Background
ART scale-up in Uganda and ARVs supply management system
Methods
Research design
PRINCIPLE | |
---|---|
Prolonged engagement | Multiple on-site visits were made to the case-study facilities across three weeks. Informal discussions were held with ART clinic managers, clinicians and pharmacists coupled with face-to-face interviews with multiple informants. |
Use of theory | This study is derived from a larger mixed-methods study which is informed by the health systems dynamics frameworks by van Olmen et al. (2012) [33] which builds on the WHO’s building blocks of the health system framework (2007). |
Case selection | Sixteen health facilities were purposefully selected from a nationally-representative sample of 195 health facilities across Uganda which participated in Uganda’s national emergency ART roll-out. |
Sampling | We aimed for a sample that had appropriate representation of health facility demographics in Uganda with respect to a) setting (rural/urban), b) ownership-type (public, for-profit, not-for-profit)c) Level of care(tertiary, secondary, primary). |
Multiple methods | Multiple methods were used including face-to-face interviews, document review and informal engagements with clinicians and the head of the HIV Clinic. |
Triangulation | Case descriptions were constructed based on triangulation across multiple data sources (Questionnaire data, interviewee data and document review). |
Peer debriefing and support | Data analysis involved a team-based process involving at least three authors at each of the stages. |
Respondent validation | A data validation workshop was conducted with involving the head of the HIV clinic in 14 of the Participating health facilities. |
Study sites and selection
Accronym | Ownership-type | Level of care in ugandan health system | Setting | Geographic sub-region | Annual art patient load (as at june 2015) | |
---|---|---|---|---|---|---|
1 | PUB-001 | PUBLIC | Referral Hospital | Urban | South West | 24,408 |
2 | PUB-002 | PUBLIC | Referral Hospital | Urban | Kampala | 2408 |
3 | PUB-003 | PUBLIC | Referral Hospital | Urban | Central 2 | 6414 |
4 | PUB-004 | PUBLIC | District Hospital | Urban | East Central | 598 |
5 | PUB-005 | PUBLIC | Health centre IV | Peri-urban | Mid-East | 458 |
6 | PUB-006 | PUBLIC | Health centre IV | Rural | Mid-north | 2034 |
7 | PUB-007 | PUBLIC | Health centre IV | Rural | East-Central | 263 |
8 | PUB-008 | PUBLIC | Health centre IV | Peri-urban | Mid-west | 298 |
9 | PUB-009 | PUBLIC | Health centre IV | Rural | North East | 126 |
10 | PNFP-001 | NOT FOR PROFIT | Referral Hospital | Urban | Kampala | 4337 |
11 | PNFP-002 | NOT FOR PROFIT | Referral Hospital | Urban | East central | 1727 |
12 | PNFP-003 | NOT FOR PROFIT | Health Centre IV | Rural | Mid-East | 647 |
13 | PNFP-004 | NOT FOR PROFIT | Health Centre IV | Peri-urban | South West | 402 |
14 | PFP-001 | FOR-PROFIT | Health centre III | Urban | Mid-West | 324 |
15 | PFP-002 | FOR-PROFIT | Health Centre II | Urban | Central 2 | 29 |
16 | PFP-003 | FOR-PROFIT | Health Centre II | Rural | Mid-North | 46 |
Data collection
Head of ART clinic |
n = 16
|
Facility in-charge |
n = 16
|
Clinicians |
n = 39
|
Pharmacists (in the case of higher-level hospitals) |
n = 7
|
Total |
78
|
Data analysis
Results
Facility-level contributors to stock-outs
Inaccurate ART medicines quantification
‘Stock-outs of ARVs are a huge problem here because of the huge number of patients that keeps swelling all the time at our ART clinic. So the consumption rate of drugs is very high’ [ART clinic manager, PUB-003].
Untimely orders of drugs
‘In fact one of the problems (of stock outs) is with us. One of the staff who worked here before being transferred was not very keen and did not place orders for ARVs on time s and that is what led to stock-outs. We cannot blame somebody else for that’ [Facility in-charge, PUB-004].
Internal stock management strategies
ARV medicines substitutions
In PUB-007, a sub-district health facility, it was reported that they often experienced prolonged stock-out of both ARVs and anti-Tuberculosis (TB) drugs lasting for as long as 3 months and longer and that during these periods, clinicians were compelled to prescribe ARVs that they had in stock but which were no longer recommended regimens following revision of the national ART treatment guidelines.‘Drug stock outs of ARVs are chronic here. There is irregular supply of commodities and sometimes certain drug combinations are not in stock. The number of clients is increasing but the supplies are reducing. In such instances, we can substitute. If drug X is not in stock, we can prescribe an alternative. We play around with drugs when we don’t have certain combinations. And we counsel our patients to accept the alternative drugs’ [ART program manager, PNFP-001].
Overstocking select ARVs
Specific medicines were repeatedly mentioned as candidates for overstocking. These include co-trimoxazole tablets (septrin) which is prescribed in HIV-infected persons to reduce the risk of opportunistic infections, more especially diarrhea, malaria and pneumonia. Dapsone was also frequently mentioned as a drug which was overstocked to prevent interruption in supply. Dapsone is prescribed to people with HIV as preventive therapy against opportunistic infections (OIs) in those patients allergic to co-trimoxazole.‘Our implementing partner had a mechanism of overstocking and alternative supply-lines approaches because these stock-outs are actually common.’ [Facility in-charge, PUB-001].
Utilizing recently expired drugs
‘When we experienced a prolonged stock-out last year, we got advice from our implementing partner that if there is a district in our region which has drugs that have just recently expired we can use them. For example, we are using second-line drugs that recently expired in September (three months back). We were told that those ones can serve but pharmaceutically we are not allowed to do that’ [ART clinic manager, PUB-007].
In-house extra purchases of medicines
‘We usually purchase ARVs that are not supplied by Medical Access (main supplier) using our own (company) funds to ensure that ART services continue without interruption’ [Facility in-charge, PFP-001].
Leveraging external networks to mitigate stock-outs
‘Borrowing of drugs’ within peer-provider networks
‘We do a lot of internal borrowing. We often experience drug stock outs. In such cases, we borrow drugs from sister hospitals such as (names of three catholic-founded providers) and we replace their drugs when we replenish our stock’ [ART program manager, PNFP-001].
‘What we do is look around other facilities which have some supplies. We borrow drugs from a neighboring NGO provider when we experience a stock-out or if we don’t have a particular combination in stock’ [ART clinic manager, PUB-001].
‘We can borrow drugs from our sister clinics if our HIV or TB drugs are not delivered on time (from supplier). There are clinics in our network of employee clinics run by the Tea Company such as (name of tea estate A) and (name of tea estate B). When they have excess septrin (co-trimoxazole) we can request and they give us’ [Facility in-charge, PFP-001].
Stock re-distribution across regions
‘Recently when we had a stock-out of second-line ARVs. We ran to neighbouring districts which still had some and they gave us. When we also have (stock) and they don’t have, we also give them’ [ART clinic manager, PUB-002]
‘We redistribute from other health facilities which have stock to those which don’t have so at least we keep moving on’ [Facility in-charge, PUB 006]
Upward referrals
‘During the two months when we had stock-outs of ARVs, patients were off treatment for two months. There was no immediate solution. So, you refer patients to the district hospital so that they can get drugs’ [ART clinic In-charge, PUB-004]
Systemic drivers of ARV stock-outs
Long lead times
‘We have a bi-monthly order cycle. The challenge is that JMS sometimes doesn’t have a certain ARV. A certain commodity X or Y. Sometimes the shortage for certain combinations are more common and hence you plan accordingly’ [ART program Manager, PNFP-001].
Close-to-expiry drugs
‘Sometimes they bring us drugs which are about to expire. They bring them when they have a short shelf life. And they tell us,’ continue using them’. You see that is the challenge’ [ART clinic manager, PUB-002].
Maldistribution of drugs
‘You find that a health facility instead of getting 10 tins of septrin (co-trimoxazole) they actually get 20, because of one reason or another. But then a nearby health facility doesn’t have any. There are cases of erratic stock. So, we share. You find that a health facility here is suffering but another health facility in a neighboring district has extra stock. But we are in one regional network. We share information about supply and logistics with each other’ [Facility in-charge, PUB-002].
Migration pressures on ARV stock
Additionally, health workers pointed out increasing cases of patients crossing from neigbouring districts in Uganda seeking HIV care at PUB-003. In all, health workers mentioned five neigbouring districts from which patients hailed. They complained about serving huge client loads from neighbouring districts who they had not planned for in terms of commodities which put pressure on the stock of ARVs available to dispense to their regular and registered clients.‘We behave like an international hospital. We even have clients coming in from (neighbouring) Rwanda and Congo (DRC). So, the consumption rate of commodities is high because of that’ [Nurse, PUB-005].