2. FRANCIS BEN KAIFALA ACC COMMISSIONER ACC HEADQUARTER OFFICE 3 GLOUCESTER STREET

1. Published by the Anti - Corruption Commission Headquarters: 3, Gloucester Street, Freetown, Sierra Leone, West Africa Tel.No: 223645 Website: http//www@anticorruption.gov.sl Bo Office address: 45, Kissy Town Road, Bo Email: info@anticorruption.gov.sl Makeni Office address: Mena Hill Reservation, Makeni Kenema Office address: Reservation Road, Off Maxwell Khobe Street Kono Office: 25, Kanawa Street, Koidu City Hotline Nos: 077 - 985985 Airtel: 161 /078 - 394111 / Comium: 101 and 102 1

4. LIST OF ABREVIATIONS ACC ......................................................... Anti - corruption Commission CCSL ......................................................... Council of Churches in Sierra Leone CHP ......................................................... Community Health Centers CMS ...................................................... .. Central Medical Stores DHMT .......................................................... District Health Management Team FCC ...................................................... .... Freetown City Council FHC ............................................................ Free Health Care FHCI ............................................................... Free Health Care Initiative GoSL ............................................................... Government of Sierra Leone MCHP ............................................................. Maternity Community Health Post MoHS ......................................................... .... Ministry of Health and Sanitation NGO .................................................... .......... Non - Governmental Organization PHU ................................................................ Primary Health Unit TB ............................................................... Tuberculosis WHO ......................................................... World Health Organization 2

7. • The team discovered that both Cost recovery and free health care drugs are displayed and dispensed within the same facility in the Hospital. Implication • Deposit of cost recovery drugs into the Hospital ’ s general account is a recipe for corruption and hence hinders accountability. • Unaccounted monies can be an act of corruption • Cost recovery drugs can be easily converted to free Health Care drugs and Vice Versa. Recommendation • Unaccounted proceeds from the sale of drugs should be repaid by the pharmacist. • Hospital Management should endeavor to open drugs account separate from the main Hospital account. All monies relating to proceeds from the sale of drugs should be credited into that account. • Cost recovery drugs should be displayed and dispensed in a separate facility in order to distinguish it from the Free Health Care drugs. 54 5 a source of revenue, which can be used to cater for other health care needs and in particular for disadvantaged populations. To improve medicines situations, multiple stakeholders from different parts of health systems need to share their different views of medicines in health systems. In this respect, the management of these resources should not only be made the responsibility of health workers, it should also include the providers, and the public as a whole. As different elements of systems must function in a coordinated fashion to ensure that medicines benefit lives from the development, production, marketing, registration, selection, financing, procurement, distribution, prescribing, the dispensing and ultimately the use of medicines – the routine inclusion of multiple stakeholders is of critical importance. Patients, households, communities, researchers, service providers, procurement officers, drug distributors, local and central health system managers and decision - makers, regulatory authorities, payers, national policy - makers in and outside the health sector, local and international pharmaceutical industries, civil society organizations (e.g. community organizations, professional associations, etc.), international funding agencies and development aid partners must all participate at various different points – and we must recognize that each has inherently different roles, values and objectives (as shown in Table 1.1).

3. 1 TABLE OF CONTENT L ist of Abbreviations ........................................................................... 2 1.1 Background .................................................................................. 3 1.2 Objective ..................................................................................... 10 1.3 Methodology and Scope ............................................................ 10 1.4 Findings and Recommendations ...................................... ............. 11 1.4.1 Internal Audit ............................................................................. 11 1.4.2 Financial Management ............................................................... 20 1.4.4 Human Resources Management .............................................. 21 1.5 Drugs Management .................................................................... 24 1.5.1 Cost Recovery Drugs ........................................................ ......... 24 1.5.2 Free Health Care Drugs ............................................................. 30 1.6 Sale of Drugs in HealthCare Facilities............................................. 44 1.6.1 Macaulay Street Government Hospital .................................... 45 1.6.2 Kingharman Road Government Hospital .......................... 49 1.6.3 Rokupa Government Hospital.................................................... 51 1.6.4 Lumley Government Hospital ................................................... 53 1.7 Summary of Analysis on Drugs Supplied by FCC .................................... 56

25. An Act was formally tabled in Parliament for the formation of NMSA which has the sole right for the procurement, storage and distribution of all health commodities in Sierra Leone. A Board has been formed and the key staff have started operations. As was mentioned earlier in our audit response, there are very few staff to execute all store functions at the same time. Because of the heavy workload, the Store In - charge on weekends update all transaction records (i.e. Inventory Control cards/Stock cards) (See enclosed sample of updated transaction records). Notwithstanding, the management of CMS will ensure that officers in charge of the respective stores update stock cards/inventory control cards immediately when items are received or issued to show a clear stock on hand balance. Management is in the process of ensuring that thermometers are available and maintained at all of the warehouses to measure temperature variations. The authorities of DDMS will ensure to revise the Donation Guidelines and ensure that donors strictly adhere to donation policies of the country. There are challenges with recruitment of personnel by the GoSL, yet the authorities are constantly in touch with the Human Resource Department for recruitment of Laborers or Store Assistants to support the Store Keepers in the cleaning and maintenance of the stores. Area of Focus: Operation of District Medical Stores In the provincial areas each Districts has its own medical store as well as the Tertiary Hospitals. The Medical Superintendent (MS) and the Hospitals Pharmacist supervise the hospital store while the DHMT Stores provide drugs and other Medical Supplies to the PHUs in the Districts. Some of the findings are generic though others are slightly different in the regions. 36 23 on monitoring, supervising, and reporting staff attendance in the workplace using the existing HR software. Additionally, the authorities of DDMS are in a transition from the paper - based attendance register to the facial recognition artificial intelligence that tracks not only attendance but also track staff movement during working hours. Area of Focus : Staffing Finding • It was observed that there is inadequate staff for the various units of the CMS. Some staff are employed in positions for which they lack the necessary skills; some are in positions that do require the skills they possess and some unit are virtually understaffed. Implication • Without adequate staff and appropriate skills required, it will be difficult for the CMS to operate effectively and efficiently in achieving the objective for which it was established. Recommendation • It is recommended that a Human Resource needs assessment be conducted with a view of identifying and addressing staffing challenges. This should include employing additional staff with the requisite skills and the redeployment of staff to areas specialization. MANAGEMENT RESPONSE Officer ’ s Response The authorities are fully aware that the various units of CMS do not have the requisite number of staff to manage its activities efficiently and effectively. There are challenges with recruitment of personnel by the GoSL, yet the the authorities are constantly in touch with the Human Resource Department for above.

28. 26 Drugs by FCC for Health Sector for 2016 and 2017 The table above shows the distribution matrix of drugs supplied in value to various hospitals by FCC on various dates. In 2016, FCC supplied Le 181,440,000 (One Hundred and Eighty one million, Four Hundred and Forty thousand Leones) worth of drugs to the aforementioned hospitals. Also in 2017 Le 78,750,000 (Seventy Eight Million, Seven Hundred and fifty thousand Leones) worth of drugs were also supplied by FCC to the hospitals. Form the above table, FCC supplied a total of Le260, 190,000 (Two Hundred and Sixty Million, One Hundred and Ninety thousand Leones) worth of drugs to the various aforementioned hospital in the periods of 2016 and 2017. We observed that procurements of the drugs are done with little or no technical support from personnel trained in the handling of drugs such as pharmacists. As a result it is difficult to assess the standard of drugs and most hospitals claimed that some drugs supplied were very close to their expiration date. 2016 2017 Hospital Date Amount Supplied Date Amount Supplied Cumulative Totals 33 • The Team observed that the various stores lack basic office equipment, including, desktop computers, laptops, printers, photocopiers and reliable internet connectivity . • It was alleged that expired drugs and other medical supplies were received and stored in the stores during the past Ebola disaster in Freetown; The CMS have failed to effectively dispose of the expired stock and they continue to occupy valuable storage space. • It was noted that some donors and other Non - Governmental Organizations supply drugs and other medical supplies directly to the hospitals and PHUs without the knowledge of CMS; and these Hospitals and PHUs in turn do not inform the CMS of such supplies. • There were poor Records management in most of the Stores visited as some store records were missing and others difficult to trace. Though they operate on the channel system, they should also be a Manual recording and filing of store documents by the storekeepers. Implication • Without proper room temperature for the storage of drugs, the maximum response from those drugs cannot be achieved and can be life - threatening. Poor handling of drugs is a safety risk. • Expired drugs can have dangerous consequences. • Poor records management is a recipe for corruption • Abandoned Medicals Supplies will attract theft and also resources used to procure such supplies will be wasted.

21. • The hospital and DMS never come across drug products like CIPROFLOXAXIN 250mg. DMS has ciprofloxacin 250mg. Area of Focus: Education on the Free Health Care Finding • Although after the introduction of the initiative, sensitizations were made to the Public on the Free Health Care. • However, it is still a challenge to administer FHC drugs to the intended beneficiaries to the extent that it is unclear to people what medical services are contained in the FHC package. • For instance in emergency cases where a patient needs blood and there is insufficient blood in the blood Bank, at that moment the patient will be ask to find a Donor. • There are times these Donors ask for money especially in instances where the Blood group is difficult to find. Though the patient is among the categories of FHC beneficiaries he or she should have to pay for that service. If situation as this is not properly explained to the patient, it may seem as if the Patient is paying for the FHC service. Implication • When patients are not properly sensitized on FHC services, there is a tendency for health care providers to perpetrate the act of Corruption. Recommendation • The Ministry of Health should conduct more sensitization on the FHCI in order for the public to clearly understand the FHC drug administration. 40 19 Recommendation • The finance unit should maintain both manual and electronic cashbook and to safe against data loss conduct daily backup of data. MANAGEMENT RESPONSE Officer ’ s Response Following post audit queries, the authorities of DDMS have ensured that the Finance Officer keeps both hard and soft copies of updated cash book to prevent against data loss (Please see enclosed samples of updated cash book). Area of Focus: Procurement of office supplies and Store Keeping The team observed that the Finance Officer also doubled as a store keeper of the administrative store. All procurements made by the institution are stored by the finance officer rather than the store keeper. Implication • Lack of segregation of duties creates opportunities for fraudulent transactions to be processed. Recommendation • The Finance Officer should relinquish the functions of a storekeeper and a skilled storekeeper should be employed. MANAGEMENT RESPONSE Officer ’ s Response The Directorate of Drugs and Medical Supplies have an existing organogram with each unit having defined roles and responsibilities. The authorities are ensuring that each unit works within their terms of reference. Nonetheless, the authorities can delegate some responsibilities as and when necessary

19. 42 a whole. Currently, the role of DDMS in the present supply chain landscape is to store and distribute health commodities to the targeted beneficiaries. UNICEF is responsible for procurement and disbursement of funds needed to execute the distribution process. The process of accessing funds from UNICEF is very time consuming and there are also long procurement lead times that impede the availability of drugs and medical supplies for onward destruction. DDMS can only distribute if there are enough health commodities to fulfill needs of the patients; taking into consideration value for money. Moving forward, we hope the new autonomous supply chain entity, NMSA will assume its responsibilities and ensure timely distribution of FHC commodities. Area of Focus: Push and Pull System of Drugs Supply Findings • The Central Medical Store uses the “ Push System ” in the supply of drugs. In this supply is not based on requisition but rather on what is available at CMS. • We observed that there is no clear cut formula on how the available drugs are allocated to Health centers in line with usage and needs. As a result most centers go with too much of certain drugs than that is needed whilst others go without. It was also made known to the review team that specialized drugs that are hardly needs are supplied in excess quantities to some facilities. These excess drugs are not redistributed and are left in stores till expiration. Implication • The PUSH SYSTEM can possibly leads to excesses or shortages of drugs Recommendation 17 • The discretionary allocation and issuance of fuel to staff creates opportunities for abuse. Recommendations • A policy on fuel distribution should be initiated taking cognizance of the interest of non - vehicle owners within the stipulated grade. • There should be segregation of duties in the management of fuel: the administrative unit should undertake the procurement process and the allocation with proper authorization from management. • The finance office should be limited to their traditional role of making payment for the fuel. MANAGEMENT RESPONSE Officer ’ s Response All procurements including fuel is the responsibility of the Procurement Unit of the Ministry of Health and Sanitation. Notwithstanding, queries from post audits pointed at inconsistencies in the management of fuel at DDMS, hence the authorities have instituted internal controls on fuel management. Area of Focus: Fixed Assets Register Finding • Central Medical store does not maintain a fixed asset register and assets are not coded. An asset register keeps track of the entity ’ s assets. It has to show the value of the asset, date of acquisition, depreciation and other necessary details.

14. 12 delivered by suppliers to stores. As result could not physically count or confirmed stock supplied in terms of quantity, quality and specification as per delivery notes. Our examination of the delivery notes and other related documents revealed that the only signature on them was that of the Auditor of the Ministry of Health and Sanitation (MoHS). Implication • When goods are supplied without going through a verification process (on the spot check), discrepancies between actual stock supplied and figures stated in delivery notes will go undetected. This may also create the possibility of misprocurement. Recommendation • All goods supplied to the CMS must be verified by the stationed internal auditor to ascertain its correctness in terms of actual stock and specification as stated in the delivery notes before storage. MANAGEMENT RESPONSE Officer ’ s Response Previous audit queries recommended the establishment of an Internal Auditor unit at Central Medical Stores compound. An internal auditor was posted to DDMS by the Directorate of Internal Audit with his clear roles, responsibilities, and reporting lines. There is only one internal auditor posted at DDMS and DDMS is overseeing ten (10) individual stores situated at four (4) locations across Freetown. There are instances whereby health commodities are delivered to stores in the four (4) different locations concurrently. With just one Internal Auditor, his presence will not be felt in all the delivery points, hence the need for the deployment of additional Internal Auditors at DDMS (Please see attached samples of delivery documents bearing the signatures of Internal Auditors). 47 • The technicians attached to the FHC Pharmacy are also the same staff working at the Cost Recovery Pharmacy. It creates opportunities for the conversion of drugs from one scheme to the other. • These technicians ’ diagnoses and /or treat patients in the pharmacy instead of referring the patients to the doctor. • Nurses were privately selling drugs to patients in the wards without referring them to the pharmacy. The reason advanced by the nurses was that sometimes during emergencies, cost recovery drugs would not be available in the hospital and they needed to save life. Also if the drugs are available in the pharmacy, the technicians would not be around to sell the drugs. Furthermore, the nurses complained that due to the high cost of the cost recovery drugs, patients are directed by health workers to buy from nearby pharmacies. • According to Article 4. of the M.O.U, it stated that “ the M.O.U comes into effect upon the signature of both sides for a 10 year period and can be renewed for another 5 year period by mutual agreement of the two sides ’’. It was observed, that the Iranian clinic is operating a cost recovery pharmacy in the same location where the government cost recovery is located, as a result the frequent sale of government cost recovery drugs are challenged. As per the M.O.U signed in 2008, the agreement has expired. • The Finance Officer is not actively involved in financial matters and also not a signatory to the drugs account. There were no proper financial records for audit trail due to poor records keeping. Implications Using government resources for personal gains constitute an offence under the ACC Act 2008. • Monies unaccounted for is an act of corrupt practice.

29. 32 going to contribute 10% of the total procurement cost for FHC drugs and will subsequently scale up their contribution in the coming years. Area of Focus: Operation of the Central Medical stores in Freetown Storage is an important aspect in the drugs management control systems. All drugs procured for FHC are stored at the CMS for subsequent distribution to District Stores. The CMS has eight (8) stores in Freetown in which drugs and other medical supplies are kept. These stores operate channel software application and quite recently M - Supply system. These systems keep records and facilitate the smooth running of the receipt and Issuance of drugs and oth- er medical supplies. Findings • Some medical stores in Freetown do not have the required conditions conducive for the safe keeping of drugs and other medical supplies. This is especially true for stores located at the CMS Compound. Some lack regular electricity supply, air conditioning etc. Some also have leaking roofs, unhealthy store environment which hinders some store keepers from staying in their offices; • There were so many abandoned medical supplies that were identified in Stores Located at the CMS Compound. In Store Four, the team identified lots of expired supplies stocked in this store; • Some of the store Keepers managing these stores are not adequately trained and equipped to carry out their functions. There were so many abnormalities identified in the store procedures used by these storekeepers. All the stores are manned by pharmacy technicians with no formal training on storekeeping. 27 We also observed the procurement of drugs supplies are irregularly and inadequate. Though the hospitals make requisitions, it was revealed that very limited supplies are procured at irregular intervals. Implication • Patient safety is a priority in procurement of drugs. Without proper quality assurance mechanism in place patients safety is at risk. Recommendations • Hospital Pharmacists should be involved in the procurement process of drugs. • To ensure the availability of essential drugs and uphold the cost recovery scheme in hospitals, we recommend that other hospitals explore possibility of replicating the arrangement of the Makeni Hospital management. Alternatively, we recommend government come up with a scheme to finance the cost recovery programe for all levels of health care sector and effectively monitor its implementation. Area of Focus: Storage and Distribution Findings • In Makeni, the drugs are supplied to the hospitals by the retail pharmacies. In the Western Area, FCC operates a system were suppliers distributes drugs paid for directly to hospitals and DHMT. • It was observed that there were no proper methods of storage and preservation of drugs at hospitals. No records or inventory existed. Drugs supplied to hospitals are distributed to individual pharmacy technicians who store them at random places; some even take them to their private houses. Implication

20. • The accountant will be unable to estimate the value of the assets of the institution. Tracking of the institution ’ s assets will be difficult as there will be no records to follow. Recommendation • CMS should institute a fixed asset register so that assets are tracked and recorded for proper reporting. • All assets have to be coded with the correct inscription to distinguish it from others to avoid duplication. MANAGEMENT RESPONSE Officer ’ s Response DDMS does not have any trained personnel on asset management; but will ensure to source the requisite expertise to code, track, and record the directorate ’ s assets for proper reporting. Area of Focus: Maintaining a Cash Book Finding The finance unit maintains a manual cash book, also referred to as Vote Service Ledger, but not an electronic version to safeguard against risk of loss of data. Implication • Heavily relying on manual financial documents is risky as they are prone to loss, damage or manipulation. • 18 MANAGMENT RESPONSE Officer ’ s Response The Top Management of the Ministry of Health and Sanitation (Including the political heads) conducted a nationwide sensitization of the FHCI. The sensitization which took place in the just concluded 2018 Phase two (2) distribution attracted a lot of stakeholders. The stakeholders included but not limited to Political Heads, Administrative Heads, Professional Heads of MOHS, Head of Local Councils, Paramount Chiefs, Resident Ministers, Community people, beneficiaries of the FHCI, and more). Area of Focus: Distribution of the FHC Drugs Findings • The distribution of the FHC drugs is not timely .During the Review process some health care facilities were without enough FHC drugs due to the untimeliness in the supply of these Drugs. Some facilities complained that they go without drugs for months. It was noted that only Anti - malaria drugs were available in almost all of the Health care facilities visited. Implication • Delay in the distribution of FHC drugs might cause health service providers a leeway to take advantage of selling drugs to patients Recommendation • Management should ensure that FHC drugs are distributed in a timely manner. MANAGEMENT RESPONSE Officer ’ s Response The authorities are very much aware of delays in the distribution of FHC commodities. There are a couple of reasons associated with these delays which are not under the control of the authorities of DDMS and the Ministry as . 41

16. 14 Audit, etc.) are routinely auditing DDMS including the stores. Reports containing audit queries, risks, recommended actions are produced and shared. DDMS had been responding and taking appropriate actions by improving systems and processes. Area of Focus: Independence of the Internal Auditor Finding • It was observed that internal audit functions are performed by an internal auditor of the line ministry (MOHS) and not by the designated internal au- ditor of the CMS. It is therefore evident that the internal audit of the CMS is not independent and lacks the freehand to carry out its functions. This fur- ther casts doubt on the level of support given to the Internal Audit. Implication • Without a strong and independent internal audit unit the credibility of internal controls and the effective running of the entity would be undermined. Recommendation • The Internal Audit at CMS should be strengthened and trained and qualified personnel employed. Management should ensure its independence and take appropriate actions on internal audit recommendations. MANAGEMENT RESPONSE Officer ’ s Response According to the Human Resource Strategic Plan, the Internal Audit Directorate is not reporting to either the professional or administrative heads of the Ministry of Health and Sanitation; but the Minister . The Internal Auditor is posted to DDMS as has his defined roles and responsibilities. The authorities Implication 45 • The Drugs procured for Cost Recovery should be used for its intended purpose and any alterations from the original purpose have to be subjected to approval by FCC. 1.6.1 MACAULEY STREET GOVERNMENT HOSPITAL The Hospital is one the secondary health care facilities that provides services for people around its vicinity and beyond. It was previously managed by the Iranian Clinic but has now been taken over by the government of Sierra Leone. The hospital is maintaining two operational Bank accounts and the drugs account at the Union Trust Bank. Revenue is generated from the registration fees and other charges. The drugs account is a special account that is maintained to supplement the cost recovery drugs at the hospital. Meanwhile, the team observed the following: Findings • Since there were no cost recovery drugs at the hospital, the hospital management agreed to withdraw six million Leones (Le6,000,000) to salvage the drug situation in February 2018.It was observed that the pharmacist only utilized (Le2,857,000) two million eight hundred and fifty seven thousand Leone of the total amount and save the rest in her personal Bank accounts the sum of (Le3,143,000) three million one hundred and forty three thousand Leones. • The Pharmacist allocated drugs to three Pharmacy Technicians to sell and the proceeds were never deposited into the hospital drugs account. These drugs were not stored in the cost recovery pharmacy but given to individual pharmacist to sell.

17. 44 1.6 DRUGS MANAGEMENT IN HEALTHCARE FACILITIES DISTRICT HEALTH MEDICAL STORE WESTERN AREA (DHMT CLINE TOWN) The District Medical Store deals with the Primary Health care (PHUs) for both urban and Rural in the Western area. This includes the Community Health Centers (CHCs), Community Health Posts (CHPs), Maternity Community Health Posts (MCHPs) etc. They also collaborate with programs like Anti - malaria, HIV, TB etc. Free Health care drugs and other Medical supplies are supplied from the Central Medical Store and cost recovery drugs are provided by the Freetown City Council for further distribution to the PHUs. The Freetown City Council (FCC) in 2017, supplied Le 13,750,000 (Thirteen million Seven hundred and Fifty Thousand Leones) worth of drugs to DHMS for the purpose of cost recovery. Area of Focus: Conversion of Cost Recovery Drugs Finding • It was observed that the DHMS in Freetown converted Cost Recov- ery Drugs to Free Health Care Drugs with no authority or formal agreement from the Freetown City Council. However, it was doubt- ful to the review team whether indeed these drugs were converted as it was claimed. Implication • The Conversion of cost recovery drugs to the Free Health Care drugs without any authority might have an underline motive for misappropriation. Recommendations 15 of DDMS does not have any mandate to dictate on who should perform audit functions, rather it is the responsibility of the Head Internal Audit. Area of Focus: Internal Auditors ’ presence in the distribution of drugs Finding • In strengthening internal controls, the presence of an Internal Auditor in the distribution of drugs should be nationwide. The team discovered that during the “ picking and packing ” process of drugs and their subsequent distribution to hospitals and lower level health facilities in the regions, no internal auditor was present to witness the process. Implication The absence of an internal audit represents lack of an independent assurance on the effectiveness of the process. Recommendation • The Internal Auditor should at all times be present for the distribution of drugs to the hospitals, DHMT and stores for proper transparency and accountability. MANAGEMENT RESPONSE Officer ’ s Response Since there is only one Internal Auditor deployed at Central Medical Stores, the Directorate of Drugs and Medical Supplies liaise with the Directorate of Internal Audit to ensure that additional Internal Auditors are deployed so as to make sure that they participate every receipt and distribution process. Also, DDMS will ensure to work closely with the Directorate of Internal Audit to source funds to support and sustain activities of the Internal Auditors in nationwide distribution of health commodities. 1 .4.2 FINANCIAL MANAGEMENT

30. 28 • Proper storage and inventory controls ensure that drugs quality are maintained and their movement are tracked and accounted for. Lack of it creates room for corruption and put patients ’ safety at risk. Recommendation • Hospital management should ensure that drugs and medical supplies are stored and preserved in a conducive environment. Also, the supply of drugs has to be controlled to avoid misuse. MANAGEMENT RESPONSE Officer ’ s Response DDMS will ensure that all hospital management duly follow the Standard Operating Procedures on drugs storage, distribution, and reporting for trans- parency, accountability, and patient safety. Area of Focus: Usage and Cost Recovery Findings • There was lack of evidence to show that drugs supplied are actually being sold at the health centers. Records such as prescription notes, sales re- ceipt and other dispensary records were none existent. • Limited recoveries were made to replenish essential drugs supply. In the four hospitals that were visited in the Western Area, two made no ecoveries for 2016 and 2017 whilst the other two made recoveries as follow: less than 15% recovery for Lumley Hospital and • FCC has not done any supervisory and monitoring activities in these hospitals to ensure that returns are made from the sale of these drugs for . 31 The FHCI provides Free of charge Health Care services to children under - five, lactating mothers and pregnant women. This initiative was a whole sum of Sierra Leone ’ s effort as it addresses issues relating to reproductive health from quality service delivery to ensuring availability and proper utilization of Resources. Moreover, after the Ebola epidemic in Sierra Leone, Ebola survivors, the disables and the destitute were also added as part of the benefici aries of the FHC initiative. However, the following were discovered during the review of the Free health Care drugs management: Area of Focus: Procurement Finding • Procurement of drugs for the FHC program is donor driven. I.e Finance and procurement are totally done by donors. Implication • Without a scheme by government to fund the FHC program, sustainability will be a challenge. Recommendation • Like the cost recovery scheme, government should develop a scheme to finance the FHC program or at least complement donor efforts. MANAGEMENT RESPONSE Officer ’ s Response Government is committed to complement donor ’ s effort in procurement and distribution of drugs and medical supplies. In the initial stage, government is .

18. 16 Financial management practices have a marked effect on the financial performance of any organization . Therefore, sound financial decisions/ practices can contribute towards meeting the desired objective of the CMS. The finance Unit is basically responsible for the effective and efficient internal financial management of an Institution and also should be seen as maintaining financial controls within the Institution. Area of Focus: Fuel Distribution Findings • We observed that finance unit undertakes the procurement of fuel for the CMS and also performs the task of allocating and issuance of fuel to staff members. • We however consider these functions with the exception of payments as administrative functions. • We also observed that the distribution of fuel to staff members is discretionary with little or no adherence to Civil Service Code for fuel Supplies or any locally developed fuel policy. In some instances certain staff members who are eligible under the Civil Service code to receive fuel allocation are not given, while some ineligible staff for example drivers, interns and secretaries are issued fuel for their personal cars. In most cases the due process is not followed. Implications • Lack of segregation for duties creates opportunities for abuse. Furthermore overriding the function of the Administrative Unit makes the unit non - functional. (Please see enclosed DDMS organogram with each unit ’ s defined roles and responsibilities ). 43 • Management should conduct a review of the supply method with a view of using a mixed of PUSH and PULL system of drugs supply. The Pull sys- tem will enable the allocation process to be properly informed on needs and requisition of the Health Centers. MANAGEMENT RESPONSE Officer ’ s Response As a result of the challenges associated with poor quality of consumption data emanating from Service Delivery points, it is very difficult to strictly follow the pull system of ordering. Notwithstanding, DDMS, DHMTs and partners have developed a model called ‘ Informed Push ’ – wherein prior to any mass distribution, an allocation matrix template is sent to all supply chain teams in the districts and hospitals. This allocation matrix has the names of health commodities available for distribution, the number of Peripheral Health Units (PHUs) per district, the maximum quantity in terms of months a facility should hold, including a column for quantity consumed and a column for stock on hand (Physical count). A formula is embedded into the allocation matrix such that when the district and hospital supply chain teams input the available consumption and stock on hand data, the quantity needed will be calculated automatically. This matrix also takes into consideration allocation of commodities based on the level of care for the category of Service Delivery Points. Consumption data and Stock on Hand data are determinants for reorder and resupply quantities. Also, health facilities sent in emergency requests before or after nationwide distributions which do not follow the official reorder trend, hence authorities of DDMS/CMS are on the verge of developing a Standard Operations Procedure (SOP) manual for reordering health commodities which will be disseminated to the respective stakeholders.

26. 24 In a swift response, the HR Unit of DDMS is currently conducting a HR needs assessment with a view of identifying and addressing staff challenges. This process will eventually lead to redeployment and recruitment of staff with the requisite skills. 1.5 DRUGS MANAGEMENT 1.5.1 COST RECOVERY DRUGS Cost recovery represents one of the schemes through which essential drugs supplies are financed and provided to health care facilities at all levels. Cost recovery refers to full or part charging for medical supplies and other items, the revenue from which is then meant to be paid into a revolving fund that will finance further supply purchases. The scheme was first implemented in Sierra Leone in 1987 and revised in 1993. In 2002 a policy was developed that aimed for 80% cost recovery. The target was later revised downwards to 40%: local facilities are permitted to retain 60% of the revenue raised from sale of medicines and remit the remainder to the district. In recent time it was reviewed to100% recovery. (Review of financing of health in Sierra Leone and the development of policy options 2008). In the review exercise the team observed various anomalies in the management of these drugs which are being identified below: Management of Cost Recovery Drugs Area of Focus: Procurement Findings Procurement and supply of cost recovery drugs by Central Medical Stores have stopped. Sources at the CMS intimated that the last supplies were made in 2013 whiles some health facilities Stated that last supplies were received as far back as 2010. MANAGEMENT RESPONSE Officer ’ s Response The authorities of Central Medical Stores (CMS) had formally requested the services of the Ministry of Health and Sanitation engineer to assess all the repairs and maintenance needed to carry out in the stores. He has produced a bill of quantities estimated cost for the overhaul of each store including fumigation (see enclosed). The Directorate of Drugs and Medical Supplies (DDMS) is planning to commence the general maintenance of all the stores. The funds secured from the Government of Sierra Leone (GoSL) could not cover the estimated budget cost for the maintenance of all the stores; hence the authorities are prioritizing areas of stores improvement based on the available funds whilst continually engaging partners to provide support to complement government ’ s effort in the maintenance of the stores. The existing central storage space is inadequate for the supplies received. The large chunk of expired and unserviceable commodities at CMS came as a result of the logistical nightmare inherited following the national emergencies such as the Ebola and Mudslide where in large volumes of medical supplies were donated to the people of Sierra Leone; some of which were substandard, expired, near to expire, and the like and could not be utilized within the period of the emergency. DDMS in collaboration with Pharmacy Board and other key stakeholders have successfully completed destruction of unserviceable and expired health and related commodities in Central Medical Stores and its surroundings. The authorities of DDMS have completed staff rotation at the Central Medical Stores and have conducted on the job training for all personnel managing the stores on three (3) thematic areas, viz: Inventory management, data management, and performance management. The authorities at DDMS are working tirelessly to ensure that all the stores have the basic office equipment, including, computers, printers, photocopiers, and reliable internet connectivity. 35

23. 38 51562020 was received on the 20/11/2017 as 250 but was recorded as 240 on the stock card on the 14/12/2017 (variance of 10). The same store Keeper manages Magburaka Government Hospital and the District Store. He is not au fait with store functions . The Pharmacist is using his personal laptop to operate the Channel System. Implication • The unavailability of stock cards will lead to theft and misappropriation. Recommendation • Laborers or store assistants should be contracted to provide support to stores in the handling and loading of stock. • Stocks cards and other store records should be available and properly used by store keepers • The pharmacist should desist from using his personal laptop to operate the Channel Systems. MANAGEMENT RESPONSE Officer ’ s Response The authorities are fully aware that all District and Hospital Medical Stores do not have the requisite number of support staff to assist the Store Keeper in loading and offloading supplies and cleaning the store and its environs. There are challenges with recruitment of personnel by the GoSL, yet the authorities are constantly in touch with the Human Resource Department for above. The authorities at DDMS have already distributed manual Logistics Management Information System (LMIS) tools (including Stock Cards/ Inventory Control Cards) to all health facilities nationwide. In addition, a refresher training on inventory management was also conducted for all supply MANAGEMENT RESPONSE Officer ’ s Response CMS Store number four (4) is the store designated for receipt and storage of all government - procured and donated hardware including automobiles. DDMS Receipt Team work closely with Transport Unit of MOHS whenever automobiles are delivered on behalf of MOHS. When the vehicles in question were delivered, CMS Store number four (4) was constraint with storage space and a decision was made to pack the vehicles at Youyi building car park. The keys of the said vehicles were handed over to the Head of Transport Unit for routine inspection and the delivery documents handed over to the Data Management Team for input into the Logistics software. DDMS Data Management Team will only generate distribution way bills from the logistics software only if they receive a formal communication from the appropriate authorities in the form of ap proved request or distribution matrix. DDMS Data Management Team never received such communication, hence the availability of the said vehicles in the logistics data provided to ACC for review. 1.4.4 HUMAN RESOURCE AND ADMINISTRATION Finding • Human Resources and Administration deals with the management of Human capital within an organization. However, in some institutions a department can handle both functions whilst in others they can be separated. • In the case of the CMS, there is a Human Resources and Administration unit headed by a pharmacist who is not trained on human resource management. 21

31. 30 and accounting of cost recovery proceeds. Area of Focus: Policy on Cost Recovery Drugs Policy on Cost Recovery Drugs will simply outline the procedures on how these drugs should be adequately managed .During the Review process; there was no policy on the processes and procedures of the Cost Recovery Drugs procured by the Freetown City Council. Implication • The nonexistence of a policy on drugs supplied to hospitals by FCC will create a loophole for corruption in the management and distribution of drugs. Recommendation • There should be a policy on the management of the Cost Recovery Drugs. MANAGEMENT RESPONSE Officer ’ s Response There is a policy on cost recovery drugs and medical supplies but was not implemented. DDMS will ensure to review and implement the cost recovery policy. 1.5.2 FREE HEALTH CARE (FHC) DRUGS The FHC initiative was introduced by the Government and its development partners in April 2010 which caters for under - fives, lactating mothers and pregnant women. This Initiative came about as a result of the High rate of maternal and neonatal mortality in the Country. 29 accountability purposes. In spite of this, FCC still honor budgets presented by the hospitals on a yearly basis. • The team discovered that, prices of drugs quoted by FCC are high and as result equitable affordability and accessibility cannot be guaranteed. Additionally Pharmacy Technicians find it very difficult to sell these drugs at cost recovery as the hospital . Implication • Lack of proper account of government resources is a recipe for Corruption. Recommendation • FCC should institute a robust monitoring on all drugs supplied to the Hospitals. • FCC should ensure that hospitals provide returns on the sale of drugs and verify that proceeds are deposited in the various hospital drugs accounts. • The hospitals should properly account for all drugs supplied and recoveries before the FCC makes subsequent allocations. The FCC should ensure that the recovered amounts are used to replenish drugs stock and any further allocations by the FCC should to be compliment stock. MANAGEMENT RESPONSE Officer ’ s Response DDMS will liaise with FCC and Directorate of Hospital and Laboratory Services to develop and agree on mechanisms for the supply, resupply, sale,

10. 8 Health Organisation (WHO) defines essential drugs ‘ as those drugs that are indispensable and necessary to satisfy the healthcare need of the majority of the population ’. They should therefore be available and accessible at all times, in the appropriate dosage forms and at prices affordable to all. Sierra Leone operate the traditional central medical stores drug supply system. The Central Medical Stores (CMS) has the responsibility of receiving, storing and distributing drugs and other medical supplies procured by the Government of Sierra Leone (GoSL). They also have the responsibility to receive donations from development partners and non - governmental organizations. The CMS serves as the central point for all drugs and other medical supplies and every district has its own mini store for storage. Western Area has a District Medical Store (DMS), both for the Urban and Rural that interface with the Director of Medical Supplies, Ministry of Health and Sanitation (MoHS), Primary Health Care Units (PHUs), Community Health Centers (CHCs), Community Health Post (CHPs) and Maternity Community Health Posts (MCHPs). They also collaborate with programs such as Malaria, Tuberculosis (TB), HIV etc. Distribution of drugs and medical supplies from CMS to the lower level stores and health facilities follow the push system of drugs distribution. In a push system, supply sources/CMS determine the types and quantities of medicines to be delivered to lower levels. Supplies are delivered according to a delivery plan made at the beginning of a period. Health facilities are expected to provide stock and consumption information to the supply source to assist planning. This is also known as an allocation or ration system (Management Sciences for Health, 2012). Stakeholders in the Health Sector have raised serious concerns on the PUSH system of drugs distribution and some of these concerns are contained in this report. In order to capture data on • All Pharmacy Technicians should account for the sale of these drugs and monies should be paid into the drugs account with immediate effect and copies of receipts forwarded to the Commission. • Stock cards should be regularly updated and displayed on the shelves in the Pharmacy. • All Health care workers should desist from selling their personal drugs in the hospitals. • The hospital management should open an account for drugs into which proceeds will be deposited. The operation of this account will provide accountability on drugs proceeds. 1 .6.3 ROKUPA GOVERNMENT HOSPITAL Rokupa Government Hospital also received procured drugs from FCC in 2016 amounting to Le73,440,000 (Seventy three Million, Four Hun- dred and forty four thousand Leones). • Upon our intervention, we observed that the shelf life of some of the drugs supplied were close to expiration; as a result Le 2,881,000 worth of drugs expired before they could be used. • Some technicians who have been transferred to other facilities failed to make returns on proceeds and/ or drugs or both to the pharmacist for rec- onciliation. The amount owed by them is Le10, 403,000 (see table 51 Year Total amount of Drugs Supplied Total amount sold / Recovery Unaccounted/ outstanding amount Value of Drugs Expired 2016 73,440,000 60,156,000 10,403,000 2,881,000 Total 73,440,000 10,403,000 2,881,000

12. 10 1.2 OBJECTIVES • To examine the various structures of the medical stores and other relevant stakeholders with a view of identifying and assessing their levels of vulnerability; and proffering appropriate actions with a view to promoting efficient service delivery; . • To strengthen transparency and accountability in the management and distribution chain of drugs and other medical supplies. • To enhance and ensure judicious use of funds allocated for the procurement of drugs, delivery, and proper distribution of same; • To identify and review policy gaps in the system of the management of drugs and other related services; • To document recommendations with a view to serving as working documents for government medical facilities in Sierra Leone; 1.3 METHODOLOGY AND SCOPE The review covers all levels of the Healthcare delivery system: the Primary Health Units, Secondary Health and Tertiary Health Hospitals. A sample of healthcare care facilities in the West Area and the regional head quarter towns were examined. It is expected that this sample size will provide adequate information to reflect findings nation - wide. The primary focus of review is the storage and distribution aspect of the drugs management cycle. In this regard, various literatures and health journals were reviewed. Best practices on drugs management from the sub - region and other parts of the 49 operate on a shift basis with its Technicians supervised by the Pharmacist. 1 .6.2 KINGHARMAN ROAD GOVERNMENT HOSPITAL Kingharman Road Government hospital is currently under construction and has been relocated to CCSL (Council of Churches Sierra Leone) compound to continue its services to the public. In 2016, the FCC procured cost recovery drugs worth fifty eight million Leones (Le58, 000,000) for the Hospital. The processes and procedures involved in managing these drugs were not properly carried out. These monies were not accounted for by recipient of the drugs (Pharmacist). The table below shows the allocation of drugs to Pharmacy Technicians in 2016 by the Pharmacist. Technicians Value of Drugs Supplied Technicians 1 14,331,000 Technicians 2 6,362,000 Technicians 3 5,417,000 Technicians 4 6,140,000 Technicians 5 5,269,000 Technicians 6 5,067,000 Technicians 7 5,726,000 Subtotal 48,312,000 Pharmacist 9,688,000 GRAND TOTAL 58,000,000

13. 48 • The Red Crescent Society of the Islamic Republic of Iran operating beyond its expiration is in contravention of the MOU signed with the Government of Sierra Leone. Recommendations • Le 91,975,000 (Ninety one million, nine hundred and seventy five thousand Leones) worth of drugs not accounted for by the hospital management should be repaid by the persons concerned with immediate effect and to be deposited into the hospital drugs account. • The Ministry of Health should review the MOU between the hospital and the Iranians with assessing the need for continued collaboration. • Nurses and other hospital personnel should desist from the sale of drugs. • The pharmacist should stop allocating drugs to Technicians a nd institute a proper cost recovery mechanism at the hospital. • Management should ensure that drugs are sold on Cost Recovery basis. • Management should ensure that a Store Keeper be assigned to the Hospital. • Staff members working in the FHC pharmacy should not be the same staff working in the Cost Recovery Pharmacy. • The finance office should handle all matters relating to finances in the Hospital and also provides quarterly financial reports to management. • The finance officer should be part of the signatories to the Drugs account. • Cost Recovery Drugs should be displayed on Shelves of the Pharmacy rather than been personalized by the Technicians. The pharmacy should developing world were also considered. The collection of data was both primary and secondary while the former involved direct contacts with persons who possess the desired information. Structured and semi - structured interviews formed part of the information gathering process through the administration of questionnaires. The latter which is the secondary data was used to collect information on service delivery, systems, practices and procedures on the management of drugs and other related services in other countries within the sub - region. The data collected enabled the team to sufficiently analyze emerging issues as well as bring out pertinent experiences of other institutions and countries in drugs management. 1.4 FINDINGS AND RECOMMENDATIONS CENTRAL MEDICAL STORE 1.4.1 INTERNAL AUDIT The internal auditor is responsible for assessing the adequacy and effectiveness of the department ’ s processes for controlling its activities and managing its risks. Consequently, it has clear authority to examine the activities of every unit of the department. Area of Focus: Verification of deliveries to stores. Finding(s) • The internal auditor of the CMS is not present when drugs are 11

11. 50 Findings • From the table above, the Pharmacist received Le58, 000,000 worth of drugs from FCC for the purpose of operating a cost recovery scheme. • The Pharmacist in turn apportioned and allocated these drugs to seven (7) Technicians to sell. A total of Le 48,312,000 (Forty Eight million, three hundred and twelve thousand Leones) worth of drugs was distributed to the Technicians. The difference of Le9, 688,000 (Nine Million Six Hundred and Eighty Eight Thousand Leones) could not be accounted for by the Pharmacist. • It was observed that there was no proper records keeping of drugs as Stock cards numbering did not correspond to the labelling of drugs on the shelves in the store. All stock cards presented by the storekeeper had the same date; this implies that most stocks stored are not recorded. • There was a massive sale of drugs by Health care workers to patients in the hospital. They are using government resources to sell their own drugs on a profit basis. • Cost recovery drugs are sold at the same facility that was housing Free Health Care drugs by the same personnel. This creates the possibility of drugs been swap from one program to the other. • The hospital does not have drugs account into which proceeds from the sale of these drugs can be deposited. • There is Poor records management. Implication • Without proper accountability on the sale of drugs, there will be no replenishment of drugs which in essence will cause a stock out. Recommendation 9 consumption and stock level at health facilities across the country, Chanel software application has been installed in all major health facilities. MANAGEMENT RESPONSE Officer ’ s Response The Directorate of Drugs and Medical Supplies (DDMS) have since moved from the “ Push ” to the “ Informed Push ” system of distribution. The “ Informed Push ” system of distribution provides the opportunity for every District Health Management Team (DHMT) and Hospital management Team (HMT) to fill in the FHC & RH Request Form prior to any upcoming nationwide mass distribution, with the quantity needed. The health facilities are required to input the current stock levels and the requested amount for the quarter based on consumption data from Service Delivery Points (SDP). Request Forms which are submitted without the current stock position will not be honored. DDMS and partners quantify the quantity of health commodities needed to fulfill needs for the targeted clients nationwide; but lessons learnt proved that funds for procurement were never enough to procure the quantified quantities; hence the quantified list is always streamlined or adjusted to align with the funds available for procurement. In addition, there are challenges with procurement lead times since procurement is done by UNICEF and DDMS have little or no control over the commodities available for distribution. Based on the above, DDMS normally rationed some health commodities in the distribution matrix according to the available supplies in stock, even though the facilities would have requested more.

22. 1.4.3 FLEET MANAGEMENT Area of Focus: Unaccounted Vehicles Finding • The team discovered that ten (10) vehicles were unaccounted for at CMS and no record was available to trace these vehicles. According to the CHANNEL Health Supply Management System, stock reception report 10008 - ebola response store 4 for the Reporting Period 2016 - 08 - 09 to 2016 - 08 - 09; the following vehicles were received: Implication • The unaccounted vehicles may have been lost or converted to personal use through unscrupulous means. This represents a huge financial loss to the CMS. Recommendations • The ministry should institute an investigation into the disappearance of the ten (10) vehicles. • ACC to investigate the disappearance of the ten (10) vehicles 20 TYPE OF VEHICLE DATE OF ARRIVAL QTY Toyota Hiace 2016 - 08 - 09 2 Toyota Land Cruiser Hard top 2016 - 08 - 09 4 Toyota Land Cruiser V8 2016 - 08 - 09 4 Total Vehicles 10 chain staff in all District and Hospital Stores. The pharmacist has a laptop that had been provided by Management Sciences for Health (MSH) to enhance effectiveness and smooth running of his assigned activities at his place of work. The model is DELL Vostro - 14 5000 series. The alleged computer (model is LENOVO M30) was the one been used by the District Information Officer provided to him by UNFPA. The battery of this computer got damaged and could not function properly. There CHANNEL operated desktop computer hosting the Logistics Management Information System data suddenly developed technical problems. This necessitated data transfer from the desktop computer to laptop computer operated by the District Information Officer and in this pro- cess, some data were lost; hence this leads to the discrepancies between the physical stock and the CHANNEL software current stock. In response to the discrepancies between physical stock and records in the stock cards, the Tonkolili supply chain team forwarded thus: • For hydrogen peroxide, during the time of visit of the team there was no hydrogen peroxide at the hospital store as stated in the discrepancies table in the report. • We do not have any product as AENOLOL (1000 Dose) but we do have ATENOLOL 50mg tablets with pack size of 1000 tablets per cup. • We do not have CHLORHENXIDINE GLUCONATE 71%. DMS has CHLORHEXIDINE DIGLUCONATE SOLUTION 7.1% with a volume of 10ml. 39

5. 1 .7 RECOVERIES MADE ON COST RECOVERY DRUGS During our intervention, a robust action was taken by the Commission in ensuring that proceeds on cost recovery sales at the hospitals are paid into their respective drugs accounts. The table below shows analysis of recoveries made as a result of our intervention. From the table above, a total recovery of Le120,795,000 (One Hundred and Twenty Million Seven Hundred and Ninety Five Thousand Leones) was made from the various hospitals with respect to outstanding proceeds on sales of drugs. MANAGEMENT RESPONSE Officer ’ s Response The Ministry of Health and Sanitation has ceased to operate a cost recovery scheme since 2013. As was already mentioned in our previous response, DDMS was not involved and is not aware of any transaction between health facilities and FCC for the purchase and sale of cost recovery drugs; hence could not comment on this issue . 56 HOSPITALS AMOUNTS RECOVERED (Le) ROKUPA GOVERNMENT HOSPITAL (RGH) 6,396,000 KINGHARMAN ROAD GOVERNMENT HOSPITAL (KHRGH) 45,617,000 DISTRIST HEALTH MEDICAL TEAM (DHMT) 13,500,000 MACAULAY STREET GOVERNMENT HOSPITAL (MSGH) 48,049,000 TOTAL 120,795,000 1.0 BACKGROUND The management of drugs and other medical supplies by government health facilities across the country have posed a challenge to the Health Sector. Accordingly, quite a number of complaints have been received by the Commission on the alleged mismanagement of drugs and other medical supplies at government medical stores, including the main Government Medical Stores at New England Ville in Freetown, Hospitals and other healthcare peripherals across Sierra Leone. The goal of health care delivery systems is to provide needed, high quality care, particularly for vulnerable populations, to improve individual and population health. At multiple points in health systems, medicines contribute to achieving, or impeding, these goals. Medicines access, affordability and appropriate use must be a core focus for any effort to strengthen health systems. Medicines are major contributors to the health and well - being of individuals and populations when used appropriately. They waste resources when used unnecessarily or incorrectly. For national health facilities to deliver services effectively, drugs and other medical supplies need to be efficiently and effectively managed. Therefore, the viability of service delivery of the Health Sector may hugely depend on the proper management of drugs, medical services, and other related resources. According to World Health Organisation (WHO), medicines involve the second highest expenditure after staff costs in a country ’ s health care system. The statistics of global spending on medicines showed that in 2010, total spending on medicine was 887 billion U.S. dollar and it is estimated that by 2020, the pharmaceutical market will increase to 3

24. 22 Implication • An untrained head will undermine the effective /smooth running of the human resource unit. Recommendation • There should be trained personnel to handle the Human Resource and Administration rather than a pharmacist. If she is to be retained she should be trained to carry out its functions effectively. Area of Focus: staff attendance Finding • A staff attendance book is maintained but no adequate control over time and attendance reporting. Most staff do not sign the attendance register and there is no proper supervision of staff attendance at work by the HR unit. Implication • Lack of proper management of the time book creates ineffective tracking of staff attendance. Staff failing to sign attendance register signifies poor monitoring of staff movement. Recommendation • The staff attendance should be properly monitored and supervised by the respective unit. MANAGEMENT RESPONSE Officer ’ s Response Even though the Head of Human Resource at DDMS is a Pharmacist by profession, she has received couple of trainings from the Human Resource for Health Department of MOHS and Human Resource development partners . 37 Pharmacist supervise the hospital store while the DHMT Stores provide drugs and other Medical Supplies to the PHUs in the Districts. Some of the findings are generic though others are slightly different in the regions. Findings • The team observed that there are no store assistants assigned to the store keepers in dispensing his duty as most of them are volunteers. • Stock cards are not displayed or available in the stores as a result most drugs and other medical supplies were not recorded. Although in some Stores photocopies of the Stock cards were used in order to manage the Situation. • In Magburaka, the following discrepancies between physical stock and records in the stock cards were discovered: The team discovered that there were variances between records of the Channel system and stock cards for some drugs and other medical supplies received. For instance Salbutamol Inhaler batch no.0008k110 , item code Name Of Drugs Stock Card Balance Physical Count Balance Variance Remarks Zinc Sulph 300 200 100 Magburaka Government Hospital Store AENOLOL (1000 Dose) 20,000 11,000 9,000 Magburaka Government Hospital Store Ciprofloxaxin 250mg 430 200 230 Magburaka Government Hospital Store Chlorhenxidinegluconate 71% 109 89 20 Magbouroka District Medical Store ButoAsma 78 40 38 Magbouroka District Medical Store Hydrogen Peroxide 30 19 11 Magbouroka District Medical Store

15. 46 Technicians Expected Sales (Drugs Supplied) Le Stock at Hand Le Unaccounted Stock/ Amt Le Technician 1 2,165,000 105,000 2,060,000 Technician 2 1,705,000 1,074,000 631,000 Technician 3 1,030,000 730,000 300,000 TOTAL 4,900,000 1,909,000 2,991,000 The table below shows the amount in value of drugs supplied to Technicians to sell From the table above, the Technicians were supplied drugs worth Le 4,900,000 (Four Million Nine hundred thousand Leones) and are expected to report same. During our intervention, it was discovered that these technicians have not accounted for 61% of the total sales. Drugs supplied by FCC to Macaulay Street Hospital From the table above, FCC supplied a total of Le91,975,000 (Ninety One Million, Nine Hundred and Seventy Five Thousand Leones) worth of drugs between the periods 2016 - 2017 costing Le40m and Le51.975m respectively. At the time of our intervention, the proceeds on the sale of drugs were not accounted for. • The hospital pharmacist is also acting as a store keeper since there is no substantive store keeper at the hospital. However, the pharmacist is most times absent from duty especially at the time one would expect her to be dispensing drugs to patient. Also she has no total control over the pharmacy technicians and they do things at their own whim and caprices. 2016 Le 2017 Le Cumulative total Le Unaccounted Stock amount Le 40,000,000 51,975,000 91,975,000 91,975,000 13 DDMS is a responsible entity and have existing Standard Operating Procedures (SOPs) guiding processes in the supply chain cycle. Stakeholders (i.e. Technical and non - technical) with different interest are always involved during delivery of health commodities all medical stores. Deliveries are done with appropriate delivery/shipping documents that specify details of items, specs, quantities, etc. to be delivered and in that event, the commodities are checked against the packing list before the delivery documents are signed off by the stakeholders. Area of Focus: Audit conducted at CMS Finding • During the review, it was observed that the Internal Auditor has not done any audit at the CMS as no audit report was produced during our intervention. Implication • Without an assessment of the department, its effectiveness will not be ascertained with respect to its readiness to ensure proper delivery of service. Recommendation • A proper internal audit should be conducted regularly on all units in order to assess the effectiveness of their internal controls. MANAGEMENT RESPONSE Officer ’ s Response Though the draft audit report does not specify the period under review, and the source of the information for this query, the Directorate of Drugs and Medical Supplies like any other government entity is subjected to audit. Different audit firms (such as Audit SL, KPMG, Internal Audit, International

9. 52 above). • Nurses are also in the habit of treating and selling drugs to patients instead of referring them to the Doctor and/to the pharmacy. Implication • There is tendency of selling substandard and expired drugs to patients which poses threat to the patient ’ s life. • Failing to make returns undermines transparency and accountability. • Expired drugs can cause fatality to patients in the hospital. Recommendation • Pharmacist should be included in the procurement process of drugs in order to ensure that drugs have the adequate life span and are not substandard. • Hospital Management should put proper mechanism for the management of cost recovery drugs and monies should not be handled by the Technicians. • The Pharmacist should stop the distribution of drugs to pharmacy technicians to be sold. • Nurses should desist from treating patient or prescribing drugs without recourse to the professional Head and the pharmacy. • All outstanding monies should be repaid by Technicians . 1. 6.4 LUMLEY GOVERNMENT HOSPITAL Lumley Hospital being a beneficiary from the drugs procured by FCC 7 DRUGS MANAGEMENT CYCLE According to WHO drugs management functions are undertaken in four principal phases, which are interlinked and are reinforced by appropriate management support systems (i.e. tools). The drug management cycle starts drug selection to drug use, passing through procurement, storage and distribution. This cycle is supported by a whole range of management capacities and use of appropriate tools within a given legal and policy framework. Good drug supply management is an essential component of effective and affordable health care services globally. SIERRA LEONE SETTING In Sierra Leone, various health care schemes/programs have been initiated to cater for the healthcare needs of its population. Central to these programs is the provision of essential drugs which should be available at all times in adequate amounts in appropriate dosage forms at an affordable cost. The World STAKEHOLDERS MAIN ROLES AND RESPONSIBILITIES OBJECTIVES Civil society Advocate for the health care needs, including medicines, of the com - munity Convene or participate in policy dia- logues. Represent interests of non - state actors Participate in strengthening the health care system Support individuals and house - holds in their community. Professional associations Negotiate relationships Train, license and monitor professionals. Maintain or improve the rights and working conditions of health professionals Maintain or improve professional capacity and professional ethics. Health - financing agen- cies responsible for revenue collection, pooling and purchasing. Set financing rules for health care and medicines man- agement strategies Pay for health care services and medicines. Prioritize fund allocation Ensure appro- priate use of funds Remain financially sustainable. Bilateral and multilateral donors; philanthropic organizations. Identify points within health systems that align with the medicines agenda for direct financial transfer, capacity building and other technical support. Contribute funding that works to strengthen health systems.

27. 34 Recommendations • There should be a flow of information from the Donors to the CMS in making any Donation to Hospitals and PHUs. Also, Tertiary, Secondary Hospitals and PHUs should in turn inform the CMS of any Donations received as this will aid CMS to plan well in the distribution of Drugs and other medical supplies. • CMS, hospitals and other peripherals should desist from receiving expired and unwanted drugs and other medical supplies as donations. • Donor ’ s attention should be drawn to the Donation Guidelines. • The management should ensure that the stores are being managed by trained stores keepers and supervised by a pharmacist. • Also, Laborers or store assistants should be contracted to provide support to stores in the handling and loading of stock. • There should be proper Store Records in place, both electronics and Manual system of Recording. • The Stores should be properly clean and maintained to make them nonhazardous to store keepers. • There should be an overhauling of Store four (4) for it to be fit for purpose • The stores should be provided with the relevant office equipment to carryout it functions. • Store Keepers managing these stores should be properly trained and qual- i f i e d a s i t w i l l e n a b l e t h e m t o h a v e t h e r e q u i s i t e s k i l l s t o c a r r y o u t t h e i r f u n c- tion effectively and efficiently. 25 • Some local arrangements have been made by some facilities to operate the cost recovery scheme. At the Makeni Government Hospital a memorandum of understanding was signed with various private pharmaceutical companies for the supply of essential drugs. • In the Western Area, the Freetown City Council has a budget line for the procurement of Cost recovery drugs which serve as a buffer stock. These drugs are procured and distributed to the Secondary Health Care and the District Health Management Team (DHMT) for further distribution to the PHUs for sale on cost recovery basis. • The table shows the Distribution schedule of Cost Recovery drugs supplied by Freetown for 2016 and 2017 to these facilities . Officer ’ s Response The Directorate of Drugs and Medical Supplies through MOHS is in the process of revitalizing the Cost Recovery scheme. The authorities of DDMS are aware of the Central Government devolving some of its functions to the Local Government in which management of hospital is within their scope. Sincerely speaking, the authorities of DDMS are not aware and have not been part of any procurement or sale of cost recovery drugs by Freetown City Council (FCC) and Hospital Managements nationwide . DDMS will engage FCC and Directorate of Hospital and Laboratory Services to ensure that they follow the policies guiding procurement and sale of cost recovery drugs and medical supplies .

8. 6 TABLE 1.1 STAKEHOLDERS MAIN ROLES AND RESPONSIBILITIES OBJECTIVES Central Government Set, implement and enforce laws, regulations and policies Allocate resources Strategically plan and coordinate with state actors Offer political leadership Ensure national security Expand or maintain international relations and trade Ensure social and economic welfare. Central Ministries of Health Set, implement and enforce health - related laws, regulations and policies Allocate resources for health care Strategically plan and coordinate with actors in health system Improve health of the population Strengthen health care and pharmaceutical systems Control expenditures on medicines Improve the access, affordability and appropriate use of medicines Provide a stewardship function for the health system that engages with key stakeholders Regional, District, Provincial or Municipal Authorities Implement and enforce laws, regulations and policies Strategi- cally plan and coordinate with state actors at the regional, pro- vincial or municipal level Maintain political leadership Ensure social and economic welfare Regional, District, Provincial or Municipal Health Authorities Set, implement and enforce health - related laws, regulations and policies locally Allocate re- sources for health care locally Strategically plan and coordinate with actors in the local health system Ensure functioning health care system, including supply, financing, delivery and use of needed medicines. Pharmaceutical manufacturers (local and international) Produce and sell safe, high - quality essential medicines Agree to and/or engage in the generic production of medicines for LMIC use Sell medicines and turn a profit Pharmaceutical distributors Ensure timely, efficient delivery of essential needed medicines Sell medicines and turn a profit Health care facilities (including primary, secondary, tertiary; public, private, and NGO) Implement health and medicines policies Deliver health care ser- vices Procure, stock, administer or dispense essential medicines Ensure health care service delivery operations Provide quality care Improve patients’ satisfaction with care Balance income and expenditures, or make profit Health care providers (formal and informal) Prescribe and dispense medi- cines Provide high - quality services Ensure patients’ satisfaction with care Maintain income level or make a profit Patients and households Pay for services and obtain medi- cines Obtain high - quality medicines at affordable prices. with the intended purpose of Cost recovery benefitted in 2016 and 2017. The table below gives a synopsis of analysis at Lumley. • They operate a single account in which proceeds from the sales of drugs and all other revenue generated are deposited. • The table above tells us that a cumulative total of Le 20,000,000 (twenty million Leones) worth of drugs was procured and supplied by FCC to the Lumley Government hospital in 2016 (Le10m) and 2017 (Le10m). In 2016, proceeds of Le2, 777,000 (Le two million seven hundred and seventy seven thousand Leones) was deposited into the hospital main account and a residual balance of Le7,333,000 (seven million three hundred and thirty three thousand Leones) could not be recovered by the Pharmacist from the Technicians. • In 2017, proceeds of Le 8,457,000 have been deposited into the hospital account. As at the time of the review, the remaining stock balance on cost recovery drugs amounted to Le 1,543,000. 53 Year Value of Drugs (Le) Amount Accounted (Le) Stock at hand Unaccounted Amount (Le) 2016 10,000,000 2,777,000 Nil 7,233,000 2017 10,000,000 8,457,000 1,543,000 Nil Total 20,000,000 11,234,000 1,543,000 7,333,000

6. 4 around 1.4 trillion U.S. dollars. The money spent on buying medicines by governments is very large and 40 to 60 percent of entire public sector health budget of any country goes into buying medicines. Despite such heavy spending, one - third of world population lacks access to essential medicine, which actually goes up to one half in Asia and Africa. Major reasons for this adverse situation are the mismanagement of available resources and according to one estimate up to 70 percent of resources are wasted in any country due to poor drug management systems. World Bank indicates that in many developing countries, a high percentage of medicine losses occur in the government procurement, storage, distribution, and utilization system. It has also been established that in certain areas, a significant proportion of essential medicines and supplies are misappropriated or diverted. To address this gap judicious management of drug systems is mandatory. (Sys Rev Pharm. 2017; 8(1):80 - 85. A multifaceted Review journal in the field of Pharmacy). Three reasons can be given to explain why drugs need to be managed properly. Firstly, drugs are part of the link between the patient and health services. Consequently, their availability or absence will contribute to the positive or negative impact on health. Secondly, poor drug management, particularly in the public sector of developing countries, is a critical issue, but major improvements are possible that can save money and improve access. Finally, drugs are no longer the responsibility of health workers only. Politi- cal, economic, financial and traditional considerations have become so crucial in health care that it has become imperative to look at drugs and health care from these perspectives. All of these factors contribute to appropriate financial expenditure, avoid wastage, increase access and ensure that drugs are properly used. As is inherent within the Bamako Initiative, proper drug management may also be 55 Health Care Facili- ties (Government Hospitals) Value of Drugs supplied FCC (le) Cumulative Total (Le) Unaccounted Amount (Le) Total unaccounted amount (Le) 2016 2017 2016 2017 Lumley 10,000,000 10,000,000 20,000,000 7,233,000 0 7,233,000 Rokupa 73,440,000 0 73,440,000 10,403,000 0 10,403,000 Macaulay Street 40,000,000 51,975,000 91,975,000 40,000,000 51,975,000 91,975,000 Kingharman Road 58,000,000 0 58,000,000 58,000,000 0 58,000,000 DHMT 0 13,750,000 13,750,000 0 13,750,000 13,750,000 GRAND TOTAL 181,440,000 75,725,000 257,165,000 115,636,000 67,268,000 181,361,000 1.7 Summary of Analysis on Drugs Supplied By FCC