that is all prices to be lower than the market price.
The situation is further complicated by the fact that there cancer diagnosis and care is limited to Kampala, meaning millions of people in rural areas can hardly find treatment.
The common cancers in Uganda are Cervical Cancer, Prostate cancer, Breast Cancer, Kaposis sarcoma, Burkitt’s lymphoma, lung cancer, skin cancer, Cancer of the bone, cancer of the eye, Cancer of the colon, and cancer of the throat.