In April this year, a number of staff at the national referral hospital in Thimphu found something wrong with the medical gloves. The latex gloves were not easy to wear and tore easily.
This meant risk. Then came similar complaints from health centres outside Thimphu.
In fact, the Haa District Hospital lodged a written complaint to the health ministry’s Department of Medical Supplies and Health Infrastructure (DoMSHI). The staff complained that some gloves contained foreign materials like hair, while others were not sealed properly.
A few had blood-like stains on them even.
Eventually, the supplier was asked to replace a huge consignment of medical gloves, some two hundred thousand pairs.
What was wrong with the gloves?
A health official at the national referral hospital said medical gloves should be a little thick, easy to wear, and should contain a modicum of powder inside. However, the gloves did not appear sterile and tore a tad too easily. Health officials soon raised questions about how the supply passed the quality check.
A surgeon at the national referral hospital said the gloves could not be used in surgery since they tore easily. He said simple medical devices like latex gloves play an important role in controlling infection.
Without sterile gloves, there could be illnesses and deaths from cross-contamination.
The gloves were supplied between 2018 and 2019, and about 726,332 pairs of three types of gloves worth Nu 4.7 million were distributed to various health centres. The supplier replaced about 200,000 pairs of gloves in May and June this year.
The director general of DoMSHI, Sonam Dawa, said the problem was noticed after the gloves were distributed to the health centres. Based on the various complaints, DoMSHI officials verified the samples and found that some gloves were indeed of inferior quality.
Quizzically, however, the tests showed that the gloves were sterile and did not have bloodstains.
A procurement officer with DoMSHI, Dorji Phuntsho, said the department immediately informed the health centres to refrain from using the gloves if they were not properly sealed, contained foreign materials or had any other defect. They were instructed to set aside such gloves for replacement at the end of the year.
DoMSHI’s chief procurement officer, Rudra Mani Dhimal, said the department had a tolerance level for defective products, both in terms of quantity and the kind of defect.
“In the case of the gloves, about 27 percent had some kind of defect, so we asked the supplier for replacement,” he said.
Rudra Mani said the gloves were not recalled immediately since doing so could have affected the service at health centres.
The department, however, makes immediate recall if it involves medicines or drugs.
The glove supplier is now barred from participating in tenders for the supply of the same, and the manufacturer has been told that Bhutan would not purchase any of its products henceforth.
Suppliers’ side of the story
Gloves are supplied in huge quantity, in truckloads. Since it is impossible to monitor each pair, random checks are carried out. The department officials said the random check did not reveal any defect.
Generally, local suppliers first order samples from the manufacturers, and most times samples are good. But then when the products arrive in bulk there are always cases of inferior quality goods included in the supply.
The supplier, UTL Pharmaceuticals and Medical Supplies claimed that his company had a good record until the glove incident. He said the medical equipment he had supplied earlier from Japan, UK, and the USA were good. “Gloves were a huge loss to me,” he said. “My counterpart in India supplied the poor quality gloves.”
Suppliers say they are at the mercy of their counterparts abroad since each and every item has to be imported. Despite this, most imports do meet the ministry’s quality check. Health officials say it is the consumables with short life span that are mostly prone to manufacturing defects or breakage. Poor or wrong packaging also leads to wastage. A poorly packaged consumable fails to sterilize even it doesn’t have any real defect.
DoMSHI’s Sonam Dawa said there were incidences of poor quality products in the past that they had to reject right at the entry point in Phuentsholing.
In case of the neonates’ death in the Neonatal Intensive Care Unit (NICU) at the national referral hospital because of bacterial infection outbreak last year, Royal Centre for Disease Control’s investigation found that the hypochlorite solution used in the hospital had only five percent of active chlorine against the required 30 percent.
The chlorine solution used for cleaning, or disinfecting, the hospital was recalled.
Health officials say there is no way the end user can gauge the quality of consumables like the disinfection solution. Technical assistance and lab tests are required.
Who are the suppliers?
The country currently has 153 registered medical suppliers. However, all the registered suppliers do not automatically participate in tenders. The suppliers must renew their certificates every three years and those who do not renew are automatically deregistered. This means the number of suppliers changes every year. Those suppliers who do not participate in annual tenders for three consecutive years are not re-registered.
Some suppliers Kuensel talked to say there are many challenges in medical procurement. The biggest threat is the system’s vulnerability to corruption since medical procurement involves huge amount of money.
Bhutan doesn’t produce anything. This means every single item, from the tiny syringe to the huge MRI (magnetic resonance imaging) machine, has to be procured from abroad. This not only adds cost but also leaves room for malpractices in the supply chain.
Sometimes foreign suppliers send inferior quality products that are rejected by the Medical Supplies Distribution Division (MSDD) in Phuentsholing. Their local counterparts have to transport it back to the point of origin, and this often results in huge loss of time and resources for all the parties involved.
Prone to corrupt practices
Health procurement is technically complex and involves many individuals with different expertise.
Bhutan’s health sector gets its medical supplies through Bhutanese suppliers since the finance ministry’s procurement rules and regulations does not allow direct procurement from the manufacturer.
Rudra Mani said there was inherent vulnerability in the supply chain since the country is totally dependent on suppliers from abroad. Except for traditional medicines, the country doesn’t produce any drug.
The supply chain is multi-layered, and this means each actor factors in his or her margin. This adds to the cost and things become expensive. As a result, the health ministry ends up paying substantially more for the same good that could have been way cheaper in India.
On the top, there is no way to monitor the quality of the product at the point of manufacture. Most quality check is done after the goods are delivered at the MSDD in Phuentsholing.
For example, when an MRI machine at the JDWNRH had to be upgraded recently, technicians came from the US. This means loss of time and discontinuation of the service.
The other big challenge is the lack of technical capacity of local medical suppliers. Many are new to the business and do have adequate knowledge of the system or the process. An observer said a lot of them are in just for the fat commission.
Sonam Dawa said Bhutanese suppliers did not engage seasoned medical equipment technicians in the process and a majority of them were not able to provide after-sales service when the equipment breaks down.
“If something breaks down, experts have to be brought in from the manufacturers outside,” he said, adding that availing spare parts was altogether a different challenge.
Such vulnerabilities have led to incidences of corruption in the past.
One such incident surfaced in 2009 when an equipment supplier sponsored a trip to Germany and China for the members of the tender committee. The company had allegedly bribed the officials.
In the Germany’s case, some officials involved were acquitted by the high court. Others were suspended after investigations revealed they had disproportionate assets. Some were accused of conflict of interest in awarding the contract and some were booked for lapses on quality inspection.
There are also systematic lapses, health officials say. For example, medical supply involves a closed list and there is no competition. The bigger caveat is allowing only Bhutanese suppliers (who have no technical capacity and knowledge) to participate in tenders.
“Bhutanese suppliers are basically middlemen,” said the official. “They just keep their cut and supply whatever their counterparts send.”
Most suppliers do not travel to verify or see the supplies for themselves even if the manufacturers are based next door in India.
“We are not in the most ideal situation when it comes to medical procurement,” said the official. “It’s challenges versus the necessity.”
When rules defeat the purpose
The government’s procurement rules do not allow the ministry to go for direct procurement from manufacturers. Procurement officials are not allowed to negotiate directly. And there are other challenges in direct procurement.
Further, manufacturing companies also do not encourage suppliers to come directly to them because of the small quantity. The companies instead encourage middlemen for their own convenience.
“When we contact them directly, they ask us to contact their agent in Bhutan,” an official said. “And we are trying to avoid the agent system here.”
Procurement of sophisticated health equipment is highly technical. This means people involved in the procurement process must have decent knowledge about functionality, safety, and laboratory analysis.
The purpose of the procurement rules and regulations is to get the best value for money. However, whether this objective is being met remains a question with the very many underlying challenges. It’s a no-win situation simply because of lack of competition in the market, because of monopoly, because of the scale involved, and because of the absence of local manufacturers.
Procurement is a suspicious sector.
There is a common belief that procurement almost always involves bribery, and people openly express their lack of trust in procurement officials. This means direct purchases negotiated by procurement officials could come under the public scanner.
After the investigation in 2009, the post of the chief procurement officer under Drugs, Vaccine and Equipment Division remained vacant for about two years. There were no applicants despite the announcement of the vacancy a number of times.
“There is a dichotomy here,” said a health official. “On one hand, you want to ensure transparency and follow the rules, and on the other, you want to reduce corruption by not directly involving procurement officials in the supply chain.”
Officials say there are inherent challenges in health procurement, and this perhaps requires looking beyond mere rules and regulations. They say other areas of the sector should also be improved and streamlined. For example, willful or careless wastage could be monitored more stringently. The idea of fixing accountability could be strengthened.
An allied health professional, during the recent high-level committee meeting at the health ministry, said maintenance of medical equipment is a major concern as the sector lacks skilled technical people.
“Do we really want to go for the lowest price or go for specific brands that have proven quality and lifespan?” he asked. “This would help cut down lots of recurring cost. Otherwise, we keep on procuring the same equipment every year.”
The best starting point, officials point out, would be to encourage Bhutanese to manufacture simple medical devices like the kidney dash, dressing trays, and forceps.
This, they say, could be the beginning of the much-needed reform in the country’s health sector.
This story is supported by Bhutan Media Foundation