\u201cThe number of clients is increasing but the supplies are reducing\u201d: provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda

Henry Zakumumpa,Freddy Eric Kitutu,Flavia Matovu Kiweewa,Felix Khuluza

doi:10.1186/s12913-019-4137-7

Henry Zakumumpa, Freddy Eric Kitutu + Show 2 more

Open Access

https://doi.org/10.1186/s12913-019-4137-7

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Abstract

BackgroundDespite 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.MethodsThis 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.ResultsParticipants 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.ConclusionHealth 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.

Highlights

Despite the increasing frequency of antiretroviral drugs (ARVs) medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities
In 2014, The Joint United Nations program on Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) (UNAIDS) unveiled the 90–90-90 targets which call for enrolling 90% of those diagnosed with HIV on sustained antiretroviral therapy (ART) as well as achieving viral suppression in 90% of those enrolled on anti-retroviral therapy (ART) [3]
Facility-level contributors to stock-outs Inaccurate ART medicines quantification Across our interviews with ART clinic in-charges it emerged that the frequent stock-outs of ARVs were partly attributed to the continually-increasing HIV client loads

Summary

Introduction

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. 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. Over the past decade, universal access to antiretroviral therapy (ART) has been gathering momentum as a global health priority [1, 2]. In 2017, the universal ‘test and treat’ (UTT) policy was implemented in several low and middle-income countries [5] The attainment of these global health goals depends substantially on the capacity of health-systems to ensure sufficient stocks of antiretroviral drugs (ARVs) to meet the escalating demand for treatment especially at the front-line level of service delivery [6, 7]. Research that documents locally-derived mitigation strategies for responding to chronic antiretroviral drugs stock-outs, especially in resource-limited settings, is critical [14, 15]

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