Free public healthcare at the point of delivery often comes under scrutiny when it fails to render the service the public rightly or wrongly expects it to. The shortage of medicine is often attributed to the ‘out of stock’ phenomenon. The recent use of expired Tamiflu medicine at Mater Dei Hospital’s intensive care unit led Health Minister Chris Fearne to set up an inquiry to establish the facts relating to this incident and also to identify any potential administrative and procedural gaps.
The first conclusion of the inquiry board came as no surprise to those who know the scientific facts about the effectiveness of expired medicine. Put simply, most medicine, including Tamiflu, do not lose their effectiveness the day after their expiry date. They start to lose their potency gradually. In fact, in 2009, the much-respected US Food and Drug Administration had authorised the use of specified expired Tamiflu batches when suppliers were faced with an abnormal demand as a result of the spread of a swine flu epidemic in some countries.
With regard to the recent use of expired Tamiflu at Mater Dei, the inquiry said that “there was no active coordination and state of preparedness to avoid this incident a priori”. In layman’s terms, the medicine procurement system, as admitted by the minister himself, is bungled with ineffective bureaucracy. The inquiry concluded that “lack of visibility, active coordination and communication between the Directorate for Pharmaceutical Affairs and the central procurement and supplies unit” is an unacceptable reality.
There is no doubt that the public procurement process needs to be revamped and reengineered “to ensure reliability, accuracy, timeliness, real-time visibility, process tracking and the stock position and replenishing requirements”. The sooner this re-engineering is undertaken in the public service the better value for money ordinary people will get.
The inquiry may have missed one important issue that is rarely debated publicly, although it has been brought to the surface a number of times by external organisations like the International Monetary Fund and the European Union. How sustainable is Malta’s free public health system? Is there a risk of rationing of health-related services, including the dispensing of free medicine, as a result of the financial stress put on our health system?
This issue was not included in the terms of reference of the inquiry but it is certainly relevant. While there is political consensus that public health services should continue to remain free at the point of delivery, the increasing cost of financing a modern health service, especially in the context of an aging population, is a matter of prime public interest. While politicians may not want to open this issue to public debate, it is not going to go away by ignoring it exists.
The patronising conclusion of the inquiry, that neither patients nor their relatives were informed that the hospital was using expired Tamiflu was acceptable in order not to cause “undue anxiety”, is astonishing. In 2009, the US Food and Drug Administration, when approving the use of expired Tamiflu in an emergency, had asked healthcare professionals to “consider discussing with patients, families and caregivers the benefits of taking antiviral (expired) medications in relation to the potential risks of untreated illness”. It wanted to ensure that doctors discussed the expired Tamiflu information with patients to help them understand and address any concerns they may have about the expired medicine.
When official communication is curtailed, the speculative grapevine often causes more anxiety.