When responsibility is fixed; systems are in place, how do you explain a scarcity of life-saving anti-tuberculosis drugs? You don't.
While we were busy, and rightly so, with the Uttarakhand floods and the
extensive damage it had caused, a public health emergency crept up on us
in the dead of the night. Well, not exactly the dead of the night,
because, certainly a few people saw it coming.
Suddenly, it seemed the country had run out of stocks of crucial
anti–tuberculosis drugs. Two key drugs in the anti-tuberculosis
cocktail: Streptomycin and Rifampicin, were in short supply. Alarmingly
so. For the health of not only the patients, but also the community.
But, we’ll come to that, in just a bit.
Citizens and activists took up a campaign both online and offline,
building a people’s movement, urging the government to act. Online, they
called for signatures on the petition:
“We urge you to take immediate steps to address India’s repeated
shortages of tuberculosis medicines. Despite clear warnings about
impending drug stock-outs, the Ministry of Health and Revised National
Tuberculosis Control Programme are failing to act with the urgency and
transparency needed to address the crisis. As a result, health centres
may run out of first line, second line, and pediatric tuberculosis
medicines. We urge you to intervene so that immediate measures are taken
to restore supplies of these life-saving drugs.” This group,
which held a public rally in Delhi last Wednesday to gather more grist
for their mill, also debunked the Health Minister’s claim that there was
no shortage:
“ It is totally untrue because we know children are not getting
drugs, 1st and 2nd line drugs are also in danger of running out
shortly.”
They also made mince meat of the WHO India head’s statement that there was only a “dip” in the supply of these drugs:
“… is a statement that is not true. Just the day before we
received a mail from WHO India giving us a clear picture. She[WHO India
head] and Dr. Mario Raviglione were CCed on that mail which said,
“There is stock out of pediatric TB drugs, rifampicin 150 and streptomycin.
No stock out of first line drugs, but the existing stock will dry out in 3-4 months
2nd line –There is no stock out.”
The bulk of the TB treatment programme in the country is run via the
public healthcare delivery systems, primarily routed through the Revised
National Tuberculosis Programme. The RNTCP, swearing by the Directly
Observed Treatment Short Course (DOTS) therapy, dispenses boxes of
potent drug cocktails of varying protocols for patients at various
stages of TB infection and treatment.
Ergo, the bulk of all anti tubercular drugs procurement in India is in the public sector, and by a single agency - the Central TB Division (CTD).
Drugs thus procured are then distributed to the different states, and
thereon to the providers, from where it is passed on to the patients.
RNTCP even has a detailed manual on Drug Procurment, Distribution and
Storage for the country.
These drugs are life-saving, definitely, when taken according to the
prescribed regimen. Deadly, literally. However, that is not all. If not
taken in adherence to the protocols specified by the medical
practitioner, they do not merely impede cure, but also facilitate the
creation of strains of bacteria that are resistant to known drugs. These
resistant strains of bacteria infect others who then have to negotiate a
more deadly form of the Tubercule bacillus right from the beginning,
making their course of treatment not only longer, but also more complex. Drug resistant conditions are famous for frustrating attempts at cure, and increasing mortality rates.
But here we go: One central procurement agency . From the point
of view of maintaining uniform standards across the country, it works.
Beautifully. But, there in is the inherent loophole: once procurement
goes wrong or is delayed, there is the gaping possibility that the
entire programme can go off the rails. And now, not merely a
possibility, but also the eventuality.
You might have heard this if you have your ear to the wall; We only got
this way because the CRD did not quite pay attention to procurement of
drugs/placing orders. Experts say sometimes the process of procurement
and distribution can take as many as 12-16 months.
Experts have been hinting to the government for a while now that the
procurement system needed a serious dekho. And, while we waited for some
one to do something about this, the shortage was up on us already.
Surprise. Surprise.
So you have to take your drugs without a break, in the dosage recommended. Only, there are no drugs.
But that was not the only kind of shortage in the market this time
around. There was also a genuine shortage of drugs, because of problems
in the manufacturing process itself, going by market gossip. Apparently,
there was a hitch in sourcing some raw material from Japan after the
earthquake and tsunami.
Supply Chain Management
Drugs, after all, do have an expiry date, and hoarding for a rainy day
is never quite the wise thing to do. However, it is possible to look at
diminishing stocks, especially when the empty shelves are not filled up
with drug boxes soon enough. It is possible to use simple SCM
applications to manage drug positions and stocks and engineer the
software to trigger an alert when dangerously low margins are reached.
All kinds and manner of logistics and warehousing companies use them
everyday, managing stock positions on the mobile phone.
It’s nice to be on the grid, but when the grid has failed, it pays to
have a Plan B, and a Plan C. Something that the Tamil Nadu government
reportedly did, not app wise, but offline. To surmount the problem of a
deficient supply, they went in for local purchase of the drugs. They
also used the loose drugs that were being scraped together and sent down
by the Centre, cobbling together the recommended dosage individually
for each patient. In anticipation of an impending shortage of paediatric
drugs, State TB officials have prepped themselves with standing
instructions to buy locally in the market the moment they sense a
shortage around the corner.
Despite several years of running the RNTCP, it is annoying that the CTD, whose only raison d’etre is to fight TB in this country, is not coughing up right. To cover a deficiency with denials is like shooting yourself, with a pistol in the mouth. Who are you fooling? The most wily Mycobacterium tuberculosis?
Source: http://to.ly/maNx
