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Opinion: Helping to fix the system

An experimental Covid-19 antiviral drug could be a game changer in treatment:(File Photo)
Written by Elna Schütz

Antiretrovirals continue to be the most reported medicine out of stock as the civil society Stop Stock Out Project continues, write Project Coordinator Monique Lines and Medicines Sans Frontieres pharmacist Tinne Gils.

The National Strategic Plan (NSP) on HIV, Sexually Transmitted Infections (STIs) and TB (2012-2016) addresses the drivers of HIV and TB epidemics and builds on the achievements of the previous NSPs to achieve its goals. The plan has four strategic objectives:

  • Addressing social and structural barriers to HIV, STI and TB prevention, care and impact
  • Preventing new HIV, STI and TB infections
  • Sustaining health and wellness
  • Increasing the protection of human rights and improving access to justice.

Ongoing supply chain issues resulting in medicine stock-outs and shortages are challenging the realisation of these NSP objectives. Since the release of its national baseline survey in November 2013, the Stop Stock Outs Project (SSP) has been hard at work to raise awareness on this issue and continue monitoring healthcare facilities across South Africa.

2014 so far …

ARVs reported out of stock or in short supply (Jan-Apr 2014)

ARVs reported out of stock or in short supply (Jan-Apr 2014)

Since January 2014, the SSP has managed 99 stock out reports. The majority of the reports received (58 percent) were originally reported by patients, with nurses and doctors only reporting 23 percent of the cases.

The success of the citizen-based reporting process can, to a certain extent, be attributed to the variety of affordable ways of contacting the SSP. ‘Please call me’ messages accounted for 38 percent of reports received, while SMS and WhatsApp messages accounted for seven percent and 13 percent of the reports, respectively. Emails, predominantly sent by health care workers made up 18 percent of the reports. When following up these stock-out reports with healthcare workers at the named facilities, 60 percent of the reports were verified.

Of concern is the 20 percent of facilities that could not be reached, either because the phone was never answered or no working contact number could be found.

Gauteng has accounted for 38 percent of the stock-outs reported in the first four months of 2014, significantly higher than the other provinces. Reports by patients and healthcare workers in the other provinces is steadily increasing: 17 percent of the cases were from Mpumalanga, 15 percent from Limpopo and 13 percent each from the Eastern Cape and Free State.

Antiretrovirals (ARVs) are still the most commonly reported medicines, with 44 percent of cases managed being ARV-related. Only six percent of cases reported were TB-related.

[quote float=”right”]44 percent of reported cases involved ARVs. Most patients reported being sent home without treatment

 When asked about patient management, most patients reported being sent home without treatment (50 percent) or were referred to another facility (11 percent). This is quite different from facility-reported management, where health care workers only reported sending patients home without treatment in a quarter of the cases. Managing stock outs by providing patients with alternative strengths or alternative dosage forms is not utilized enough as only five percent of patients and six percent of facilities  reported this.

This is a potential indicator of poor communication on the part of medical supply depots or district pharmacies in terms of making facilities aware of available alternatives before patients are sent home empty handed.

Action taken when a stock-out is reported

When someone contacts the SSP to report a stock-out/shortage, all the information provided by the reporter is documented. A case is opened, which tracks the stock-out from the time it was reported until the stock out or shortage is resolved and the medicine is available at the facility.

Once a stock out is reported, the relevant clinic is contacted and more information is obtained. Sometimes the health care workers at the facility are unable to verify that there is a stock out, e.g the health care workers say the medicine is available, they do not want to provide information, or the clinic cannot be reached by phone. The report is still logged and escalated for further investigation.

If the healthcare workers verify that the medicine is out of stock, then more information is obtained:

  • When did the medicine run out?
  • When last did the clinic place an order?
  • Is the facility expecting a delivery soon?
  • If relevant, has an emergency order been placed? And if the depot is out of stock of the medicine, has the facility  enquired about availability of alternative pack sizes and/or strengths of the item or possible therapeutic alternatives that can be substituted?
  • Has the healthcare worker borrowed medicine from a neighbouring facility?
  • Have the facility staff reported the problem to anyone?

All the information about the stock-out is then escalated to the relevant district pharmacist responsible for overseeing that clinic or hospital. If feedback is not provided timeously the report is also escalated to the relevant depot manager and/or the Head of Pharmaceutical Services in that province. If the medicine reported is an ARV, the provincial ARV monitor is also informed of the stock out.

All the information regarding the reported stock-outs is also made available to the National Department of Health’s Affordable Medicines Directorate. The escalated information and feedback provided by the various Department of Health employees is documented and tracked. The cause of the stock out or shortage is identified based on the feedback provided and the case is closed once the medicine is available at the clinic or hospital again.

Although the SSP is not directly involved in resolving the stock outs or shortages reported, the responsible individuals are identified and made aware of the problem and put under pressure to address the issues as soon as possible.

In conclusion

[quote float=”right”]”Individuals have to take responsibility for their own health and hold the healthcare system accountable”

Everyone living in South Africa has the right to access to health care services as enshrined in section 27 (1)(a) of the Constitution of the Republic of South Africa, including access to essential medicines. Individuals have to take responsibility for their own health and hold the healthcare system accountable, while the Department of Health must continue its efforts to develop governance and accountability mechanisms to ensure the provision of adequate services and access to treatment for all.

Although health care facilities are supposed to report medicine supply problems and the Department of Health is supposed to respond to these reports, this is not always the case. Patients are slowly beginning to hold the Department of Health accountable for upholding their constitutional right to access treatment by reporting shortages and stock-outs occurring at their clinics and hospitals.

Since reporting to the SSP is an anonymous process, patients are also able to raise awareness within civil society on the challenges that they experience when accessing health care facilities without the fear of being victimised or discriminated against.

As a ‘watchdog’, the SSP is able to communicate with various individuals and stakeholders within the Provincial and National Departments of Health to ensure that shortages and stock-outs are responded to and resolved in a timeous manner. By reporting and investigating stock outs and shortages, causes of supply chain breakdowns can be identified and steps can be taken to strengthen and improve the system going forward.

A longer version of this opinion piece was originally published in the NSP Review, which was released at the South African TB Conference. The conference concludes today.


About the author

Elna Schütz

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