A quarter of all hospital beds in the country are allocated to patients in need of surgery. However, the shortfall in pharmaceuticals has left medical doctors unable to perform the surgeries for the past few weeks.

Scenes inside the emergency room of Addis Abeba's Menelik II Referral Hospital were nothing short of chaotic last week. Frantic staff members were rushing about, struggling to care for a crowd of patients needing urgent medical attention. Stretchers were clogging the dimly lit hallways, which, though relatively hushed, echoed with the whispers of patients and the occasional grunts of discomfort. The air carried the smell of sanitary chemicals distinct to medical facilities, made slightly overwhelming by the heat the capital has been experiencing in recent weeks.

Near Jan Meda, on Russia Street, Menelik II Hospital is one of the oldest, opened in 1909. However, the prestigious history was overshadowed by the goings on in its wards. Nurses were shaking with pent-up anxiety and distress, checking on patients seated on long benches pushed up against the beige-coloured hallways. One of the nurses was visibly irritated when patients approached her, asking for accommodation.

Emergency departments (ER) are ideally meant to serve as brief ports in trouble, with patients staying just long enough before transferred to other sections or sent home with instructions to follow up with various maladies. But the ER section of Menelik II Referral Hospital has transformed into an overflow unit. Some of the patients seated in wheelchairs were hooked up to IVs, while others spoke quietly to medical staff.

The atmosphere was quite the opposite in a separate hospital section designated for admitting elective surgery patients.

Abebaw Molla, 30, sat in that section last week, supporting his weary head with his hands. A father of two, Abebaw had come to the hospital without an appointment. It was his third visit in the last couple of months.

Five months ago, he underwent a small bowel resection operation at the hospital - a surgery to remove part of his small intestine, which had been damaged. Doctors made an incision around his right kidney to connect a tube to a colostomy bag, where faeces would be passed until Abebaw's bowels healed. The surgery was a success, and he was instructed to return after three months for another procedure to close the wound.

The past few months, however, were tumultuous at best for Abebaw. He was glued to a chair, unable to work. Before his surgery, he was the family's breadwinner, working as a daily labourer at construction sites.

“The wellbeing of my family is in danger,” he told Fortune.

Abebaw thought of little else but the follow-up procedure that would allow him to regain a semblance of normalcy. However, the relief has not yet come to pass. He does not know when to get an appointment for the second surgery. A debilitating shortage of anaesthesia drugs hit hospitals across the city, forcing doctors to suspend surgery procedures. It has been a month since Menelik II Hospital has admitted scheduled patients for surgery. No elective surgery was conducted at the hospital for two weeks.

“We're struggling to cope with the mounting need for surgeries in the ER section,” a doctor told Fortune.

The halls of Menelik II Referral Hospital's emergency department are overflowing with patients, many of whom lie on stretchers hooked up to IVs. The Hospital has not admitted patients scheduled for surgery in a month for a lack of anaesthetics.

With 800 beds and over 2,300 staff, Menelik II Hospital is one of five referral hospitals under the supervision of the Addis Abeba City Administration. It treats an average of 15,000 patients each day. Others include Tirunesh Beijing, Gandhi, Zewditu, and Yekatit 12 hospitals. The municipality also oversees a little more than 100 health centres in the capital.

A receptionist sitting behind a worn desk at Menelik II Hospital could not do much for Abebaw except put his name on the waiting list.

There are a dozen drugs necessary to perform surgery. Anaesthetic suxamethonium, a muscle relaxant drug, facilitates windpipe intubation and mechanical ventilation procedures. It is a fast-acting drug used in emergency surgery. It was unavailable in Menelik Hospital. Supplies of cisatracurium, ketamine, and atropine – also anaesthetics – fare no better.

The shortages were visible at other health centres.

St. Paul's Hospital in the northwest of the capital used to stock 10 of the 12 drugs used for surgical procedures. It is the second-largest hospital after Tikur Anbessa (Black Lion), which houses 1,000 beds and employs over 3,400 people. The hospital's administration ordered three months of medicine stock at a given time from the Ethiopian Pharmaceuticals Supply Agency, a federal agency importing and supplying medications and medical supplies to public health institutions.

The Hospital stocks around 1,200 types of medication. It requires at least 400 units of suxamethonium a month to conduct surgeries. Each unit carries 20mg of the substance.

“We've only two weeks' stock of suxamethonium,” said Berhane Tsehay, a representative of St. Paul's medical director.

The shortages have forced the medical team to stop surgery for non-emergency patients.

The dearth of vital medications has become increasingly common in the capital and elsewhere in the country, mainly due to foreign currency unavailability and disruptions in global supply chains. The predicament is in sharp contrast to the 10 billion Br spent importing medications over the first half of this year. It is not sufficient to cover the need. Prices are on the rise, too.

Type-1 diabetic patients have to pay 310 Br to get medicine to cover their needs for a few weeks, double what they were paying a year ago. It is estimated close to three million people live with diabetes in Ethiopia.

Public and private health institutions face acute shortages of morphine and pethidine, drugs used to relieve moderate and severe pain, especially after patients undergo surgeries. Patients are forced to buy these strong painkillers from the informal market, at higher prices.

Those in the medical field point their fingers at global logistics hurdles and increased shipping tariffs. The cost of shipping a 40ft container from ports in China has quadrupled to nearly 13,000 dollars over the past two years. It is an ill omen for a country whose economy is largely dependent on imports. Imports cover close to 90pc of Ethiopia's annual pharmaceutical demand. Less than 10 of the 13 pharmaceutical manufacturers are currently active. The total import bill surpassed the 10 billion dollar mark in the first eight months of the financial year, fourfold the export revenues over the same period.

Nonetheless, almost all public hospitals are stretched to the limit as they struggle to respond to the demand, suffering from a lack of supplies, staffing and funding.

“There should be no greater priority than the wellbeing of citizens,” a urologist told Fortune. “The government should allocate sufficient forex to importers and the Agency."

Although medicine is at the top of the central bank's import priority list, the 200 importers and wholesalers are not spared the struggle to get their hands on foreign currency. They supply the healthcare system dominated by public institutions, made up of primary hospitals, health centres, and health posts. The government introduced a health sector development programme 25 years ago, identifying surgical and anaesthetic care as priority areas. However, the provision of anaesthetics remains limited to specialised teaching hospitals, medical facilities in large urban centres, and a handful of private hospitals.

Less than half of all health facilities provide essential surgical services, while no more than 300 general surgeons are deployed at 116 federal hospitals, serving a population of over 100 million. It is a depressing ratio exacerbated by a shortfall in medical professionals specialising in anaesthesiology. They number fewer than 100.

Little more than 200,000 surgical procedures are carried out annually, representing less than five percent of the estimated demand for surgical interventions. Last year 21,000 more surgeries were performed, with major surgeries accounting for half. A quarter of the procedures - similar to what Abebaw underwent - took place in public hospitals such as Menelik II and St. Paul's. Close to a quarter of all hospital beds are allocated to patients who require surgery.

To meet the World Health Organisation's (WHO) universal health coverage goal in 10 years, Ethiopia must attain 80pc coverage of emergency and essential surgical and anaesthesia services. It is a far cry from the present circumstance.

In 2016, officials at the Health Ministry launched a programme they hoped would help attain the minimum standards of surgical care. A second phase was introduced last year, aspiring to reduce delays for elective surgery to a month from 51 days. It envisions 5,000 surgeries for every 100,000 people by 2030. The ratio is 192 for every 100,000.

The chronic shortage of medicines is a significant barrier to these goals. Though the problem is not new, those in the medical industry observed that it had reached new peaks as the administrators of public hospitals raised alarms that stocks had run out months before the end of the budget year. Though public hospitals can procure essential medicines independently during shortfalls, their efforts prove futile more often than not.

"No one appears to be interested in tenders floated by hospitals," said Berhane of St. Paul's. "We're dependent on medicine imported by the government."

Established in 1947, the Ethiopian Pharmaceuticals Supply Agency has the mandate to provide over 1,000 types of medicines and medical equipment to over 5,000 public health institutions. Its expenditures have ballooned tremendously over the past few years. In 2019, its annual import bill hovered near 10 billion Br. It had grown to 17 billion Br last year, while the Agency has spent the equivalent over the first half of this year.

The Agency procures surgical and anaesthetic drugs mainly from India, China, and Indonesia.

Solomon Nigussie, deputy head of the Agency, acknowledged the shortages. He confirmed that the Agency does not have suxamethonium in stock. He blames an international supplier for failing to deliver a batch of the drugs the Agency had procured recently.

Still, officials say a batch is scheduled to arrive in the coming weeks.

United Pharma, an India-based company, has been contracted to supply a large stock of the drug.

“We'll have ten months of stock,” Solomon told Fortune.

Distribution of suxamethonium procured from United Pharma to public hospitals will start this week, according to the Deputy Head.

Abebaw, who had to make his way home after his pleas for relief went unheeded last week, may rejoice at the news. However, he knows he still has a long way to go on the road to recovery.

“I don’t know when I'll regain my health,” he said.

PUBLISHED ON May 28,2022 [ VOL 23 , NO 1152]

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