Dataset Information

"The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda.

ABSTRACT:

Background

Despite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on 'upstream' or national-level drivers of ARVs stock-outs with less empirical attention devoted 'down-stream' or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chronic stock-outs of ARVs.

Methods

This was a qualitative research design nested within a larger mixed-methods study. We purposively selected 16 health facilities from across Uganda (to achieve diversity with regard to; level of care (primary/ tertiary), setting (rural/urban) and geographic sub-region (northern/ central/western). We conducted 76 Semi-structured interviews with ART clinic managers, clinicians and pharmacists in the selected health facilities supplemented by on-site observations and documentary reviews. Data were analyzed by coding and thematic analyses.

Results

Participants reported that facility-level contributors to stock-outs include untimely orders of drugs from suppliers and inaccurate quantification of ARV medicine needs due to a paucity of ART program data. Internal stock management solutions for mitigating stock-outs which emerged include the substitution of ARV medicines which were out of stock, overstocking selected medicines and the use of recently expired drugs. The external solutions for mitigating stock-outs which were identified include 'borrowing' of ARVs from peer-providers, re-distributing stock across regions and upward referrals of patients. Systemic drivers of stock-outs were identified. These include the supply of drugs with a short shelf life, oversupply and undersupply of ARV medicines and migration pressures on the available ARVs stock at case-study facilities.

Conclusion

Health facilities devised internal stock management strategies and relied on peer-provider networks for ARV medicines during stock-out events. Our study underscores the importance of devising interventions aimed at improving Uganda's medicines supply chain systems in the quest to reduce the frequency of ARV medicines stock-outs at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes.

SUBMITTER: Zakumumpa H

PROVIDER: S-EPMC6521347 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

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"The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda.

Zakumumpa Henry H Kiweewa Flavia Matovu FM Khuluza Felix F Kitutu Freddy Eric FE

BMC health services research 20190515 1

<h4>Background</h4>Despite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on 'upstream' or national-level drivers of ARVs stock-outs with less empirical attention devoted 'down-stream' or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chro ...[more]

PMID: 31092245

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Project description:BackgroundHIV and TB programs have rapidly scaled-up over the past decade in Sub-Saharan Africa and uninterrupted supplies of those medicines are critical to their success. However, estimates of stock-outs are largely unknown. This survey aimed to estimate the extent of stock-outs of antiretroviral and TB medicines in public health facilities across South Africa, which has the world's largest antiretroviral treatment (ART) program and a rising multidrug-resistant TB epidemic.MethodsWe conducted a cross-sectional telephonic survey (October-December 2015) of public health facilities. Facilities were asked about the prevalence of stock-outs on the day of the survey and in the preceding three months, their duration and impact.ResultsNationwide, of 3547 eligible health facilities, 79% (2804) could be reached telephonically. 88% (2463) participated and 4% (93) were excluded as they did not provide ART or TB treatment. Of the 2370 included facilities, 20% (485) reported a stock-out of at least 1 ARV and/or TB-related medicine on the day of contact and 36% (864) during the three months prior to contact, ranging from 74% (163/220) of health facilities in Mpumalanga to 12% (32/261) in the Western Cape province. These 864 facilities reported 1475 individual stock-outs, with one to fourteen different medicines out of stock per facility. Information on impact was provided in 98% (1449/1475) of stock-outs: 25% (366) resulted in a high impact outcome, where patients left the facility without medicine or were provided with an incomplete regimen. Of the 757 stock-outs that were resolved 70% (527) lasted longer than one month.InterpretationThere was a high prevalence of stock-outs nationwide. Large interprovincial differences in stock-out occurrence, duration, and impact suggest differences in provincial ability to prevent, mitigate and cope within the same framework. End-user monitoring of the supply chain by patients and civil society has the potential to increase transparency and complement public sector monitoring systems.

Project description:Low- and middle-income countries have been undertaking health finance reforms to address shortages of medicines. However, data are lacking on how medicine availability and stock-outs influence access to health services in Tanzania. The current study assesses the effects of medicine availability and stock-outs on healthcare utilization in Dodoma region, Tanzania. We conducted a cross-sectional study that combined information from households and healthcare facility surveys. A total of 4 hospitals and 89 public primary health facilities were surveyed. The facility surveys included observation, record review over a 3-month period prior to survey date, and interviews with key staff. In addition, 1237 households within the health facility catchment areas were interviewed. Data from the facility survey were linked with data from the household survey. Descriptive analysis and multivariate logistic regressions models were used to assess the effects of medicine availability and stock-outs on utilization patterns and to identify additional household-level factors associated with health service utilization. Eighteen medicines were selected as 'tracers' to assess availability more generally, and these were continuously available in ∼70% of the time in facilities across all districts over 3 months of review. The main analysis showed that household's healthcare utilization was positively and significantly associated with continuous availability of all essential medicines for the surveyed facilities [odds ratio (OR) 3.49, 95% confidence interval (CI) 1.02-12.04; P = 0.047]. Healthcare utilization was positively associated with household membership in the community health insurance funds (OR 1.97, 95% CI 1.23-3.17; P = 0.005) and exposure to healthcare education (OR 2.75, 95% CI 1.84-4.08; P = 0.000). These results highlight the importance of medicine availability in promoting access to health services in low-income settings. Effective planning and medicine supply management from national to health facility level is an important component of quality health services.

Project description:BackgroundThis paper explores the extent of community-level stock-out of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs) and identifies the reasons for and consequences of essential medicine stock-outs.MethodsA systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006-March 2021. Papers containing information on (1) the percentage of CHWs stocked out or (2) reasons for stock-outs along the supply chain and consequences of stock-out were included and appraised for risk of bias. Outcomes were quantitative data on the extent of stock-out, summarized using descriptive statistics, and qualitative data regarding reasons for and consequences of stock-outs, analyzed using thematic content analysis and narrative synthesis.ResultsTwo reviewers screened 1083 records; 78 evaluations were included. Over the last 15 years, CHWs experienced stock-outs of essential medicines nearly one third of the time and at a significantly (p < 0.01) higher rate than the health centers to which they are affiliated (28.93% [CI 95%: 28.79-29.07] vs 9.17% [CI 95%: 8.64-9.70], respectively). A comparison of the period 2006-2015 and 2016-2021 showed a significant (p < 0.01) increase in CHW stock-out level from 26.36% [CI 95%: 26.22-26.50] to 48.65% [CI 95%: 48.02-49.28] while that of health centers increased from 7.79% [95% CI 7.16-8.42] to 14.28% [95% CI 11.22-17.34]. Distribution barriers were the most cited reasons for stock-outs. Ultimately, patients were the most affected: stock-outs resulted in out-of-pocket expenses to buy unavailable medicines, poor adherence to medicine regimes, dissatisfaction, and low service utilization.ConclusionsCommunity-level stock-out of essential medicines constitutes a serious threat to achieving universal health coverage and equitable improvement of health outcomes. This paper suggests stock-outs are getting worse, and that there are particular barriers at the last mile. There is an urgent need to address the health and non-health system constraints that prevent the essential medicines procured for LMICs by international and national stakeholders from reaching the people who need them the most.

Project description:BackgroundGlobally, the monitoring of prompt and effective treatment for malaria with artemisinin combination therapy (ACT) is conducted largely through household surveys. This measure; however, provides no information on case management processes at the health facility level. The aim of this review was to assess evidence from health facility surveys on malaria prescribing practices using ACT, in the presence and absence of ACT stock, at time and place where treatment was sought.MethodsA systematic search of published literature was conducted. Findings were collated and data extracted on proportion of patients prescribed ACT and alternative anti-malarials in the presence and absence of ACT stock.ResultsOf the 14 studies identified in which ACT prescription for uncomplicated malaria in the public sector was evaluated, just six, from three countries (Kenya, Uganda and Zambia), reported this in the context of ACT stock. Comparing facilities with ACT stock to facilities without stock (i) ACT prescribing was significantly higher in all six studies, increasing by a range of 21.3% in children < 5 yrs weighing ≥ 5 kg (p < 0.001; Kenya 2006) to 51.7% in children ≥ 10 kg (p < 0.001; Zambia 2006); (ii) SP prescribing decreased significantly in five studies, by a range of 14.4% (p < 0.001; Kenya 2006), to 46.3% (p < 0.001; Zambia 2006); (iii) Where quinine was a reported alternative, prescriptions decreased in five of the six studies by 0.1% (p = 1.0, Kenya 2010) to 10.2% (p < 0.001; Zambia 2006). At facilities with no ACT stock on the survey day, the proportion of febrile patients prescribed ACT was < 10% in five of the nine target groups included in the six studies, with the proportion prescribed ACT ranging from 0 to 28.4% (Uganda 2007).ConclusionsPrescriber practices vary based on ACT availability. Although ACT prescriptions increased and alternative anti-malarials prescriptions decreased in the presence of ACT stock, ACT was prescribed in the absence, and alternative anti-malarials were prescribed in the presence of, ACT. Presence of stock alone does not ensure that treatment guidelines are followed. More health facility surveys, together with qualitative research, are needed to understand the role of ACT stock-outs on provider prescribing behaviours and preferences.

Project description:BackgroundAnnually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya.Methodology/principal findingsThis study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible.ConclusionsAccess to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.

Project description:Malaria rapid diagnostic tests (RDTs) are particularly useful in low-resource settings where follow-through on traditional laboratory diagnosis is challenging or lacking. The availability of these tests depends on supply chain processes within the distribution system. In Mozambique, stock-outs of malaria RDTs are fairly common at health facilities. A longitudinal cross-sectional study was conducted to evaluate drivers of stock shortages in the Cabo Delgado province.Data were collected from purposively sampled health facilities, using monthly cross-sectional surveys between October 2011 and May 2012. Estimates of lost consumption (consumption not met due to stock-outs) served as the primary quantitative indicator of stock shortages. This is a better measure of the magnitude of stock-outs than binary indicators that only measure frequency of stock-outs at a given facility. Using a case study based methodology, distribution system characteristics were qualitatively analysed to examine causes of stock-outs at the provincial, district and health centre levels.15 health facilities were surveyed over 120 time points. Stock-out patterns varied by data source; average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost consumption percentage were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each ten-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage indicating that higher rates of stock-outs occurred at higher levels of observed consumption. Causes of stock-outs included inaccurate tracking of lost consumption, insufficient sophistication in inventory management and replenishment, and poor process compliance by facility workers, all arguably stemming from inadequate attention to the design and implementation of the distribution system.Substantially high levels of RDT stock-outs were found in Cabo Delgado. Study findings point to a supply chain with a commendable degree of sophistication. However, insufficient attention paid to system design and implementation resulted in deteriorating performance in areas of increased need. In such settings fast moving commodities like malaria RDTs can call attention to supply chain vulnerabilities, the findings from which can be used to address other slower moving health commodities.

Project description:BACKGROUND:Access to sexual and reproductive health services continues to be a public health concern in Kenya, Tanzania, Uganda and Zambia: use of modern contraceptives is low, and unmet family planning needs and maternal mortality remain high. This study is an assessment of the availability, affordability and stock-outs of essential sexual and reproductive health commodities (SRHC) in these countries to inform interventions to improve access. METHODS:The study consisted of an adaptation of the World Health Organization/Health Action International methodology, Measuring Medicine Prices, Availability, Affordability and Price Components. Price, availability and stock-out data was collected in July 2019 for over fifty lowest-priced SRHC from public, private and private not-for-profit health facilities in Kenya (n = 221), Tanzania (n = 373), Uganda (n = 146) and Zambia (n = 245). Affordability was calculated using the wage of a lowest-paid government worker. Accessibility was illustrated by combining the availability (≥ 80%) and affordability (less than 1 day's wage) measures. RESULTS:Overall availability of SRHC was low at less than 50% in all sectors, areas and countries, with highest mean availability found in Kenyan public facilities (46.6%). Stock-outs were common; the average number of stock-out days per month ranged from 3 days in Kenya's private and private not-for-profit sectors, to 12 days in Zambia's public sector. In the public sectors of Kenya, Uganda and Zambia, as well as in Zambia's private not-for-profit sector, all SRHC were free for the patient. In the other sectors unaffordability ranged from 2 to 9 SRHC being unaffordable, with magnesium sulphate being especially unaffordable in the countries. Accessibility was low across the countries, with Kenya's and Zambia's public sectors having six SRHC that met the accessibility threshold, while the private sector of Uganda had only one SRHC meeting the threshold. CONCLUSIONS:Accessibility of SRHC remains a challenge. Low availability of SRHC in the public sector is compounded by regular stock-outs, forcing patients to seek care in other sectors where there are availability and affordability challenges. Health system strengthening is needed to ensure access, and these findings should be used by national governments to identify the gaps and shortcomings in their supply chains.

Project description:BackgroundUniversal access to high quality essential medicines is critical to sustainable development (SDG 3.8). However low- and middle-income countries struggle to ensure access to all medicines on their national essential medicines lists (EML). Market registration is the first step in determining both access and availability yet the extent to which essential medicines are registered for use at country level is not known. Companies apply for a marketing authorisation, however low price or lack of a market is a disincentive. Local production has been promoted to ensure availability of essential medicines but research in this area is also limited.MethodsThe study took place between 2011 and 2015. We systematically examined the registration status of medicines and vaccines listed in the Ugandan 2012 EML and conducted 20 interviews with regulators, ministry of health representatives, donors, and pharmaceutical producers and analysed quality assurance issues affecting registration, procurement, and local production of medicines in Uganda. In 2017 we conducted a further three interviews to clarify issues around non-registration of essential medicines highlighted by our analysis.ResultsOf the 566 essential medicines and vaccines nearly half (49%; 275/566) had no registered product in 2012. Of the 3130 registered products, just over a quarter (28%; 880/3130) were listed on the EML. Six local producers had registered 138 products of which 40 corresponded to 32 unique essential medicines. Interviews highlighted alternative routes to availability other than registration. Local producers faced considerable barriers to achieving international quality standards required for international procurement of medicines for the domestic market.ConclusionsMonitoring and audit of the registration of essential and non-essential medicines should be a priority nationally and, regionally through harmonisation of registration requirements in the East African Community. National and regional manufacturing plans should consider local production of unregistered essential medicines.

Project description:BackgroundInternational medical donation programs can help alleviate the burden of illness and serve as a safety net for the global health care system. However, to our knowledge no studies have assessed the number of individuals served through medical donation programs. As such, this study aimed to evaluate the impact of the Americares Foundation's (Americares) medical donation program in terms of the number of patients served.MethodsWe conducted an outcome evaluation study in 34 health facilities in 10 countries that receive medical donations from Americares. Medical records were randomly sampled at each participating facility and evaluated for types of medications and number of courses of prescribed treatments. Facility level data and donation inventory data were also collected. We developed an algorithm for converting quantities of donated medicines into the number of individuals served at the facility level. These estimates were then extrapolated to the country and region levels to assess the total impact of medications donated in 2015. Probabilistic sensitivity analysis was conducted to derive 95% credible ranges for projected estimates and to assess model uncertainty.ResultsRecords of 3,205 unique patients were reviewed, encompassing 10,449 medical visits. The average number of medications and courses of treatments prescribed per visit were 2.63 and 2.68, respectively. The average medication destruction rate ranged from 0% to 24% at facilities, with a cross-country average of 7%. For the 10 countries included in the study, we project that 700,377 unique individuals were served through the program (95% credible range: 518,401-905,982). Scaled across all regions receiving Americares donations, we project that the program supported an estimated 5.1 million beneficiaries, including 484,188 chronic care and 4.65 million acute care patients.ConclusionsThis study provides a novel methodology for medical donation programs seeking to estimate one of their key outcomes-patients served-and global reach. Rigorous assessments of program outcomes can provide important insights into the value of medical donation initiatives.Trial registrationHuman subjects approval was received from the University of Washington Institutional Review Board (Approval #52316; 7/19/2016).

Dataset Information

"The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda.

Background

Methods

Results

Conclusion

Publications

"The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda.

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