Stock-Outs of Essential Medicines Among Community Health Workers (CHWs) In Low- And Middle-Income Countries (LMICs): A Systematic Literature Review of The Extent, Reasons, And Consequences

Abstract

Background: This 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. Methods: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006 - March 2021. Papers containing information on (i) the percentage of CHWs stocked out or (ii) 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. Results: Two reviewers screened 1083 records; 78 evaluations were included. Over the last fifteen 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. Conclusion: Community-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.

Community Health Workers in Pandemics: Evidence and Investment Implications

“…While this study did not look specifically at equity, previous studies have established that many community-oriented primary health care programs have an explicit equity promotion component, 28 CHWs promote equitable access to promotive, preventive, and curative services at the household level, 29 and CHW-delivered interventions (including home visits) improve equity in maternal and newborn health. 30 Despite such high potential and powerful equity dividend, the majority of CHWs globally remain unpaid, without essential medications, 31 inadequately supervised, and largely unsupported. This evidence suggests that the opportunity cost of not professionalizing CHWs may be substantially larger than previously estimated in light of the inevitability of future pandemics.…”

The role of community health workers in the inventory management of antimalarial medicines in Rwanda: a case study of Bugesera district in Rwanda

“…Compared to 2014, this has improved as there was unstructured approach with no de ned rules or processes to drive resupply as indicated in a study done from Ethiopia, Malawi, and Rwanda. In this research, ndings revealed that 62% of CHWs resupplied based on (nonstandard) documentation; 19% of CHWs used a variety of ("other") methods; 8% of CHWs provided the same as previous month before the study; 7% and 4% of CHWs "didn't know" or used a formula, respectively [19].…”

“…Products were considered available if product is not stock-out (if physical count is not zero) on the day of visit in the CHWs store. [19] This study reported 3.2% antimalarial stock out on the day of the visit. Compared to other African countries, Rwandan prevalence of antimalarial stock out is a bit lower as indicated by a study conducted in Uganda, which stated that ACTs/Coartem -20/120 mg, a drug used to treat Malaria, was the least available (at 3.3 %) of all the iCCM (Integrated Community Case Management) medicines [12].…”

Improving the efficiency of scale-up and deployment of community health workers in Mali: A geospatial analysis

“…Fourth, our analysis did not account for the possibility of accessing health services across national boundaries, an important consideration for border communities and migrant populations. Fifth, our analysis did not account for social and economic barriers to care-seeking which may impact access to and use of health services independently of physical accessibility or through interactions with physical accessibility [60][61][62]. Lastly, our analysis did not consider the stockouts of equipment, supplies or commodities, quality of services and the potential for bypassing [63,64].…”