Reimagining healthcare in the Eastern Cape: Back to Basics is the right medicine to fix stockouts

In 2012, operations at the Mthatha Medical Depot collapsed, leading to widespread medicine stockouts at health facilities across the Eastern Cape. At the time, the depot supplied medicines on the essential medicines list to about 470 public facilities in the province.

The impact of this collapse cannot be overstated.

Healthcare users across the 15 districts served by the depot could not access treatment ranging from medicines for HIV, tuberculosis and several chronic diseases. Doctors without Borders (MSF) and the Treatment Action Campaign (TAC) quickly intervened, and reached an agreement with the Eastern Cape Department of Health, which saw the two organisations deploy volunteers who packaged, loaded and dispatched medicines.

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Fast-forward eight years to 2020 and very little has changed in terms of a reliable medicine supply in the province. If anything, the situation has worsened.

The Stop Stockouts Project (SSP), established in 2012 partly in response to the Mthatha Depot crisis, has regularly highlighted stockouts in the province. Data collected by SSP shows that the total number of stockouts between April and October 2020 was double that for the same period in 2019 – likely due to the provincial healthcare system’s inability to cope with the COVID-19 pandemic. The province also faced challenges with the availability of personal protective equipment (PPE).

With the likely reorganisation of the healthcare system under the proposed new national health insurance system, and with recent changes in the provincial health department’s leadership, there is arguably a window of opportunity to achieve change for the better. Healthcare users and healthcare providers may expect, and maybe should demand, such change for the better.

Nature of the problem

As with the many other problems facing the provincial health department, the challenges plaguing medicine supply chain in the Eastern Cape are well documented. Medicine supply is a long, complex and globalised chain with many links – the slightest change in this chain can mean empty pharmacy shelves.

Stockouts can be caused by a range of factors including shortages of active pharmaceutical ingredients (API), changes in global production or demand as we saw during lockdowns in a number of countries due to the COVID-19 pandemic, and disruptions to the relatively small number of pharmaceutical companies who may make certain drugs.

While some links in the global medicine supply chain, such as shortage of active pharmaceutical ingredients, are beyond the ambit of provincial departments of health, there are some aspects that are well within their control. Indeed, much of the time the problem is as simple as dysfunction at medicines depots or a lack of coordination between depots and healthcare facilities. In short, the problem is often firmly at the door of provincial health departments – something that is clear when you consider that some provinces have a lot more stockouts than others, differences that can obviously not be explained by issues in international supply chains.

Serious consequences

Besides violating the right to access to healthcare services, the unavailability of these medicines poses both immediate and long-term problems for our health system. In the short term, the general wellbeing of the population is placed at risk, they also cannot participate optimally in the economy and instead of directing the little means they have towards purchasing other essential goods, this money is spent in private pharmacies. Severe consequences for patients on HIV and TB medicines include developing resistance to their treatment and becoming increasingly ill.

For healthcare users, an ideal situation would be sufficient medicine stocks at the clinic closest to them rather than having to resort to private pharmacies. Doctors and nurses all agree that treating their patients would be much more efficient and effective if the patients always have sufficient medicines and not risk defaulting.

Pharmacists that SSP has engaged with have highlighted the need for an integrated stock management system that would make stock taking and ordering much more efficient, minimising the risk of stockouts at facilities.

This vision of a medical supply chain that is reliable, responsive and agile to respond to the needs of those who rely on it is one that fits squarely within what the constitution requires of the state, the progressive realisation of the right to access healthcare services.

What then needs to change for this vision to become reality?

The fact that stockouts result from various factors also means there is no one-size-fits-all solution. What worked in the Western Cape may not necessarily work for the Eastern Cape – but that does not mean that lessons cannot be drawn from the experiences of other provinces in mitigating and resolving stockouts.

The first step that the Eastern Cape Department of Health needs to take is to conduct a thorough analysis of the root causes of perpetual stockouts in the province. Since success will ultimately lie in an informed and coordinated response, this analysis needs to be done at all levels of the supply chain – province, district and facility level.

The second step will be for the department to develop and implement an action plan with clear time frames to resolve and prevent stockouts. The plan must address the following:

• Surveillance and increased visibility of stockouts: Unless facilities and depots adhere to standard stock management procedures, stockouts will continue to plague the province. The department must work towards strengthening the capacity of pharmaceutical personnel so they can effectively monitor, manage, and report stock levels through the Stock Visibility Solution (SVS) application. The SVS is an electronic monitoring system rolled out by the National Department of Health to monitor availability of medicines in the facilities. The Department of Health must also ensure facilities have enough storage capacity for buffer stock with regular reporting of stock levels. It must also implement a safety stock policy that keeps stocks of essential medicines at a set level in order to mitigate the impact of supplier disruption related stockouts.
• Rapid response mechanisms for stockouts: Maintain adequate stock levels at the depots to ensure continuity of supply, even when the suppliers have failed to deliver. Besides having early warning indicators to address shortages before it results in a crisis, the system must also facilitate borrowing between facilities if necessary, and ensure patients are not going home empty-handed.
• Governance, accountability and transparency along the supply chain.

At any time, there should be traceability of medicine stock until it reaches the end user of the healthcare system (the patients).

• Supply chain strengthening and procurement reforms: This will include ensuring that suppliers are paid on time so that accounts are not put on hold and suppliers withhold stock.
• Human resources: A report by the North West Department of Health found that where management of drug supplies was assisted by pharmacists, incidences of stockouts were minimal compared to facilities which did not have pharmacists’ assistance. The report concluded that staffing of all primary healthcare facilities with pharmacist personnel must be prioritised. In addition, the depots must be staffed with skilled supply chain practitioners. Staff must also be adequately trained to interact with the National Department of Health’s medicine stockout application.
• Communications between local, provincial and national authorities to prevent and resolve stockouts: Timing is everything. Shortages must be reported timeously to prevent stockouts, and once there is a stock out, this too must be reported immediately.
• Facilitating healthcare user participation in the management of facilities: Structures such as clinic committees are an invaluable link between the community and primary healthcare facilities. They can assist reporting stock shortages timeously.

Emergency interventions such as the one by MSF and TAC in 2012 are no doubt useful, but not sustainable. Ultimately, it is the responsibility of government to ensure that the medicine supply chain is not interrupted and that where it is interrupted, contingency plans are in place and healthcare users are not disadvantaged.

None of the interventions proposed are new, but if implemented, they could help solve the vicious cycle of medicine stockouts in the province. But, as always, successful implementation will require commitment at all levels of the healthcare system, and maybe more importantly,  high-level political will and leadership that prioritises the right to access healthcare services.

*Tendai Mafuma is a legal researcher at SECTION27. Ruth Dube is the project coordinator for the Stop Stockout Project.

*This article is part of Spotlight’s ‘Reimagining health in the Eastern Cape’ series – in which activists, healthcare workers, policy-makers and others are asked to reflect on how access to healthcare in the province can be improved.

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