In-depth: Fewer meds stockouts at SA clinics, but contraceptives often not available
A condom dispenser at Boitekong Clinic in the North West that is used as a rubbish bin. PHOTO: RitshidzeThere are fewer medicine stockouts in South Africa’s public healthcare facilities than in previous years but lack of access to contraceptives continues to pose a problem, according to a report from the Stop Stockouts Project (SSP) launched on Tuesday.
According to the report, 6.9% of patients report at least one medication being out of stock when they were at one of the 380 facilities surveyed during a three-month period. Four out of ten shortages were of a contraceptive, with injectable contraceptives being the least available option.
“It’s likely that we are under accounting for stockouts,” explains Sasha Stevenson, head of SECTION27’s Health Rights Programme. “The people who are at the facilities and answering the questions in the survey have not given up on the healthcare system – they are going back. But there will be other people who haven’t been able to get what they need for several months and may not have come back.”
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Even with stockouts remaining a problem in the public healthcare system, over two-thirds of patients are still leaving with a medication – with healthcare workers offering an alternative option in the event of a stockout, the report says.
Overall, there have been fewer stockouts reported when compared to previous years when the survey was conducted, notes Stevenson. But the one area that remains unimproved is contraceptives.
Providing women with options
There are over 162 million women globally who have an unmet need for contraception, meaning they do not wish to become pregnant but are unable to access some form of birth control, according to a July study in The Lancet.
The study, which was the largest of its kind, found that around half of women in South Africa between the ages of 15 and 49 were using some form of birth control. One in ten women in the country had an unmet need for contraception, the study found.
Theoretically, women in South Africa should have their choice of contraception, regardless of whether they use a private or public healthcare facility. The options available include hormonal methods like pills, injectables, an implant, patch, or vaginal ring as well as non-hormonal choices like an intrauterine device (IUD), condoms, or female and male sterilisation.
“In reality, it’s quite a lot different depending on what women want and what is pushed by healthcare providers,” cautions Diane Cooper, a professor of public health at the University of the Western Cape. “Healthcare providers tend to recommend the injectable, they tend not to trust that women are going to remember to take a pill daily.”
The IUD and implant require training for healthcare workers to both insert and remove the devices, which is why some healthcare workers may be more reluctant to offer these options to women, says Cooper.
Both of these methods were the least requested options by those surveyed in the SSP report, with around 8% trying to get an implant and one in 20 women seeking an IUD.
“Not knowing how to provide a method also plays a part in stock orders – low demand from the client can also be the result for the low promotion or request of these methods,” said Lucy O’Connell, Key Populations Advisor in Doctors Without Borders (Médecins Sans Frontières) Southern Africa’s Medical Unit, who spoke at the launch.
In South Africa, there are two injectable contraceptives on offer – Noristerat (a two-monthly regimen) and Depo-Provera (given every three months). These are the most widely used form of birth control in the country.
“Some women are in situations where they’re hiding [the] use of contraception and then the pill is difficult,” notes Cooper. “Some women prefer the injectable because they don’t want to come back as often, or they don’t want to remember to take something all the time.”
A 2017 study in the South African Medical Journal found that around 46% of women had used an injectable contraceptive at some point in their life and a quarter of those surveyed were currently using the method.
The problem is that while injectables are the most widely used contraceptive in South Africa, they are also the most commonly out of stock, making up 76% of the reports received by the SSP.
“While it is reassuring to see that 95.6% of patients requesting contraception in this survey were able to get what they wanted, it is concerning that contraception – specifically injectable contraception – stands out as the most reported medicine shortage across the country,” the SSP report notes.
The trouble with switching methods
Two-thirds of healthcare workers said they offered an alternative medication to people coming into the clinic, according to the SSP report. When it came to contraception, around 58% suggested patients switch methods during the period the contraceptive of choice was unavailable.
This solution isn’t ideal, however, as it can have negative consequences for women who are forced to abruptly change medications.
When medications aren’t available, it places the burden on the person seeking them to find an alternative way to access them or return to the clinic which comes at a cost, explains Cooper.
“They have to take off work or even if they’re not working, they’re still losing time. If they have to go to a private clinic or pharmacy, it costs money,” she says. “If their particular method isn’t available, they’re used to that method and don’t necessarily want to try another option. So, women may stop taking contraception or there will be a gap when they could fall pregnant. Stockouts or periods of time when there aren’t services or methods available are a real problem for women.”
Contraception shortages mean that women have fewer options available to them and remove some of the control they have over their own sexual and reproductive health. If the onus of family planning falls on the woman, it may become difficult to get a man to wear a condom if her method of choice is unavailable.
Most women in South Africa are not able to negotiate condom use with their partners, particularly if there is a power imbalance or financial dependence component to the relationship, according to a 2021 study in the African Journal of AIDS Research.
“When women come for the first time, for anything, is a gap of about a month before its properly effective – and the same applies if you switch,” explains Cooper. “That’s when providers encourage the use of condoms because you could become pregnant during the month before the contraceptive is effective but not all women are able to use condoms.”
If their particular method isn’t available, they’re used to that method and don’t necessarily want to try another option. So, women may stop taking contraception or there will be a gap when they could fall pregnant. Stockouts or periods of time when there aren’t services or methods available are a real problem for women.
The fallout of unintended pregnancy
The other issue is that each form of contraception can come with its own set of side effects and not all women will react to the intervention in the same way.
“The more you switch methods, the more your body has to adapt to that method,” says Melanie Pleaner, a senior technical advisor at the Wits Reproductive Health and HIV Institute. “For someone who has a preferred method that they’re settled well with, they’re more likely to stick with that contraceptive. Whereas if they start something new, they might decide not to continue using that method until they can get their preferred contraceptive.”
Pleaner explains that changing contraceptives also requires “reorientation” around [its] use. For instance, someone used to being on an injectable that requires a clinic visit every three months may struggle with needing to take a daily pill. This could lead to interruptions in how people take their contraception and in turn lead women to abandon using a birth control method altogether, she cautions.
“It’s quite confusing for women and it leaves women a lot more vulnerable,” says Pleaner. “Particularly in that first year, if you’re switching between contraceptives, it leads to discontinuation and it leads to increased pregnancy.”
Indira Govender, a public health medicine specialist and member of the Rural Doctors Association of South Africa gave a breakdown of the findings of the report.@MSF_southafrica @SECTION27news @TAC
@doctors_rural #STOPSTOCKOUTS pic.twitter.com/y9ZEfYtdvt— SECTION27 (@SECTION27news) August 30, 2022
Around one in five births in South Africa were “unwanted”, where the woman was not planning to have any more children, according to a 2020 report by StatsSA. This rate is even higher among women living with HIV, with around half reporting an unplanned pregnancy in a 2021 Nature paper.
These types of pregnancies come with health risks to the mother and child as well as socio-economic consequences, such as preventing the mother from pursuing higher education or impacting their job prospects. A 2019 study by the World Health Organization found that half of the women who had aborted an unintended pregnancy ended up not using a contraceptive method afterward, either due to health concerns or inconvenience.
“When women and girls cannot access a contraceptive, or the contraceptive of their choice, there can be really serious fallout and you can get unwanted pregnancy,” explains Claire Waterhouse, Regional Advocacy Coordinator for Doctors Without Borders. “An unwanted pregnancy impacts literally every aspect of a woman’s life – emotionally, mentally, and financially, professionally, educationally. There is no area of a girl or woman’s life that will not be impacted by a pregnancy they would have preferred to prevent.”
This rise in unintended pregnancy also creates a cycle of reliance, said Baone Twala, a legal researcher at SECTION27, who also spoke at the report launch. “It forces women to re-engage with a system that failed them in providing them with contraception to come and seek abortion from that same system and have it fail them once again.”
‘A system that fails women’
Having to wait in long lines at healthcare facilities and then having rushed consultations with healthcare workers where you aren’t given enough information about switching contraceptives only increases the barriers that women face when trying to access sexual and reproductive health services, explains Pleaner.
“Barriers will prevent effective use of contraception and what stockouts are doing is adding to the barriers,” she says.
To help healthcare workers present the numerous options available, the National Department of Health introduced contraception clinical guidelines in 2012, with the most recent revision released in 2019.
Pleaner, who was involved in the development of these guidelines, says that the department also included training on the implementation of the new guidelines, part of which focused specifically on counselling.
“In reality, the kind of counselling that a woman needs to make an informed decision – from understanding how a method works to managing possible side effects – takes more than health providers might have time for.”
As a nurse, I can sense and speak about the absence of support to the frontline healthcare workers who are more than aware of the contraceptive needs of their communities, yet they have limited agency to demand adequate supplies and services.
The SSP report noted that a “lack of clinical guidance on how to manage hormonal contraceptive stockouts put staff and particularly patients in a difficult position”. The report notes conflicting responses from healthcare workers about whether or not they have sufficient guidance on how to handle these shortages.
“The health system is under-resourced and understaffed,” said O’Connell at the launch. “As a nurse, I can sense and speak about the absence of support to the frontline healthcare workers who are more than aware of the contraceptive needs of their communities, yet they have limited agency to demand adequate supplies and services.”
It’s not just about contraceptives but also about the tools women need for their sexual and reproductive health. In addition to contraception shortages, one in ten stockouts reported were of pregnancy tests.
“Depriving women of contraceptives and then not offering other services they may need afterward is all interlinked,” Waterhouse tells Spotlight. “It’s all interlinked in the sense that somewhere along the line, women and girls’ health is not being seen as a priority in the healthcare system and it needs to be.”
Ultimately, Waterhouse and Stevenson argue that there needs to be better support put in place to help women and girls make informed decisions about their sexual and reproductive health. That doesn’t just come down to making contraception available but starts with providing information at school and carries through to other family planning services they may require.
“The different ways that we fail women, it’s just completely heart-breaking,” says Stevenson. “We’re not providing sufficient comprehensive sexuality education at school. We’re not ensuring that women are able to access contraceptives and we’re then not providing abortion services to the extent that they are required and where they are required. The contraceptives issue shouldn’t just be seen by itself as a medical problem but it’s a link in this chain of failing women in our health system,” says Stevenson.
NOTE: Representatives of SECTION27 are quoted in this article. Spotlight is published by SECTION27 and the Treatment Action Campaign, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.