Drug stock outs: the crisis continues
South Africa has one of the most extensive HIV and TB epidemics in the world. A reliable supply of life-saving medication is a constitutional right as well as critical to personal and public health. Well-functioning supply chains to deliver medicines and vaccines are crucial in responding to the needs of the population and ensuring effective treatment programmes. The Stop Stock Outs Project (SSP), a civil-society coalition that ensures transparency and accountability along the supply chain, was formed to ensure that all patients have access to the medicines they require. The SSP receives day-to-day reports of essential medicine stock outs from patients and healthcare workers via a confidential hotline.
The SSP uses these reports to liaise with the Department of Health (DoH), along different levels of the supply chain, to facilitate and monitor the resolution of each case. Additionally, the project aims to engage with government in its efforts to improve the procurement, distribution and management of essential medicine stocks in the longer term. Through the hotline, in 2014, the SSP received 614 reports (and from January to May 2015, 198 reports) of essential medicine stock outs from the general public.
The SSP also undertakes annual national surveys to systematically assess and quantify the extent of medicine stock outs in public-health facilities across South Africa. Thus far, two telephonic surveys have been conducted, in the fourth quarters of 2013 and 2014 respectively. Last year, this survey was conducted over six weeks, from October to November. Survey administrators were trained to use the same questionnaire, in order to collect standardised information. Upon calling a facility, the surveyor asked to speak to (in order of preference) the pharmacist, pharmacy assistant, or person who orders the facility’s medicine. A stock out was defined as no medicine on the facility shelf. Facilities reporting a stock out on the day of the call were asked if they were willing for their facility to be identified for follow-up. 77% (314/410) of facilities agreed, and details were forwarded weekly to NDoH.
To access the full report of the 2014 stock outs survey results, and view action plans and narratives on medicine availability from the provincial Department of Health (DoH) of Gauteng, Limpopo, North West, Northern Cape and Western Cape, visit www.stockouts.org
“I’m a 45-year-old single lady. I live in an informal settlement close to the Lillian Ngoyi clinic, called Aaron Motsoaledi. The majority of the people who live there are from rural areas in provinces outside of Gauteng. I was diagnosed with HIV 16 years ago and started ARV treatment in September 2014. In February 2015, after taking FDC for 5 months, I experienced what it is like to not be able to take treatment because of stock outs. When I arrived at my clinic, I was told that my treatment was not in stock and sent home with no medicine. I called the Stop Stock Outs project for help. I am not formally employed and I rely on informal employment, which happens irregularly. Having to return repeatedly to the clinic to check if medication is available has negatively impacted my chances of employment. Employers have started seeing me as unreliable and I am paid less due to being late for work after checking to see if my FDC was available yet. The stock out lasted for three weeks until I was able to get my treatment. I was very happy when I finally received it.” Maria, from Michael Maponya Clinic, Soweto, Gauteng
Summary of the 2014 National Stock Out Survey Results
As in the 2013 survey, there was a high participation rate by respondents in the 2014 survey, indicating a willingness from facility staff to resolve issues. Over 80% of facilities in every province, except for Free State, were willing to participate. Free State had a significant drop in participation by facilities in 2014. In 2013, 87% of facilities in Free State shared information on stock outs, while in 2014 only 63% did so. This suggests a change in context, where healthcare workers are unable to report stock outs.
HIV and TB
Nationally, during the survey period, 25% (614/2 454) facilities reported a stock out of any ARV or TB medicine in the three months prior to the survey, compared to 21% (459/2 139) in 2013.
- Stock outs of Fixed Dose Combinations (FDCs) were more infrequent in 2014 and were reported in only 75 facilities, an improvement compared to 2013.
- There were frequent stock outs of other 1st-line HIV medicine, 2nd-line HIV medicine, paediatric HIV medicine, isoniazid preventive treatment (IPT) for TB, and medicine for complicated TB. Patients who require medicine other than FDCs are often already more vulnerable because they have clinical complications such as resistance, side effects, and/or other co-existing conditions such as renal failure, or because they are children or adolescents.
- The five provinces with the largest proportion of facilities reporting stock outs were Mpumalanga (40%), North West (39%), Limpopo (29%), Eastern Cape (28%) and Free State (28%). The lower response rate in the Free State suggests this figure probably underestimates the true rate of facilities affected by stock outs.
- Proportion (%) of facilities reporting at least one ARV/TB stock out in the three months prior to contact by province, 2013 & 2014.
Six provinces had an increase in the number of facilities reporting ARV/TB stock outs in 2014 compared to 2013: Eastern Cape, Gauteng, KwaZulu-Natal, Mpumalanga, North West, and Northern Cape.
- In 22% (175/779) of the cases where an ARV/TB was reported out of stock, the patient was sent home with no medication (high impact). In 35% (230/779) of cases, the patient was either given a smaller supply, their pill burden was increased, or a less than optimal medicine was given (medium impact). In 43% (334/779) of stock outs reported, the facility was able to borrow medicine and the patient went home with their full supply of treatment (low impact).
Childhood Vaccines (Rotavirus, Pentaxim1, Measles)
Nationally, 12% (249/2 157) of facilities reported a stock out of at least one of the three selected vaccines.
- Pentaxim stock outs were most frequently reported in Limpopo, where 28% (67/238) of facilities were affected.
- Rotavirus vaccine stock outs most often reported in Eastern Cape, where 10% (42/428) of facilities were affected.
- Measles vaccine stock outs occurred most frequently in Mpumalanga, where 8% (15/182) of facilities were affected.
Other essential medicines
During the 2014 stock outs survey, stock outs of other key essential medicines were reported:
- Salbutamol inhaler (asthma) was most often out of stock in North West, where 43% (92/214) of facilities were affected.
- Sodium valproate (epilepsy) was most often out of stock in KwaZulu-Natal, where 22% (76/345) of facilities were affected.
- Enalapril/perindopril (hypertension) was most often out of stock in Northern Cape, where 20% (21/96) of facilities were affected.
The objective of the survey is to determine the extent of stock outs in order to bring the problems faced by patients and healthcare workers alike to those responsible for their resolution. While recommendations on how to fix ongoing problems are not the primary objective of this report, there are some overlapping issues that might contribute to the sustainable resolution of stock outs.
Wide variation among provinces, districts and facilities
- This survey highlights wide variation in the types of medicines out of stock, the length of stock outs, and the patient impact – both between and within provinces. The diffuse nature of the stock outs indicates that there are complex underlying reasons that differ by province and even district. Hence an analysis of root causes and the identification of solutions is needed at all levels of the supply chain, from facilities, to district teams, to provincial and national level. Co-ordinated efforts, especially between district health and pharmaceutical services, are necessary.
- Urgent action is needed in areas most severely affected.
- Improved visibility of medicines at facility level is required.
- It is critical to assess and identify what factors help to prevent stock outs in different areas. Examples of these key factors include adequate and trained human resources, district support with ordering and forecasting, on-time payment of manufacturers, and accountable and responsive facility, district and provincial managers.
- The varied results of the survey demonstrate that well-functioning systems are possible in South Africa, and targets should be set against those standards
- Given that Pentaxim, Measles and Rotavirus vaccines are supplied by the same manufacturer, the different proportion of stock outs between the different vaccines is surprising, and should be investigated.
Urban and rural areas
- There was a differential distribution of the stock outs between rural and urban areas.
- Rural districts in KwaZulu-Natal and Eastern Cape are notably affected, as well as many urban districts in Free State, Mpumalanga and North West
- Rural areas are particularly hard hit, as it is already hard to ensure an uninterrupted supply there, and these patients risk being further affected. The scale of patient numbers in urban areas also has a marked impact on stock outs.
- Assessing the various features of these areas and facilities, such as their delivery and transport systems, the varied demand for services, human resources capacity, storage space for medicines and buffer stocks, stock management systems and infrastructure (e.g. phone lines and space) can lead investigators to root causes and to effective solutions.
- The number and duration of high-impact stock outs (where patients leave without any medication) should be minimised. DoH can issue timely communication (circulars/memos) for alternative medicines, and ensure consequences for non-compliance of manufacturers are implemented. Facilities can switch to a different dosage of the same medication, monitor stock levels closely, place emergency orders, borrow medication from other facilities, and ensure they escalate stock outs to district teams, depots, and provinces.
- The long duration of the stock outs in certain provinces could be indicative of a need for more effective mechanisms, to react more quickly to stock outs. In all provinces except for Western Cape, more than 20% of stock out cases lasted for over one month
Collaboration with the Department of Health
The findings of this survey have been presented to the National Department of Health (NDoH) and the Provincial Departments of Health (DoH) in the Free State, Gauteng, Limpopo, North West, Northern Cape and Western Cape.
The aim of this report is to contribute to a constructive dialogue between civil society, DoH and its partners. Therefore, all departments were invited to include in the report a response to the report, or plan of action to address the crisis quantified in the report.
The National Department of Health and the Gauteng, Limpopo, Northern Cape, North West, and Western Cape provincial departments have engaged with civil society on causes of stock outs and potential solutions to improve the supply chain. We applaud their committed action plans to resolve stock outs; the action plans are located in the full report (www.stockouts.org).
Strong commitment and political will is necessary for the implementation of these action plans. Despite repeated attempts to discuss the findings of the report and plans to resolve stock outs, the Eastern Cape, Free State, KwaZulu-Natal and Mpumalanga provincial departments of health have not responded. We call on these provincial departments to follow the example set by the National Department of Health and the other provincial departments, and engage constructively with civil society to implement action plans to ensure that their facilities have the medicines that patients require.
Recommendations and the way forward
Urgent action is needed in the worst-affected seven districts and two provinces, where close to 40% of facilities reported stock outs.
1. North West and Mpumalanga had, respectively, 40% and 39% of facilities reporting an ARV or TB stock out.
The seven most severely affected districts, with over 40% of facilities reporting ARV/TB stock outs, are:
- Joe Gqabi 46% (16/35), Eastern Cape
- Alfred Nzo 50% (28/56), Eastern Cape
- Bojanala 44% (34/77), North West
- Nkangala 44% (25/57), Mpumalanga
- Gert Sibande 41% (23/56), Mpumalanga
- Lejweleputswa 42% (13/31), Free State
- Fezile Dabi 42% (11/26), Free State.
An emergency task force is needed to resolve urgent stock outs, in order to respond to the crises in these districts. The NDoH should urgently facilitate provinces with the formation of this task force.
2. Provincial and National health departments must work together to establish and implement national minimum standards for supply chain management and resolution of stock outs in all provinces.
Provincial health departments should develop and implement provincial action plans to resolve and prevent stock outs in every province, with clear timelines and evaluation of these action plans, and provision for emergencies; and they should focus on worst-hit districts.
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