Essential medicine stock-outs in rural primary health care.pdf

International Journal of Development and Sustainability, 2018

Stock-outs of essential medicines and medical items remains a persistent problem in Tanzania, despite the several policy initiatives and interventions since the 1990s. We conducted a qualitative case study, which involved 24 in-depth interviews and eight focus group discussions with the Community Health Fund stakeholders who were facility in-charges, grassroots leaders, and members of Health Facility Governance Committees from eight primary health facilities in Kasulu District Council. The analysis involved transcribing and coding textual data to identify the key themes that emerged. The study identified four main themes that explained how the politics contribute to persistent stock outs, especially: 1) stock-outs as capital in electoral politics; 2) misinformation and rent-seeking; 3) dyads among street-level bureaucrats; and 4) competition and struggle for power and control over resources. We also identified four themes reflecting the dominant perceptions associated with stock-outs in the study communities namely: 1) feeling marginalized; 2) mistrust and suspicion of authority; 3) frustration of health workers; and 4) informal drug sellers as 'the best'. These perceptions influence the way communities tend to define their role in health care financing and governance as well as the relationship between communities and health workers. While economic, administrative, and technical forces might influence stock outs, the politics within the management and governance of the Community Health Fund, which included rent-seeking, misinformation, and competition, significantly affected the legitimacy of the Community Health Fund. The resulting low enrollment and unwillingness to contribute makes medicines' financing from community sources unsustainable. Therefore, empowering communities to mobilize locally available resources and exercise autonomous control over financial resources and medicine is imperative for addressing persistent stock outs.

Journal of Pharmaceutical Policy and Practice

Background In low- and middle-income countries, too, public–private partnerships in health insurance schemes are crucial for improving access to health services. Problems in the public supply chain of medicines often lead to medicine stock-outs which then negatively influence enrolment in and satisfaction with health insurance schemes. To address this challenge, the government of Tanzania embarked on a redesign of the Community Health Fund (CHF) and established a Prime Vendor System (Jazia PVS). Informal and rural population groups, however, rely heavily on another public–private partnership, the Accredited Drug Dispensing Outlets (ADDOs). This study takes up this public demand and explores the potentials, pitfalls, and modalities for linking the improved CHF (iCHF) with ADDOs. Methods This was a qualitative exploratory study employing different methods of data collection: in-depth interviews, focus group discussions, and document reviews. Results Study participants saw a great pote...

2012

Malawi is one of the poorest countries in the world. The government has introduced some measures to improve the health of its people, but a number of major problems remain. One of these is the lack of essential medicines in government health clinics – known as ‘stock-outs’. These medicines should be free to poor people, but most find that they have to pay. This case study – one of a series of Programme Insights on Local Governance and Community Action – looks at an innovative campaign which aimed to tackle this problem by enhancing the capacity of local communities and civil society organizations to demand the right to access these medicines. The campaign lobbied for a commitment to increased availability and accessibility in rural areas and carried out budget and resource tracking. The case study looks at the difficulties the campaign faced and outlines the factors that contributed to its success.

Health Systems, 2013

Objective: Assess whether reform in the Tanzanian medicines delivery system from a central 'push' kit system to a decentralized 'pull' Integrated Logistics System (ILS) has improved medicines accountability. Methods: Rufiji District in Tanzania was used as a case study. Data on medicines ordered and patients seen were compiled from routine information at six public health facilities in 1999 under the kit system and in 2009 under the ILS. Three medicines were included for comparison: an antimalarial, anthelmintic and oral rehydration salts (ORS).

BMC Health Services Research, 2019

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 'downstream' 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, redistributing 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 stockouts at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes.

2014

Improving health care requires access to affordable essential medicines, yet critical shortages of those medicines persist in Tanzania. • Shortages result not just from a lack of resources and technical challenges: local politics, accountability relationships and how information is used matter too. • This briefing sets out four new ideas for how to address these institutional issues-and calls for a new coalition aimed at 'getting things done'. What role can citizens play in addressing stock outs? This brief was written and produced by Rakesh Rajani, Varja Lipovsek, Julia Tobias, Joseph Wales and Leni Wild. It is based on the report produced jointly by Twaweza and Overseas Development Institute titled Stock-outs of essential medicines in Tanzania,

To understand how supply chain factors affect product availability at the community level, the Improving Supply Chains for Community Case Management of Pneumonia and Other Common Diseases of Childhood Project developed a theory of change (TOC) framework for gathering, organizing, and interpreting evidence about supply constraints to community case management (CCM). Baseline assessments in Ethiopia, Malawi, and Rwanda conducted in 2010 provided information on the strengths and weaknesses of existing CCM supply chains for five main products: antibiotics for pneumonia, oral rehydration solution, ready to use therapeutic food, zinc, and artemether/lumefantrine. The assessments tested the strength and validity of causal pathways identified in the TOC that were believed to influence availability of CCM products among community health workers (CHWs) for treating common childhood illnesses. Results of the assessments showed product availability to be weak in each country, with more than half of CHWs stocked out of at least one tracer product on the day of the assessment. This report will focus on the findings related to three key preconditions of the TOC and how these were used to inform the design of the CCM supply chain improvement strategy in each country. The three key preconditions include product availability at CHW resupply points, supply chain knowledge and capacity among CHWs and their supervisors, and availability of appropriate transportation. Quantitative survey, interviewer reported Key obstacles reported by CHWs to obtaining CCM supplies % CHWs reporting each type of obstacle (coded from open-ended and multiple responses) Quantitative survey, CHW interview * CHWs = community health workers; CCM = community case management; ORS = oral rehydration salts; AL = artemether/lumefantrine. The Improving Supply Chains for Community Case Management of Pneumonia and Other Common Diseases of Childhood Project collects other key indicators, such as training on reporting and storage that are not highlighted in this report.

South African Medical Journal , 2017

Shortages of essential medicines are a daily occurrence in many of South Africa (SA)’s public health facilities. This study focuses on the responses of healthcare workers to stock-outs, investigating how actors at the ‘front line’ of public health delivery understand, experience and respond to shortages of essential medicines and equipment in their facilities. Findings are based on focus groups, observations and interviews with healthcare workers and patients at healthcare facilities in the Eastern Cape Province of SA, conducted as part of the Mzantsi Wakho study. The research revealed a discrepancy between ‘informal’ definitions of stock-outs and their reporting through formal stockout management channels. Front-line healthcare workers had designed their own systems for classifying the severity of stock-outs, based on the product in question, and on their potential to access stocks from other facilities. Beyond formal systems of procurement and supply, healthcare workers had established vast networks of alternative communication and action, often using personal resources to procure medical supplies. Stock-outs were only reported when informal methods of stock-sharing did not secure top-up supplies. These findings have implications for understanding the frequency and severity of stock-outs, and for taking action to prevent and manage stock-outs effectively.

BMC Pregnancy and Childbirth, 2014

Background: Provision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC). Methods: In-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach. Results: Participants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation. The unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds.

BMC Health Services Research, 2014

Background: Decentralised health systems in Tanzania depend largely on funding from the central government to run health services. Experience has shown that central funding in a decentralised system is not an appropriate approach to ensure the effective and efficient performance of local authorities due to several limitations. One of the limitations is that funds from the central government are not disbursed on a timely basis, which in turn, leads to the serious problem of shortage of financial resources for Council Health Management Teams (CHMT). This paper examines how dependency on central government funding in Tanzania affects health activities in Kongwa district council and the strategies used by the CHMT cope with the situation. Methods: The study adopted a qualitative approach and data were collected using semi-structured interviews and focus group discussions. One district in the central region of Tanzania was strategically selected. Ten key informants involved in the management of health service delivery at the district level were interviewed and one focus group discussion was held, which consisted of members of the council health management team. The data generated were analysed for themes and patterns.