“I am a patient at a clinic in Tzaneen and have been on ARVs since 2005.  I went to the clinic this year and was given only 2 weeks supply and told to come back when finished.  When I went back at the end of 2 weeks, I was told that the drugs were out of stock and I went for 2 weeks without treatment.  At present, I have found out that my CD4 count has decreased from 1000 to 500.  Five people from my support group have died in the past year due to resistance.  I am scared of developing resistance.”  Patient Interview October 2013

The Chronic Crisis

On 10 October 2012, staff at Mthatha depot in the Eastern Cape staged a strike, leaving the depot with only 10 out of more than 40 working employees.  Coupled with chronic supply chain issues this precipitated widespread medicine stock-outs in the region.  An estimated 53% of facilities served by the depot experienced ARV and/or TB medicine stock-outs and 24% sent patients home without any antiretrovirals.

In December 2012 MSF & TAC responded to the crisis by supporting staffing, management and medicine delivery at the depot.  As part of a wider civil society collective, which included the Southern African HIV Clinician’s Society, SECTION27, Treatment Action Campaign (TAC), Rural Health Advocacy Project (RHAP), Rural Doctor’s Association of Southern Africa (RUDASA) and Médecins Sans Frontières (MSF), these finding were published in a report, with the objective to effect positive changes in the provincial supply system.

Returning to the area in May 2013 to evaluate progress, we were surprised and saddened to find that 40% of facilities contacted continue to experience on-going or intermittent stock-outs of ARV and/or TB medicines.

To better understand why stock-outs were occurring we contacted patients and health care staff over the country and quickly realised that stock-outs were occurring across every province. What this means is unnecessary death, sickness and medicine resistance.  As painfully illustrated by patient testimonies, the most vulnerable are the most at risk and the least able to advocate their own case.

This brings us to where we are now, reporting the results of a national survey of medicine stock-outs completed during the months of September and October 2013.  This is a survey conducted by the civil society consortium mentioned above, in response to the failures of ARV and TB medicine supply witnessed. In Africa’s wealthiest nation, in the world’s largest HIV programme, this situation must end. The system must become accountable to the patients it serves.

How did we investigate the extent of stock-outs in South Africa?

To measure the extent and impact of HIV and TB stock-outs we set out to call by telephone as many clinics as we could, to ask them directly about what they were seeing and doing.  A stock shortage was defined as less stock of a medicine available than required for projected usage until next order received (as identified by the health care worker responding).  A stock-out was defined as physically having no stock on shelf or in facility when required for patient use.

Of all the facilities in the country we identified, we were able to contact 61% (2432 facilities out of 3827). The overwhelming majority of those, which were contactable, provided information (91%), with only 9% of facilities refusing to answer the survey questions. This very high rate of collaboration of health staff is encouraging and shows both recognition of the problem and a willingness to do something about it. The calculated proportion of facilities affected was carried out using only facilities that provided information as a denominator.

What did we find?

We found stock-outs to be alarmingly common across the country.

Of the 2144 facilities providing information across South Africa, one in four facilities faced a stock-out or shortage of ARV or TB supply within the previous 3 months before they were contacted.  Half of these facilities, which reported a supply issue in the previous 3 months, had an on-going, persistent supply issue at the time they were called.

There were large differences between provinces for ART and/or TB drug stock-outs or shortages, with shockingly high levels in some provinces:

• One in two facilities in Free State affected
• Two in five facilities in Limpopo,
• One in five facilities in Mpumalanga

The median length of stock-out or shortage of ARV or TB supply reported was 30 days (inter-quartile range: 14-60 days) with a minimum of 1 day to a maximum of more than 165 days. Most often facilities reported relying on a depot for delivery (one in two facilities); one in three relied on a hospital, one in ten on a sub-depot, one in thirty on alternative facilities and one in three hundred on direct supply.

Impact of stock ruptures on patients

Health care workers in facilities were asked about the impact of stock-outs or shortages on their patients. We have divided their responses, for simplicity, into high impact (if the patients were sent home without medication or referred elsewhere without medicine), medium impact (regimen changes or if patients were given less than their full supply) and low impact (the facility borrowing to meet patient need or the patient given an alternative pack size).

The breakdown of patient impact can be seen in the pie chart below.

ARV and TB Supply

Stock-outs and shortages were reported more often for ARVs than for TB medicine. Only one in thirty facilities
reported a problem with TB medicine.  North West reported the lowest number of facilities with problems (one in two-hundred) and Limpopo the highest (one in fifteen). Problems with ARV supply were much more frequent, with one in four facilities nationwide reporting stock-outs or shortages in the past 3 months. Western Cape reported the least (one in forty) while Free State had an alarmingly high level of stock-outs and shortages (more than 50% of facilities).  Lamivudine and Efavirenz were the two medicines most often facing a stock-out or shortage of.

Discussion

This national survey uncovered alarmingly high numbers of stock-outs and shortages of ARVs and TB drugs. Supply issues need to be urgently addressed so that no patient leaves a health facility without their life saving medicines.

The survey does not allow pinpointing of the failures in the supply chain that have led to stock-outs. It is now evident that focused interventions at all levels of the complex health system are essential to improve patient access to medication.  Yet there are some key focus areas that need urgent attention, including, but not limited to, the following:

• Stock-outs and medication shortages are underreported and monitoring systems must improve.
• The first step in solving the problem is acknowledging that it exists.
• Poor visibility of stock-outs leads to lack of accountability and delayed responses.
• A number of health professionals reported that primary health care staff often lack adequate training to manage medication supply.
• Staff at facility level also needs to be trained on strategies to ensure minimal harm to patients if a stock item is not available.

Stopping stock-outs will take concerted effort

We call upon the National Department of Health to appoint a national task force to investigate and address the issue of stock-outs.

Each individual Provincial Department of Health needs to work in collaboration with the National Department in order to stop stock-outs.  This will require an agreed clear strategy, with pre-defined targets and timelines to be followed.

Given the magnitude of the identified challenges in the Free State and Limpopo, as well as individual districts with exceptionally high levels of stock-outs, emergency joint action, from both provincial and national departments of health is needed immediately.  Failure to do so has the potential to cause unnecessary suffering and death.

The National Strategic Plan lays out achievable goals and an admirable vision for the health service in South Africa.  If we are to achieve this vision, then ongoing problems concerning medication stock-outs cannot be ignored.

However, solutions are available.  Not least making the system more accountable to the people it serves: the patients.

Civil society has an important role in helping to bring stock-outs to an end

The Stop Stock-outs Project (SSP) is civil society’s response to bring transparency to medicine problems facing patients.  The main goal of the SSP is to bring awareness to stock-outs as they occur and highlight problem areas in the supply chain that need attention.  The project aims to empower the tens of thousands of patients and clinicians affected by stock-outs.

It is time to stop stock-outs.  The system must be accountable to those it serves and an appropriate response from all levels of the health system is required.

To report stock outs to the SSP, send a SMS or “Please Call Me” to 084 855 7867 or email report@stockouts.co.za