TB drug shortages in Zimbabwe: A risk to adherence

Tuberculosis is one of the top ten killers in the world, according to the World Health Organisation (WHO). The infectious disease is particularly dangerous for people living with HIV and Aids.

Global leaders have made a commitment to end TB by 2030. One of the strategies for doing this is by reducing the number of new infections and ensuring adherence to medication for those infected. Zimbabwe has had a setback towards this goal. The country has been experiencing drug shortages since mid-2018.

In August 2018, early reports published in local newspapers stated that the country had been facing a shortage of TB medication since June. Some of the people interviewed reported travelling from Harare to Mwurwi, a town 100 kilometres north of Harare to get access to drugs. The Herald, one of Zimbabwe’s main dailies published that some adults were allegedly taking paediatric combinations as a way of mitigating their failure to access their regular treatments.

The Ministry of Health and Child Care released a statement in August blaming the shortfall on delayed deliveries by the regular supplier. To alleviate the scarcity, the government received assistance from non-governmental organisations whilst they waited for their delivery.

Member of Parliament for Matabeleland North, who is also the Chairperson of the parliamentary portfolio committee of Health, as well as a Member of the Country Coordination Mechanism for the Global Fund, Honorable Ruth Labode, highlighted that the government’s dependence on foreign funds for supplies contributed to an unreliable flow of drugs to the country: “We have a bankrupt government which depends on donor funding for TB and HIV/Aids drugs.” She added, “There is very little MPs can do except condemn the misrule that brought us here in the first place.”

The dailies quoted the Community Working Group on Health (CWGH) which accused the government of poor planning. The group explained that the government needed to allocate adequate foreign funds for the procurement of drugs, to ensure a sufficient supply for all healthcare centres.

Zimbabwe has been affected by foreign currency shortages since it began running on a multi-currency system. The country is using up more foreign currency than it trades in. Making it difficult to fund foreign currency payments.

Recently the country has been facing shortages of imports in fuel, medicine, and raw materials for the manufacturing of certain goods. Zimbabwe started experiencing cash shortages in 2016. To address the issue, the Reserve bank introduced bond notes, a currency which was backed by a 2million USD facility to Afriximbank. However, the bond notes only work in Zimbabwe and cannot be used to make payments outside the country.

Patients pay the price

TB drugs come in a single dose or fixed dose, where several medicines are combined in one tablet. In attempts to allay the deficit the Ministry of Health suggested that pharmacies combine single dose formulation medicines to constitute the four-drug FHZE combination. This solution meant an increased pill burden on patients.

Insert in The Herald about concern over TB drug shortage

However, this is a lesser evil when compared to the threat of developing drug resistant or multi-drug resistant TB. According to the WHO, drug resistance emerges when anti-TB medicines are used inappropriately through incorrect prescription by healthcare providers, poor quality drugs, and/or patients stopping treatment prematurely.

The shortage of drugs means that patients may stop treatment as soon as they run out of supplies. Multi-drug resistant TB can be treated by a second line of drugs. However, options for these are limited. The process takes longer and the medicines are expensive.

Constant access to recommended medication is important for TB patients’ successful treatment. TB is one of the leading killers of people living with HIV. People who are infected with HIV are 20 - 30 times more likely to develop active TB. The risk of death in co-infected individuals is twice that of HIV infected individuals without TB. They are the most likely to suffer from the shortages. Lack of access to medication may also lead to a weaker immune system making way for other opportunistic diseases. Shortage of TB medication presents serious problems for the healthcare sector.

Funding of the Zimbabwean Health System

The Ministry of Finance has for years been criticised for not prioritising local funding of the health sector. More than 50% of the health budget is foreign-funded. The situation presents a high risk for ordinary people who depend on public institutions for access to medical services.

Criticism has been levelled at the government’s failure to prioritise the funding of the health sector. Judgment has mainly been based on how little is allocated to the sector in annual budgets; only 7.7% in the 2018 national budget. In 2017, the allocation was set at 6%. Despite outcry from civil rights groups and economists, the allocations have remained relatively low over the years. Zimbabwe fails to meet the Abuja Declaration target of 15%.

Foreign currency shortages worsen the situation. Government is allocating foreign currency to critical sectors such as energy and manufacturing, while the health sector struggles to stay afloat. Amidst all the problems the Zimbabwean government is faced with, it still needs to address the drug supply issue to avoid a public health crisis.