COVID-19: Pandemic puts pressure on medicine supply
Reports of drug shortages and stock-outs across South Africa have the Department of Health in a race against the clock to ensure a supply of essential medicines. With manufacturing operations around the world, particularly in India and China still facing challenges due to the COVID-19 pandemic, the country is battling to meet the demand for contraceptives, tuberculosis (TB) medicines and psychiatric medicines.
Director of Affordable Medicines at the National Department of Health, Khadija Jamaloodien says that the availability of medicines in the country is roughly 84 percent, describing the severity of shortages as “moderate”. The North West and Limpopo provinces are most affected, she says.
In a survey of 109 healthcare facilities conducted during the lockdown, The Stop Stock-outs Project (SSP) found that stock-outs were ongoing, particularly for ARVs, TB medicines, contraceptives and childhood vaccines.
“If reports about fewer patients visiting clinics during the lockdown are correct, then it might imply that there would be fewer medicines out of stock,” says SSP Project Coordinator Ruth Dube.
From the survey data, SSP identified the North West and the Free State as the two provinces experiencing the most supply issues. Recently, Spotlight reported on severe shortages of essential medicines in the North West.
“Our hot spotting data definitely confirms the problem in [the] North West province. We had 40 out of 105 reports coming from the North West. Free State is second with 17 cases reported,” says Dube.
Following the Free State are the Eastern Cape, KwaZulu-Natal, Gauteng, Western Cape, Mpumalanga and Limpopo – in that order, she adds.
Issues with supply
“COVID-19 has caused issues at all steps of [the] supply chain,” says Jamaloodien. “We found that due to the lockdown, manufacturing capacity has been negatively impacted as factories need to deal with a reduced workforce. Some shipments are also delayed due to some staff on the in-bound cargo vessels testing positive for COVID-19, requiring the need to place the ship under quarantine for 14 days. Volatility in demand due to stockpiling in preparation for COVID-19 has created additional pressure on the supply chain, and most companies cannot produce according to the demand.”
Jamaloodien says that non-COVID-19 related challenges like outstanding manufacturing issues at facilities, freight delays and ever-changing demand continues to impact supply.
Adding to this, she notes late payments by provinces to suppliers, and suppliers failing to accurately report data to the department to allow issues to be quickly resolved.
ARVs, TB and psychiatric medicines
Regarding ARVs, Jamaloodien says that a delay in the roll-out of the updated HIV treatment guidelines had led to incorrect estimations of medicine requirements. “Suppliers have struggled to adapt quickly to this mismatch resulting in shortages,” she says.
Less than two weeks ago, Dr Norbert Ndjeka, Director of HIV, TB and DR-TB at the National Department of Health told Spotlight that certain drugs used to treat drug-resistant TB were facing shortages. “We have been running short of Terizidone from February although we have sufficient stock of [P-amino salicylic acid] PAS and Ethionamide which are used so long. In some instances Delamanid is used as a replacement. We shall get Terizidone in eight weeks [now roughly six weeks] time, but there is no crisis.”
“Regarding levofloxacin, we have enough moxifloxacin which is used as replacement,” he added.
Neither Ndjeka nor Jamaloodien noted any shortage of the BCG vaccine.
Alongside ARVs and TB medicines, some psychiatric drugs are in short-supply. Jamaloodien says that the COVID-19 pandemic had compounded pre-existing poor performance by suppliers of these medicines.
Spotlight spoke to patients both in the Western Cape and KwaZulu-Natal who said that during the lockdown period they had struggled to get medication for bi-polar disorder and depression, namely Lithium. Earlier in May, Professor Bonga Chiliza, President of the South African Society of Psychiatrists, warned of shortages of Lithium and sedation medicines.
In response Jamaloodien told Spotlight, when stock [of any kind] is not available from a contracted supplier, they look for alternative suppliers. “In the case where no stock is available in the market, therapeutic alternatives are recommended as an interim measure,” says Jamaloodien.
Another major concern for SSP is the availability of contraceptives, such as the Depo-Provera injection.
“Women on contraception usually want to avoid having abortions but we see that contraception is out of stock, movement between places is restricted so the option of accessing this medication elsewhere may not be possible and access to abortion services has been targeted as non-essential in some places,” says Dube. If women are turned away without Depo-Provera, they should send a please call me, SMS or phone the SSP Hotline at 084 855 7867, she advises.
Jamaloodien confirms shortages of contraceptives and says it is an ongoing issue due to manufacturing constraints worldwide.
“Shortfalls in the supply of one contraceptive commodity, unfortunately, results in an increase in demand for other contraceptive commodities, above the initial tender estimates. Ultimately, this has led to a domino effect, with a number of contraceptive suppliers struggling to match the demand from public health facilities,” she says.
However, Jamaloodien says that the situation is quickly improving.
“There is [a] dedicated team that is specifically tasked to identify problematic products and source stock where available in the market to ensure security of supply,” she says.
Ensuring availability of chronic medicines
The Central Chronic Medicine Dispensing and Distribution (CCMDD) programme is functioning as normal, according to Jamaloodien, but it has been impacted by shortages as a result of supply issues due to the COVID-19 pandemic. The CCMDD programme allows people to collect medicines at various pick-up points to reduce clinic visits.
According to the Health Department there are over 3 million patients registered for this programme.
“There is a plan to provide three months’ supply of medicines to stable patients requiring chronic medications to reduce the number of facility visits thus reducing their risk of exposure to the virus,” says Jamaloodien. “In order to support this the department has been working towards securing the required quantities from suppliers. However, this depends on [the] supplier’s ability to deliver against the demand.”
Dube points out that patients who can’t get chronic medication are at risk of adverse outcomes related to their conditions. “These adverse outcomes will need to be attended to in clinics or hospitals. This puts additional strain on the health system at a time when we should do everything to reduce unnecessary patient visits, to limit crowding in health facilities and consumption of resources,” she emphasises.