Over the past 10 years, the National Health Department has rolled out a range of electronic surveillance systems to monitor medicine stocks throughout healthcare facilities countrywide, yet while many staff feel the new systems are having a positive impact, stockouts persist due to a host of ongoing supply challenges, writes Jesse Copelyn for Spotlight.
According to a recent report from community healthcare monitoring group Ritshidze, between May and June this year, there were more than 400 unique medicine stockouts reported in just 72 healthcare facilities in North West Province.
In roughly the same period, Eastern Cape doctorsr reportedly struggled to treat patients with bone marrow cancer because of provincial shortages of crucial chemotherapy drugs.
And in August, Africa’s largest hospital, Chris Hani Baragwanath, allegedly faced a stockout of adrenaline for two days.
Though the problem is not exclusive to South Africa, recent news about medicine stockouts paints a gloomy picture of the country’s capacity to manage essential medicines.
But the National Health Department’s Khadija Jamaloodien said these reports shouldn’t overshadow a broader trend. She said the department had made significant strides to improve medicines availability through a series of national drug stock surveillance programmes.
But what are these systems, and are they as effective as the department claims?
Ramping up surveillance
In November 2013, a nationwide survey of hospitals and clinics conducted by the Stop Stockouts Project found more than one in five had experienced stockouts of ARVs or TB drugs in the previous three months alone.
The National Health Department appeared to have little understanding of the severity of the problem. In April 2014, it claimed that in the previous 12 months there had been only a few stockouts of ARVs, restricted to two provinces.
As media attention on shortages grew, the department began to prioritise the issue and developed an extensive surveillance system to better monitor medicine levels throughout the country.
One key program is RxSolution, a computer-based stock management system that pharmacists and nurses use to record the quantities of drugs ordered, received and dispensed at their facilities.
The software was rolled out incrementally at hospitals from 2014 and is now used countrywide. The data feed back to a series of national, provincial and district-level dashboards that show medicine levels across facilities.
The central software platform that hosts these dashboards is called the National Surveillance Centre. Jamaloodien said it “allows stakeholders at national and provincial levels to quantify or predict challenges in medicine supply…”
Additionally, RxSolution generates reports which advise hospital staff on how much of a particular drug they need to order to prevent shortages or overstocking, and which medicines are due to expire.
A similar online tool is the Stock Visibility System, which measures medicine levels at primary healthcare facilities. Unlike RxSolution, it’s accessed on a cellphone app and the data are stored in the cloud (RxSolution requires an in-house server). Healthcare workers scan medicines using the app to capture stocks.
By October 2021, 3 826 healthcare facilities had used the Stock Visibility System, RxSolution or other online systems to track drug stocks (roughly 90% of all public hospitals and clinics, according to our calculations).
SA better at managing ARVs – trends unclear for other drugs
Evidently, shortages remain, but according to Jamaloodien, these systems have made a positive impact: “Good surveillance systems are one factor in a multi-factor situation but do play an important role in reducing stockouts. This can be seen in the downward trend of major stockouts since introducing the surveillance systems…”
Verifying this is difficult, however, as the department wasn’t able to provide data over a long period, and independent research has historically focused only on TB drugs or ARVs.
Shortages of the latter do appear to have become less common. In 2013, a national survey found that 19% of healthcare facilities had suffered a stockout of ARVs in the previous three months. By contrast, interviews with healthcare workers this year suggest that, depending on the quarter, only 5% to 9% could recall shortages of HIV medicines in the past three months.
Whether the surveillance systems played any role in this decline, and whether the same trend holds for stockouts of other drugs, is unclear.
Software reduces stockouts
A paper published in June assessed the attitudes of 114 users of the National Surveillance Centre, mostly managers and pharmacists at different levels in provincial health systems, who are responsible for monitoring drug stocks and reporting shortages.
Two-thirds of them said the launch of the National Surveillance Centre in 2016 had improved medicines availability, as having so much data on drug stocks allowed them to be more proactive – for instance by redistributing stocks from facilities that had an excess of a particular medicine to those with shortages.
Before this system, many of these staff had monitored stocks by physically going to facilities or waiting for healthcare workers to notify them of a stockout.
Another paper published in May found positive attitudes toward the Stock Visibility System among healthcare workers who used the system at clinics in KwaNulu-Natal (mostly nurses and pharmacists). Almost three-quarters of the 206 surveyed staff felt that the phone app had improved stock management, though it had reportedly increased their workload.
This lines up with a national survey in 2017 which found that 87% of healthcare staff reported that the Stock Visibility System had reduced the frequency of stockouts.
Mncengeli Sibanda, a pharmacy expert at Sefako Makgatho Health Sciences University, said the application has clear benefits: “In the past we’d have to count stocks physically and write it by hand, now it’s captured electronically, limiting capture errors and allowing stock counts to be done more regularly…And at a national level, they can intervene [to prevent shortages] because they have data on stock levels at (most) clinics.”
Load shedding hinders roll-out
RxSolution – which is PC-based – appears to have been similarly well-received. Phelelani Dludla, the acting clinical manager of Benedictine Hospital in Nongoma in KwaZulu-Natal, said when the system was introduced in 2019 “it would assist us in making orders before we ran out of stock”.
“It would tell us (which) stocks would run out and so we’d…reorder a week earlier than our usual routine”.
But particularly for rural hospitals like Benedictine, infrastructural problems can pose obstacles. Since 2021, said Dludla, network problems caused by load shedding have prevented the use of RxSolution throughout the hospital ward,” he says.
Monitoring suppliers
The National Health Department has also been monitoring drug suppliers. Jamaloodien said that companies awarded national tenders to provide medicines are “contractually bound to (provide) up-to-date production pipeline data for products they supply”.
“The mandatory six-month pipeline window allows for proactive prediction and management of looming supply challenges.”
Policies like this have good international precedent. Preliminary evidence found that Canada managed to reduce drug stockouts by forcing pharmaceutical companies to notify them of any supply interruptions.
To work, they need to be implemented effectively, however, and the National Health Department has previously complained that companies weren’t routinely notifying them of supply interruptions.
Yet if the Health Department has generally been making such positive strides toward reducing shortages, why are there still so many stockouts?
Global shortages
Part of the problem is international, said Andy Gray, a pharmacy expert at the University of KwaZulu-Natal: “Globally, there is a problem with the security of supply in the industry. For example a number of older cancer drugs are out of stock in the US at the moment, and the UK has had persistent problems with antibiotics.”
In fact, last week the European Union announced details of a “solidarity mechanism” in which member states facing drug shortages can now request donations from other European countries if they have exhausted all other options.
This was after Europe faced repeated shortages of key medicines over its winter.
If a single factory runs into a problem, this can disrupt global supply, including in South Africa, where locally made drugs usually require active ingredients from abroad. A 2020 paper found that pharmacists in Gauteng’s hospitals were often left waiting for medicine orders for months after the delivery deadline, and many believed that this was due to contracted suppliers facing shortages of active pharmaceutical ingredients.
Local dynamics also play a role, however. Problems have historically included the failure of provinces to pay contracted suppliers on time, staff shortages at clinics (which force overworked nurses to be in charge of stock management) and delays in the awarding of pharmaceutical tenders.
Split tenders to reduce vulnerability of supply
Gray said another issue is the over-reliance on individual companies: “All too often the contract (to supply a particular drug) is awarded to a single supplier.”
The conditions of pharmaceutical tenders often stipulate that if the company can’t meet its contractual obligations, the government can turn to alternative suppliers. But that’s easier said than done, he said: “If that single supplier is unable to meet demand…the alternative suppliers simply don’t have the volumes to substitute…especially if there’s no prior warning that there is going to be a problem in supply.”
Jamaloodien said many contracts are currently awarded with quantities split among suppliers.
However, doing so more frequently would present its own problems, as requiring several companies to produce small amounts of drugs “can invite higher prices because the price is largely related to economies of scale”.
In other words, it’s cheaper for one company to supply all the drugs.
Gray acknowledged this but said trade-offs need to be made more often in certain cases: “Vital medicines, for which there are no alternatives, are being given to maybe one or two suppliers. The vulnerability this creates can come at enormous cost to patients.”
For vital medicines more split tenders are crucial, he added.
See more from MedicalBrief archives:
Hospital union to seek action after stockouts, no water for five years
TB drug shortages hamper North West healthcare
Contraception shortages are failing South African women – Stop Stockout Report