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INTRODUCTION: The large number of deaths among children with HIV is driven by poor antiretroviral treatment (ART) coverage among this cohort. The aim of the study was to assess the availability and stock-outs of paediatric and adult ART formulations in Kenya and Uganda across various regions and types of health facilities. METHODS: A survey on availability and stock-outs of paediatric ART at health facilities was adapted from the standardized Health Action International-WHO Medicine Availability Monitoring Tool. All preferred and limited-use formulations, and three phased-out formulations according to the 2021 WHO optimal formulary list were included in the survey, as well as a selection of adult ART formulations suitable for older children, adolescents, and adults. Availability data were collected in June-July 2022 and stock-out data were obtained over the previous year from randomly selected public and private-not-for-profit (PNFP) facilities registered to dispense paediatric ART across six districts per country. All data were analysed descriptively. RESULTS: In total, 144 health facilities were included (72 per country); 110 were public and 34 PNFP facilities. Overall availabilities of preferred paediatric ART formulations were 52.2% and 63.5% in Kenya and Uganda, respectively, with dolutegravir (DTG) 10 mg dispersible tablets being available in 70.2% and 77.4% of facilities, respectively, and abacavir/lamivudine dispersible tablets in 89.8% and 98.2% of facilities. Of note, availability of both formulations was low (37.5% and 62.5%, respectively) in Kenyan PNFP facilities. Overall availabilities of paediatric limited-use products were 1.1% in Kenya and 1.9% in Uganda. At least one stock-out of a preferred paediatric ART formulation was reported in 40.0% of Kenyan and 74.7% of Ugandan facilities. Nevirapine solution stock-outs were reported in 43.1% of Ugandan facilities, while alternative formulations for postnatal HIV prophylaxis were not available. CONCLUSIONS: Recommended DTG-based first-line ART for children across all ages was reasonably available at health facilities in Kenya and Uganda, with the exception of Kenyan PNFP facilities. Availability of paediatric ART formulations on the limited-use list was extremely low across both countries. Stock-outs were reported regularly, with the high number of reported stock-outs of neonatal ART formulations in Uganda being most concerning.
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Infecciones por VIH , Instituciones de Salud , Uganda , Kenia , Humanos , Infecciones por VIH/tratamiento farmacológico , Niño , Instituciones de Salud/estadística & datos numéricos , Fármacos Anti-VIH/provisión & distribución , Fármacos Anti-VIH/uso terapéutico , Fármacos Anti-VIH/administración & dosificación , Piridonas/provisión & distribución , Piridonas/uso terapéutico , Antirretrovirales/provisión & distribución , Antirretrovirales/uso terapéutico , Compuestos Heterocíclicos con 3 Anillos/provisión & distribución , Compuestos Heterocíclicos con 3 Anillos/uso terapéutico , Compuestos Heterocíclicos con 3 Anillos/administración & dosificación , Adolescente , Preescolar , Accesibilidad a los Servicios de Salud , Nevirapina/provisión & distribución , Nevirapina/uso terapéutico , Nevirapina/administración & dosificación , Lactante , Masculino , Femenino , Lamivudine/provisión & distribución , Lamivudine/uso terapéutico , Lamivudine/administración & dosificación , Oxazinas , PiperazinasRESUMEN
Background: HIV/AIDS commodity stock-outs are still rampant in most African Countries causing treatment interruption, antiretroviral resistance, treatment failure, morbidity and mortality. Therefore, this study aimed at assessing the determinants of the availability of HIV Tracer Commodities in Health Facilities in Wakiso District, Uganda. Methods: A descriptive cross-sectional design was conducted in 42 Health Facilities [HFs] offering HIV/AIDs services in Wakiso District, Uganda. Semi-structured questionnaire adapted from the Anti-Retroviral Therapy Supervision Performance and Recognition Strategy [ART SPARS] tool Version 2.0 | 2018111 was used to collect data. Results: The majority of the HFs 28 [67%] had all the seven tracer commodities on the day of the visit. The majority of the HFs 33 [78.6%] were using Manual stock management tools that were fully updated. The availability of HIV tracer commodities was high in facilities that made timely ordering [AOR: 2.538, 95% CI: 2.126-3.304, p-value = 0.003] while the use of manual LMIS alone at the facility [AOR: 0.623, 95% CI: 0.131-0.958, p-value = 0.002] was associated with low availability. Conclusion: This study indicated that 67% of health facilities visited had all HIV Tracer commodities on the day of the visit. ART commodity management should be computerised and orders made on time to ensure the availability of commodities.
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BACKGROUND: With countries moving towards reaching the UNAIDS 90-90-90 goal to achieve HIV epidemic control, there are going to be an unprecedented number of persons who will need to be tested, treated, and regularly monitored for viral suppression. However, most of the countries with the greatest burden of HIV/AIDS experience regular stock outages which could be detrimental to reaching these targets. ART and other commodities such as HIV test kits and laboratory supplies need to be readily and consistently available to achieve these targets. The main objective was to improve access to HIV/AIDS related commodities and strengthening institutional capacity for the management of HIV/AIDS logistics services through the MAUL procurement and supply chain strengthening project (PSSP) that rolled out four interventions on mentorship and support supervision, stock level monitoring, spatial visualization of stock indicators using GIS, and using WhatsApp to submit order reports as photo images. METHODS: Medical Access Uganda Limited, a private-not-for-profit supply chain management company in Uganda, implemented these interventions as part of a procurement and supply chain strengthening project (PSSP). These interventions were evaluated using performance monitoring indicators from 2011-2016. We tested for the significance in the change in scores of performance monitoring indicators using the test for difference in proportions. Health facilities were scored on 6 categories and accredited as bronze, silver or gold based on their total scores. Kaplan-Meier estimates were computed for time to silver, and gold ranking and univariate and multivariate Cox proportional hazards models were computed for time to gold ranking. RESULTS: We observed a significant reduction in reported stock-outs from 46 to 4% (p < 0.001) in the analysis period. Accurate stock card inventory rose from 79 to 91% (p < 0.001); adequate stock levels rose from 54 to 71% (p = 0.002) and stock reporting rates from 91 to 100% (p < 0.001). The stock order fill rate improved from a high of 93% to 97% (p = 0.375). Patient load (medium vs low adjusted hazard ratio (aHR): 2.19, p = 0.026; high vs low aHR: 2.97, p = 0.034) and number of support supervision visits (6-10 aHR: 3.33, p = 0.024; > 10 aHR: 5.78, p = 0.003) were associated with better stock management ranking scores. CONCLUSIONS: Improvements in supply chain management in countries committed to achieving the 90-90-90 goals are crucial to achieving HIV epidemic control. Health system strengthening and mentorship investments in Uganda were feasible and are essential for sustainable disease control efforts.
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An uninterrupted supply of vaccines at different supply chain levels is a basic component of a functional immunization programme and care service. There can be no progress toward achieving universal health coverage and sustainable development without continuous availability of essential medicines and vaccines in healthcare facilities. Shortages of vaccines, particularly at health facility level is an issue of grave concern that requires urgent attention in South Africa. The causes of vaccine stock-outs are multifactorial and may be linked to a broader systems issue. These factors include challenges at higher levels such as delays in the delivery of stock from the pharmaceutical depot; health facility level factors, which include a lack of commitment from healthcare workers and managers; human resource factors, such as, staff shortages, and lack of skilled personnel. Therefore, there is a compelling need to address the factors associated with shortages of vaccines in health facilities. This paper highlights the challenges of vaccine availability in South Africa, the associated factors, the available interventions, and recommended interventions for the expanded programme on immunization in South Africa. We propose a system redesign approach as a potentially useful intervention.
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Medicamentos Esenciales , Vacunas , Instituciones de Salud , Humanos , Atención Primaria de Salud , SudáfricaRESUMEN
BACKGROUND: Although adverse drug reactions resulting from the use of nevirapine (NVP) are well described in adults (estimated frequency of 6% - 10%), it has previously been considered less common in children (0.3% - 1.4%). Stock-outs of antiretroviral agents occur frequently in South Africa and result in interruptions in therapy and drug substitutions. OBJECTIVES: To report on a case series of paediatric patients who suffered cutaneous drug reactions to NVP at rates not previously described in children. METHOD: We describe a retrospective observational case series of six children living with HIV who developed Stevens-Johnson Syndrome (SJS) following exposure to NVP because of a prolonged stock-out of efavirenz 200 mg tablets in South Africa. RESULTS: Of the 392 paediatric patients receiving antiretroviral therapy at the institution, 172 were affected by the efavirenz stock-out. Of these, 85 children were changed to NVP of which six developed NVP-induced SJS (7.1% incidence rate). The median time between initiating NVP and developing symptoms was 27 days (range 12-35 days). All patients responded well to NVP cessation and symptomatic treatment. One patient was referred for specialist care. Two patients were successfully rechallenged with efavirenz after developing SJS and three continued lopinavir/ritonavir. CONCLUSIONS: This is the second largest case series of NVP-induced SJS in children to date and raises the possibility that the incidence of SJS in children may be higher than previously described. Further research is required to explore the risk factors associated with NVP-induced SJS in children. This case series highlights the negative impact of drug stock-outs on patient health outcomes.
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INTRODUCTION: The year 2017 marked a transition period with the end of the implementation of Cameroon´s 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target. METHODS: We conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access. RESULTS: A total of 137 staff and 642 people living with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04-4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16-7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs "HIV test kits (21%), antiretrovirals (ARVs) (71.4%), viral load testing reagents (100%)" are the major barriers to service delivery and uptake along the cascade. CONCLUSION: We identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target.
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Fármacos Anti-VIH/administración & dosificación , Atención a la Salud/organización & administración , Infecciones por VIH/terapia , Prueba de VIH/estadística & datos numéricos , Adolescente , Adulto , Anciano , Camerún , Niño , Estudios Transversales , Femenino , Infecciones por VIH/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Factores Socioeconómicos , Carga Viral , Adulto JovenRESUMEN
INTRODUCTION: To describe vaccine stock-outs at national, district, and health facility levels in the WHO African region. AREAS COVERED: We conducted a systematic review to identify studies reporting on vaccine stock-outs at national, district, and health facility levels in 47 African countries. We searched both published and unpublished literature, including the WHO/UNICEF Joint Reporting Form (JRF), for eligible studies. EXPERT OPINION: Countries within the WHO African region continue to face the challenge of vaccine stock-outs at national, district, and health facility levels and this impacts on the delivery of immunization services. The frequency and the proportion of stock-outs vary between countries and between regions within a country. Countries need to put more efforts toward finding lasting solutions to vaccine shortages. We look forward to having more countries reporting vaccine stock-outs especially at the health facility level. Furthermore, countries are currently exploring different approaches for improving vaccine stock management. It is expected that in half a decade from now, more well-designed studies will be available that will inform decision-making.
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Vacunación , Vacunas/provisión & distribución , África , Instituciones de Salud , Humanos , Organización Mundial de la SaludRESUMEN
BACKGROUND: Poor stock management has been identified as one of the causes of vaccine stock-outs in health facilities. This study assessed the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care facilities in OR Tambo district of the Eastern Cape province, South Africa. METHODS: Descriptive cross-sectional study design was used in this study to assess both the stock management practices and the availability of vaccines in the facilities. The study was conducted in 64 primary health care facilities across all sub-districts in OR Tambo. Data were collected using a questionnaire administered by the researcher, record checks and through observation. The occurrence of stock-outs of six tracer vaccines on the day of the visit and in the preceding 24 months were assessed. The data were captured into REDCap tool and analysed using STATA version 14. RESULTS: Most standard stock management procedures were not adhered to, as these procedures were mostly handled by health care workers who either required formal training or refresher training on vaccine management. Cold chain capacity was not adequate and some vaccines were exposed to freezing. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which contributed to stock-outs. A total of 49 (77%) health facilities had at least one stockout for at least one vaccine on the day of the visit. Furthermore, BCG and OPV were the most affected vaccines in 37 (58%) and 28 (44%) of facilities, respectively. CONCLUSION: Interventions for improving vaccine availability should be considered, especially those targeting human resources and the entire stock management system.
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Instituciones de Salud , Vacunas , Instituciones de Atención Ambulatoria , Estudios Transversales , Humanos , Atención Primaria de Salud , SudáfricaRESUMEN
OBJECTIVE: In 2011, the government of Cameroon launched its performance-based financing (PBF) scheme. Our study examined the effects of the PBF intervention on the availability of essential medicines (EM). METHODS: Randomised control trial whereby PBF and three distinct comparison groups were randomised in a total of 205 health facilities across three regions. Baseline data were collected between March and May 2012 and endline data 36 months later. We defined availability of multiple EM groups by assessing stock-outs for at least one day over the 30 days prior to the survey date and estimated changes attributable to PBF using a series of difference-in-difference regression models, adjusted for relevant facility-level covariates. Data were analysed stratified by region and area to assess effect heterogeneity. RESULTS: Our estimates suggest that PBF intervention had no effect on the stock-outs of antenatal care drugs (P = 0.160), vaccines (P = 0.396), integrated management of childhood illness drugs (P = 0.681) and labour and delivery drugs (P = 0.589). However, the intervention was associated with a significant reduction of 34% in stock-outs of family planning medicines (P = 0.028). We observed effect heterogeneity across regions and areas, with significant decreases in stock-outs of family planning products in North-West region (P = 0.065) and in rural areas (P = 0.043). CONCLUSIONS: The PBF intervention in Cameroon had limited effects on the reduction of EMs stock-outs. These poor results were likely the consequence of partial implementation failure, ranging from disruption and discontinuation of services to limited facility autonomy in managing decision-making and considerable delay in performance payment.
OBJECTIF: En 2011, le gouvernement du Cameroun a lancé son programme de financement basé sur la performance (FBP). Notre étude a examiné les effets de l'intervention du FBP sur la disponibilité des médicaments essentiels (ME). MÉTHODES: Essai contrôlé randomisé dans le cadre duquel le FBP et trois groupes de comparaison distincts ont été randomisés dans un total de 205 établissements de santé dans trois régions. Les données de base ont été recueillies entre mars et mai 2012 et les données finales 36 mois plus tard. Nous avons défini la disponibilité de plusieurs groupes de ME en évaluant les ruptures de stock pendant au moins un jour au cours des 30 jours précédant la date de l'enquête et avons estimé les changements attribuables au FBP en utilisant une série de modèles de régression des différences dans les différences, ajustés pour les covariables pertinentes au niveau des établissements. Les données ont été analysées stratifiées par région et par zone afin d'évaluer l'hétérogénéité des effets. RÉSULTATS: Nos estimations suggèrent que l'intervention du FBP n'a eu aucun effet sur les ruptures de stocks de médicaments pour les soins prénataux (P = 0,160), les vaccins (P = 0,396), les médicaments pour la prise en charge intégrée des maladies infantiles (P = 0,681) et les médicaments pour le travail et l'accouchement (P = 0,589). Cependant, l'intervention a été associée à une réduction significative de 34% des ruptures de stock de médicaments pour la planification familiale (P = 0,028). Nous avons observé une hétérogénéité des effets entre les régions et les zones, avec des diminutions significatives des ruptures de stock de produits de planification familiale dans la région du Nord-Ouest (P = 0,065) et dans les zones rurales (P = 0,043). CONCLUSIONS: L'intervention du FBP au Cameroun a eu des effets limités sur la réduction des ruptures de stock des ME. Ces mauvais résultats étaient probablement la conséquence d'un échec partiel de la mise en Åuvre, allant de la perturbation et de l'interruption des services à une autonomie limitée des établissements dans la gestion des prises de décisions et à un retard considérable dans le paiement pour les performances.
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Medicamentos Esenciales/economía , Costos de la Atención en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Camerún , HumanosRESUMEN
We make the case for why continuous pharmaceutical manufacturing is essential, what the barriers are, and how to overcome them. To overcome them, government action is needed in terms of tax incentives or regulatory incentives that affect time.
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Industria Farmacéutica/legislación & jurisprudencia , Preparaciones Farmacéuticas/química , Tecnología Farmacéutica/legislación & jurisprudencia , Control de Medicamentos y Narcóticos/legislación & jurisprudenciaRESUMEN
INTRODUCTION: The strategy to Eliminate Yellow Fever Epidemics (EYE) is a global initiative that includes all countries with risk of yellow fever (YF) virus transmission. Of these, 40 countries (27 in Africa and 13 in the Americas) are considered high-risk and targeted for interventions to increase coverage of YF vaccine. Even though the World Health Organization (WHO) recommends that YF vaccine be given concurrently with the first dose of measles-containing vaccine (MCV1) in YF-endemic settings, estimated coverage for MCV1 and YF vaccine have varied widely. The objective of this study was to review global data sources to assess discrepancies in YF vaccine and MCV1 coverage and identify plausible reasons for these discrepancies. METHODS: We conducted a desk review of data from 34 countries (22 in Africa, 12 in Latin America), from 2006 to 2016, with national introduction of YF vaccine and listed as high-risk by the EYE strategy. Data reviewed included procured and administered doses, immunization schedules, routine coverage estimates and reported vaccine stock-outs. In the 30 countries included in the comparitive analysis, differences greater than 3 percentage points between YF vaccine and MCV1 coverage were considered meaningful. RESULTS: In America, there were meaningful differences (7-45%) in coverage of the two vaccines in 6 (67%) of the 9 countries. In Africa, there were meaningful differences (4-27%) in coverage of the two vaccines in 9 (43%) of the 21 countries. Nine countries (26%) reported MVC1 stock-outs while sixteen countries (47%) reported YF vaccine stock-outs for three or more years during 2006-2016. CONCLUSION: In countries reporting significant differences in coverage of the two vaccines, differences may be driven by different target populations and vaccine availability. However,these were not sufficient to completely explain observed differences. Further follow-up is needed to identify possible reasons for differences in coverage rates in several countries where these could not fully be explained.
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Salud Global/economía , Vacuna Antisarampión/economía , Vacuna Antisarampión/inmunología , Vacunación/economía , Vacuna contra la Fiebre Amarilla/economía , Vacuna contra la Fiebre Amarilla/inmunología , África , Humanos , Esquemas de Inmunización , Almacenamiento y Recuperación de la Información/economía , América Latina , Sarampión/economía , Sarampión/inmunología , Organización Mundial de la Salud/economía , Fiebre Amarilla/economía , Fiebre Amarilla/inmunología , Virus de la Fiebre Amarilla/inmunologíaRESUMEN
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.
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Instituciones de Atención Ambulatoria/organización & administración , Antirretrovirales/provisión & distribución , Infecciones por VIH/tratamiento farmacológico , Antirretrovirales/uso terapéutico , Recursos en Salud , Humanos , Entrevistas como Asunto , Investigación Cualitativa , UgandaRESUMEN
BACKGROUND: Inadequate vaccine stock management in health facilities leads to vaccine stock-outs. The latter threatens the success of immunisation programmes. Countries have used various approaches to reduce stock-outs and improve vaccine availability, but we are not aware of a systematic review of these interventions. This protocol describes the methods we will use to assess the effects of existing approaches for improving vaccine stock management. METHODS: We include randomised and non-randomised studies identified through a compehensive search of peer-reviewed and grey literature databases. We will search PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, PDQ-Evidence and Scopus. We will also search websites of the World Health Organisation (WHO), Global Alliance for Vaccine and Immunisation, PATH Vaccine Resources Library and United Nations Children's Fund. In addition, we will search the WHO International Clinical Trials Registry Platform and reference lists of included studies and relevant reviews. Finally, we plan to do a citation search for included studies. We will use Cochrane recommended methods to screen search outputs, assess study eligibility and risk of bias, extract and analyse study results. We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool to assess the certainty of the evidence on the effects of the interventions. DISCUSSION: We believe that the findings of this review will serve as valuable information for policy makers on ways to improve vaccine stock management and vaccine availability. When vaccine availability is improved, those who need them, especially children, will be adequately protected from vaccine-preventable diseases. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018092215.
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Programas de Inmunización/organización & administración , Inventarios de Hospitales/métodos , Vacunas/provisión & distribución , Instituciones de Salud , Administración de Instituciones de Salud/métodos , Humanos , Revisiones Sistemáticas como AsuntoRESUMEN
BACKGROUND: Community health workers (CHWs) continue to play a crucial role in supporting health service delivery globally. Several CHW programmes around the world face vast challenges which affect their performance. OBJECTIVES: This study assessed the performance of CHWs and associated factors in a rural community in Wakiso district, Uganda. METHODS: This was a cross-sectional study that employed a structured questionnaire to collect quantitative data from 201 CHWs in Wakiso district. The main study variable was CHW performance based on various roles carried out by CHWs. Multivariable logistic regression in STATA was used to establish the predictors of CHW performance. RESULTS: Only 40 (19.9%) of the CHWs had a high performance which was associated with having attended additional / refresher trainings [AOR=12.79 (95% CI: 1.02-159.26)], and having attained secondary level education and above [AOR=3.93 (95% CI: 1.17-13.24)]. CHWs who were married [AOR=0.29 (95% CI: 0.09-0.94)] were less likely to perform highly. Among CHWs who had received essential medicines for treatment of childhood illnesses, the majority 90.3% (112/124) had experienced stock-outs in the 6 months preceding the study. Despite the majority of CHWs, 198 (98.5%), stating that being motivated was very important in their work, only 91 (45%) said that they were motivated. CONCLUSION: Additional / refresher trainings are necessary to enhance performance of CHWs. In addition, level of education should be considered while selecting CHWs. The health system challenges of low motivation of CHWs as well as stock-out of medicines need to be addressed to support their work.
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Agentes Comunitarios de Salud/educación , Agentes Comunitarios de Salud/organización & administración , Éxito Académico , Adulto , Agentes Comunitarios de Salud/normas , Estudios Transversales , Medicamentos Esenciales/provisión & distribución , Femenino , Humanos , Capacitación en Servicio , Masculino , Motivación , Investigación Cualitativa , Población Rural , Factores Socioeconómicos , UgandaRESUMEN
This paper examines the stock-outs of medicines and diagnostic devices in Uganda. Our aim is to trace and compare interruptions in the supply of antiretrovirals and Rapid Diagnostic Tests in order to provide an ethnographic account of the complex role that improvisations play within global health infrastructures. We will argue that the fragmented and mobile infrastructures of these key global health technologies require and necessitate improvisations by the different actors involved as well as on almost all levels of the Ugandan health-care system. The extent and abundance of improvisations in itself works to acquire infrastructural capacities, a process that we will call the infrastructuring of care and treatment. We will also show how this process of infrastructuring of care and treatment - here rendered visible through improvisations - produces new dilemmas and uncertainties. Our approach to infrastructure challenges technocratic overtones prevalent in current debates around the much-needed strengthening of health systems. Our study of stock-outs aims to show how the infrastructure of under-resourced health systems is maintained by a complex nexus of socio-material practices and improvisations.
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Antirretrovirales/provisión & distribución , Pruebas Diagnósticas de Rutina , Infecciones por VIH/prevención & control , Accesibilidad a los Servicios de Salud , Malaria/prevención & control , Programas Nacionales de Salud/organización & administración , Humanos , UgandaRESUMEN
Over the past decade, several countries across all regions, income groups and procurement methods have been unable to secure sufficient BCG vaccine supply. While the frequency of stock-outs has remained rather stable, duration increased in 2014-2015 due to manufacturing issues and attracted the attention of national, regional and global immunization stakeholders. This prompted an in-depth analysis of supply and demand dynamics aiming to characterize supply risks. This analysis is unique as it provides a global picture, where previous analyses have focused on a portion of the market procuring through UN entities. Through literature review, supplier interviews, appraisal of shortages, stock-outs and historical procurement data, and through demand forecasting, this analysis shows an important increase in global capacity in 2017: supply is sufficient to meet forecasted BCG vaccine demand and possibly buffer market shocks. Nevertheless, risks remain mainly due to supply concentration and limited investment in production process improvements, as well as inflexibility in demand. Identification of these market risks will allow implementation of risk-mitigating interventions in three areas: (1) enhancing information sharing between major global health actors, countries and suppliers, (2) identifying interests and incentives to expand product registration and investment in the BCG manufacturing process, and (3) working with countries for tighter vaccine management.
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Vacuna BCG , Tuberculosis/epidemiología , Tuberculosis/prevención & control , Vacuna BCG/provisión & distribución , Salud Global , Necesidades y Demandas de Servicios de Salud , Humanos , Vigilancia en Salud Pública , VacunaciónRESUMEN
The functioning of the supply chain may be a driving factor behind the development of human immunodeficiency virus (HIV) drug resistance (HIVDR) in many low- and middle-income countries (LMICs). Additionally, the effectiveness of supply chains will likely impact the scale-up of both viral-load monitoring and HIVDR testing. This article describes the complexities of global supply chains relevant for LMICs and presents early data on stock-outs and drug substitutions in several countries supported by the US President's Emergency Plan for AIDS Relief. Supply chain systems will need to be strengthened to minimize interruptions as new antiretroviral therapy regimens are introduced and to facilitate adoption of new laboratory technologies.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Países en Desarrollo , Infecciones por VIH/tratamiento farmacológico , VIH/efectos de los fármacos , Fármacos Anti-VIH/provisión & distribución , Países en Desarrollo/estadística & datos numéricos , Farmacorresistencia Viral , Infecciones por VIH/prevención & control , Infecciones por VIH/virología , Humanos , Cooperación Internacional , Carga Viral/efectos de los fármacos , Carga Viral/estadística & datos numéricosRESUMEN
BACKRGOUND: Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs. METHODS: Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively. RESULTS: Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms. CONCLUSIONS: While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers' accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods.
Asunto(s)
Auditoría Clínica , Anticonceptivos/provisión & distribución , Servicios de Planificación Familiar/organización & administración , Administración de Instituciones de Salud , Personal de Salud , Motivación , Equipos y Suministros , Estudios de Evaluación como Asunto , Femenino , Investigación sobre Servicios de Salud , Humanos , Mozambique , Calidad de la Atención de Salud , Estadísticas no ParamétricasRESUMEN
The under-performance of supply chains presents a significant hindrance to disease control in developing countries. Stock-outs of essential medicines lead to treatment interruption which can force changes in patient drug regimens, drive drug resistance and increase mortality. This study is one of few to quantitatively evaluate the effectiveness of supply chain policies in reducing shortages and costs. This study develops a systems dynamics simulation model of the downstream supply chain for amikacin, a second-line tuberculosis drug using 10 years of South African data. We evaluate current supply chain performance in terms of reliability, responsiveness and agility, following the widely-used Supply Chain Operation Reference framework. We simulate 141 scenarios that represent different combinations of supplier characteristics, inventory management strategies and demand forecasting methods to identify the Pareto optimal set of management policies that jointly minimize the number of shortages and total cost. Despite long supplier lead times and unpredictable demand, the amikacin supply chain is 98% reliable and agile enough to accommodate a 20% increase in demand without a shortage. However, this is accomplished by overstocking amikacin by 167%, which incurs high holding costs. The responsiveness of suppliers is low: only 57% of orders are delivered to the central provincial drug depot within one month. We identify three Pareto optimal safety stock management policies. Short supplier lead time can produce Pareto optimal outcomes even in the absence of other optimal policies. This study produces concrete, actionable guidelines to cost-effectively reduce stock-outs by implementing optimal supply chain policies. Preferentially selecting drug suppliers with short lead times accommodates unexpected changes in demand. Optimal supply chain management should be an essential component of national policy to reduce the mortality rate.
Asunto(s)
Amicacina/provisión & distribución , Antibacterianos/provisión & distribución , Medicamentos Esenciales/provisión & distribución , Tuberculosis/tratamiento farmacológico , Humanos , Asignación de Recursos , Sudáfrica , Análisis de SistemasRESUMEN
Backrgound: Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs. Methods: Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively. Results: Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms. Conclusions: While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers' accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods.