“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. Electronic supplementary material The online version of this article (10.1186/s12913-019-4137-7) contains supplementary material, which is available to authorized users.

Population-based monitoring of HIV drug resistance early warning indicators in Uganda: A nationally representative survey following revised WHO recommendations

“…This low rate could be attributed to, poor drug procurement and supply management systems, resulting from inappropriate forecasting and quantification at facility level. This is further compounded by the implementation of the 'test and treat' policy in Uganda in 2017 that recommended all people tested HIV-positive to start treatment immediately leading to increase in ART enrolment [10,22]. Despite the introduction of a web-based ARV ordering system, there still remains a need to train of dispensers and pharmacists at health facilities in the use of this system.…”

“…Zakumupa et al in their appraisal of the ARV supply chain system in Uganda [22,23], observed that inaccurate ART medicine quantification, untimely ARV orders,over stocking of select ARVs, maldistribution of drugs contributed to stock-outs of drugs at facilities. In addition, Windisch noted that poor quality and inefficiencies in the drug supply chain management in Uganda was caused by parallel processes and information systems amplified by inadequacies at all levels of the health system, including the areas of financing, governance, human resources and information [23].…”

Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

“…Face-to face interviews were conducted in participants' offices within the health facilities between April and June 2019. The interviews were conducted by the first author who holds a PhD in health systems and has an academic background in the social sciences and an expertise in qualitative research [22], [25]. The first author was assisted by three Research Assistants (RAs) experienced in qualitative health services research.…”

Providers' Definitions of Quality and Barriers to Providing Care: a Qualitative Study in Rural Mpumalanga Province, South Africa

“…The fourth major barrier identi ed was a chronic lack of equipment, medication, and other resources in the facilities, also documented in previous studies in South Africa (2,35,39) and within the Agincourt HDSS study area. (40,41) A 2018 study intervention to improve hypertension care in PHCs in the Agincourt HDSS was unsuccessful, in part due to unreliable blood pressure machines and cuffs, intermittent drug shortages, and lack of space.…”

“…(40,41) A 2018 study intervention to improve hypertension care in PHCs in the Agincourt HDSS was unsuccessful, in part due to unreliable blood pressure machines and cuffs, intermittent drug shortages, and lack of space. (40) Mitigating strategies to combat this lack of resources, such as relying on peer-provider networks and drug substitution (39) are not su cient to address the problem of chronic medication shortages. Even when facilities are able to share, providers may often have to use their own money for transport to pick them up.…”