Why are there no medicines at the clinic?
When patients go to clinics or hospitals many are told that the medicines they need are unavailable. Why does this happen and what can be done about it?
The Treatment Action Campaign (TAC) regularly responds to complaints about stock-outs of essential medicines at health facilities. On some occasions, patients have suffered because they have been unable to obtain antiretroviral (ARV) drugs. At other times, clinics have run short of TB medicines and basic pain medications.
When TAC helps with complaints like these, we first try to communicate directly with the staff at the facilities and depots involved to find out why medicines have not been delivered. At other times we have had to ask the Department of Health to provide emergency stocks of ARVs when provincial structures have failed to do so. What these cases reflect consistently is the deplorable state of our provincial health systems, the lack of management skills at all levels, and a lack of political will to address weaknesses directly.
Nonyameko Ntiyo (38) was without antiretrovirals for three months because of stock-outs at the village clinic in Lusikisiki in the Eastern Cape. Ntiyo, who is taking ARVs and anti-TB medication, said that the doctors had changed her treatment regimen. She was supposed to receive AZT, Aluvia and 3TC. However, no Aluvia was available from February to April 2012. During this time Ntiyo fell ill and spent almost two weeks in hospital.
“Every time I went to the clinic I would be turned away without any pills. Aluvia (lopinavir/ritonavir) was always not available. It cost me R17 to get to the clinic by taxi and when I didn’t have [the] taxi fare I walked for about an hour to reach the clinic. I would sometimes ask my dad to fetch my pills for me when I became too weak to go by myself,” Ntiyo recalls.
She says her health deteriorated rapidly and matters only improved when her friends and neighbours reported the stock-outs to the TAC office.
“That is when things started to change,” she says.
“The clinic gave us two weeks’ supply and we had to come back for more when they were finished, which meant I had to go to the clinic twice in one month. Sometimes the nurses would also try to assist by sending one of their staff members to the Gateway Clinic, but they would do that only after we became aggressive and firm with them. Otherwise they just told us to go ourselves in search of ARVs,” says Ntiyo.
She says some patients gave up trying to access their medication.
Ntiyo says the pharmacist did not explain to them that alternatives were available and was sarcastic to her. The pharmacist said he was not in the business of manufacturing pills, only receiving and distributing drugs.
“We must thank TAC for educating us that we can stand up for our rights,” she said.
The clinic that Tholakele Mhleshe (64) relies on frequently runs out of antiretrovirals (ARVs). The lack of consistent treatment may have contributed to her contracting tuberculosis and losing weight, along with a plummeting CD4 cell count. Mhleshe tested positive for HIV in 2007 and started taking ARVs four years later at the SAPPI Clinic, near her home in Mthethwa, KwaZulu-Natal.
According to Mhleshe the stock-outs started last year and have become more frequent. “That was when I started getting sick and contracted TB, lost a lot of weight and became very weak with my CD4 count dropping significantly,” she recalls.
Mhleshe said patients at the clinic would often share experiences about how the lack of treatment was affecting their health.
“We would be told to go to Ethembeni Clinic by the nurses and a return trip would cost me R50. This is too much for me. I had to try not to add it all up because I knew this concerned my life”.
From the factory to the patient
The distribution supply chain for drugs is long and complicated. Things can go wrong at various points along the way.
The distribution chain described above has many links. At each point in the chain, good management is required to ensure that the medicines flow as they should. Many of the recent stock-outs in South Africa are likely to have been caused by poor management at various points along this complex chain.
The monitoring of what happens along the distribution chain in South Africa is insufficient. While the Department of Health is able to track stock levels at depots, it is unable to track stock levels at the facility level. This makes it difficult to track where and why the system is failing. It also increases the risk of medicine thefts at the clinic level.
The distribution supply chain
- Suppliers (medicine manufacturers and importers). The state buys ARVs from pharmaceutical companies according to the conditions of a special two-yearly ARV tender. If pharmaceutical companies fail to deliver the required quantities on time this can lead to medicine stock-outs at health facilities. It is essential that the state orders the right quantities of medicines from suppliers. Accurate forecasting of future needs is needed.
- Depots receive medicines from suppliers. The drugs are then distributed to sub-depots and, in some cases, directly to health facilities. Good stock management and prompt responses to orders from sub-depots and health facilities are essential if problems are to be prevented down the line.
- Sub-depots are the ‘middle-man’ between the depots and the health facilities. Medicine stock-outs occur if, for example, sub-depots are slow to respond to orders placed by health facilities. Similarly, if the sub-depots don’t place their orders on time with the provincial depots, there may be shortages. Some sub-depots struggle because they don’t have enough space to store medicines.
- Health facilities (clinics and hospitals) place their medicine orders with the depots. If the orders are late or incorrect, stock-outs of essential medicines may happen. In a well-functioning clinic, good planning, good stock management, and correct and timely ordering are essential.
- Patients who do not get HIV treatment when they need it can develop drug resistance and get sick. Medicine stock-outs may also lead to patients being given smaller amounts of medicine. This means they have to visit the clinic more regularly. Patients will then have to spend more money on transport and this will impact particularly on the poor.
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Eight causes of medicine stock-outs
- Lack of human resource capacity
- Lack of an early-warning system
- Suppliers failing to meet tender quotas
- Premature exhaustion of budgets and/or provinces failing to pay suppliers
- Faulty processing at depots
- Faulty ordering practices at facilities
- Lack of transport between depots and facilities
How do we solve the problem?
Improving the quality of medicine distribution cannot be achieved immediately. In the long-term, the Department of Health must ensure that more qualified and capable people are put in charge of medicine distribution, management and budgeting. In the shorter-term a number of structural changes and technological solutions could be implemented:
- More direct distribution: the distribution process can be simplified by omitting some of the existing steps described above. The Department of Health has launched pilot projects to test whether it is more efficient, for instance, to distribute medicines directly from drug suppliers to health facilities. Direct distribution from depots to health facilities (thus skipping the sub-depot link) may also deliver improved results.
- Using private sector pharmacies: another option being considered by the Department of Health is allowing public sector patients to collect their medicines from private sector pharmacies. The Department of Health is holding discussions with various private sector pharmacies and a pilot project is expected to begin in early 2014.
- Electronic records at facilities: the Department of Health’s computer systems only provide information about stock levels at depots. Information about stock levels at the facility level is not collected. If stock levels at facilities are stored electronically, shortages or potential shortages could be identified faster and stock levels managed better.
- Split tenders: to reduce the risk of supply shortfalls, the Department of Health has split some tenders between companies. The new fixed-dose combination of antiretrovirals, for example, which is provided as a first-line treatment in the public sector is purchased from three different companies (Aspen, Mylan and Cipla). If one company is unable to supply the drugs on time, it should be possible to rely on the others in the short-term.
The Stop Stock-Outs Project
The frequency of widespread stock-outs of essential medicines has led a number of civil society organisations to explore alternative solutions to improving the reliability of drug supplies. TAC, the Rural Health Advocacy Project, the Southern African HIV Clinicians Society, the Rural Doctors Association of South Africa, SECTION27, and Médecins Sans Frontières (MSF) have formed the Stop Stock-outs Project (SSP).
The aim of this project is to provide patients, nurses and doctors with an easy way to report stock-outs either over the phone or via the internet. Reports will be fed into a central database and responded to as needed. All data will be anonymised and shared openly with the Department of Health and other parties. (Further details can be found at www.stockouts.co.za)Marcus Low is joint editor of NSP Review and editor of Equal Treatment magazine. Mary-Jane Matsolo is a junior communications officer at the Treatment Action Campaign.