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Stock Outs in South Africa
Second Annual Report
2014 Stock Outs Survey
Stop Stock Outs Report: 2014
Table of Contents
Perspectives: Treatment Action Campaign & Southern Africa HIV Clinician's Society . 4-5 Executive Summary . 6 Introduction: 2nd Annual Stock Outs Survey . 10 Results: Survey Response . 13 Results: ARV and TB Stock Outs . 14 Results: Provincial Overview (ARV and TB Stock Outs) . 26 Results: Vaccine and Other Essential Medicine Stock Outs . 37 Key Findings . 40 Strengths and Limitations . 41 Analysis and Discussion. 41 Collaboration with Department of Health . 42 Recommendations and Way Forward . 44 Provincial Department of Health Narratives and Action Plans . 45 Northern Cape . 62 Western Cape . 72 Published June 2015 Treatment Action Campaign, Doctors without Borders/Medecins San Frontieres, Rural Health Advocacy Project, Rural Doctors Association of Southern Africa, SECTION27, Southern Africa HIV Clinician's Society Second Annual Report 2


Stop Stock Outs Report: 2014
on the public health system. The absence of medication causes people to suffer unnecessary pain. Babies who should be protected during delivery acquire HIV, grannies to be laid low by One of the biggest frustrations faced by rural clinicians at the an avoidable stroke and uncomplicated TB infections turn into coalface of healthcare delivery in clinics and district hospitals is resistant ones. Each time a medication is out of stock, there is a that short, yet devastating sentence: "Sorry, it's out of stock". It measurable human impact, in terms of hours wasted, hard-saved is hard to describe the helplessness and anger one feels when money spent on taxi fare to no avail, diseases left untreated, cheap, yet important medications such as anti-hypertensives, and confidence lost in our public health system. Stock outs of anti-epileptics, ARV's, antibiotics and even simple analgesics are medications on the essential drugs list are never acceptable. not available. I do not know a single healthcare provider working Every stock out is a dire emergency and should be treated as such. in a government hospital, rural or urban, who has not often heard and does not always dread that sentence uttered; sometimes This survey quantifies the level of stock outs of a few basic, several times a week, potentially signalling death for the people essential medications in the government sector and aims to we serve. When medication is not available, it means that trained help start a conversation to identify causes and find solutions to health professionals are practicing without some of the most an unacceptable situation. If we are to ensure a reliable supply important tools at their disposal. And of course, medicine stock of medicines to all South Africans, regardless of where they outs are worse in rural areas, where pharmacists and pharmacy live, every level of the healthcare system will need to tackle this assistants are scarce, and the supply chain is long and weak. problem and work together from districts, to province and to the National Department of Health.
Such shortages are hugely demotivating for healthcare workers – doctors, nurses and therapists alike. Yet, much more significant Dr. Karl le Roux, Rural Doctors Association of Southern Africa is the suffering it engenders for the many South Africans reliant 3 Second Annual Report


Stop Stock Outs Report: 2014
The Treatment Action Campaign: A view from
the trenches

Over the first months of 2015, members from
the Treatment Action Campaign (TAC) reported
a number of stock outs from Mpumalanga. Some
of these were for paediatric antiretrovirals, some
were for childhood vaccines, and some were
for hypertension medicines. We have engaged
Mpumalanga leadership from various levels about
these problems continually over the last year, but to no avail. Even in 2015,
children with HIV are forced to go without the medicine they require and to which
they have a right. We consider this to be a crisis.

As this report of the Stop Stock Outs Project (SSP) shows, South the ground in every province, in every district, in every Africa is not winning the fight against stock outs of essential healthcare facility. This is our demand. Our struggle will medicines. Yes, we appear to be doing a better job of getting the continue until the day our members tell us that there standard first-line fixed-dose combination out to patients, but are no more stock outs at their local clinic. This will be a long the overall picture is the same, or worse, than that painted by road, but we are ready and willing to be part of the solution. the previous SSP report. This bleak conclusion is also reflected in The reality is that in many provinces we are faced with reports from the TAC's active membership of over 10 000 users political obstacles that require political solutions. As TAC we of the public healthcare system.
are committed to finding these political solutions where the interests of our members and users of the public healthcare As we have often said in recent years, there is some hope. system require it. Minister of Health Dr Aaron Motsoaledi and his team seem We do not accept that the people of the Free State should committed to solving the problem of stock outs. And, as suffer. We do not accept that the people of Mpumalanga reported in this publication, that cooperation, at least in word, must suffer. We do not accept that children with HIV should now extends to a number of provinces. We are committed to suffer because of the mediocre political leadership in engaging constructively with these provinces and to try to play these two provinces. This report quantifies the problem our part in finding sustainable solutions to the crisis of stock and indicates the extent of the human suffering it causes – suffering felt worst by the poorest and most vulnerable among us. It also signals the struggle ahead. TAC is ready. That said, we won't be silenced merely by a bald promise to do the right thing. The proof of the pudding will be Aluta continua
in the eating. The Constitution requires real change on Anele Yawa, TAC General Secretary
Second Annual Report 4
Stop Stock Outs Report: 2014
Southern African HIV Clinician's Society: A view from the wards
For those living with HIV and/or TB, antiretroviral therapy and anti-tuberculosis
treatment are lifesaving. We need an uninterrupted supply of these medications for
public health, to prevent ill health and death, to control transmission and to prevent
resistance developing in both infections.

In 2015 in South Africa, the vast majority of HIV infected from management and logistical challenges between the individuals are adults who are on first line therapy consisting of medical depot and the clinic. In 9 facilities with FDC stock outs single day dosage fixed combination (FDC). In addition, most patients were sent away with no treatment and in 18 facilities individuals who present with TB will respond to a FDC of anti- they were given a smaller supply requiring patients to return tuberculosis medication containing rifampicin - the first line more often to the clinic. In the balance of the facilities, treatment. While FDC is the most common form of treatment, extra supplies were borrowed or patients were switched to there are clinical reasons why individuals with HIV and/or TB appropriate therapy. Although significant stock outs of other may need other medications or formulations. These would medications including ARVs were still seen, the relatively low include resistance, age, side effects and other comorbidities patient impact of FDC stock outs is encouraging.
including renal failure. The supply of other single drugs and formulations will always, therefore, be necessary, but to a Equally encouraging is the openness of the National lesser extent than the fixed dose.
Department of Health and some provincial departments of health to dealing with the problems as quantified in this To be able to effectively manage the dual epidemics of report. Our aim as a civil society consortium is to collaborate HIV and TB, it is important that the health care system with the government at all levels to ensure that there is an end can deliver the most commonly utilized treatment to all to stock outs. With the recent collaboration displayed by the people who need it. A focus on FDC makes sense from national and certain provincial departments of health, there a public health perspective. In this survey, we found 75 are signs that this will be achievable. facilities with FDC stock outs. There were no stock outs of FDC at a national level indicating that these FDC stock outs result Dr. Francesca Conradie, President
5 Second Annual Report
Stop Stock Outs Report: 2014
Executive
South Africa has among the largest HIV and TB epidemics in the world. A reliable
supply of life-saving medication is a constitutional right as well as critical to
personal and public health. The Stop Stock Outs Project (SSP), a civil society
coalition, seeks to ensure that all people have access to the medicines they require
and to which they have a right. The SSP does so by monitoring and communicating
about shortages and stock outs of medication, and ensuring that transparency
and accountability exists along the supply chain. With its free hotline, the SSP
ensures that patients and health care workers can ring the alarm when stock outs
occur anywhere in the country. Rapid communication to public health authorities
aims to speed up resolution of stock outs and gradually improve the supply chain.
To systematically assess and quantify the extent of medicine stock outs in public
health facilities across South Africa, the SSP undertakes annual national surveys.
Thus far, we have conducted studies in the fourth quarters of 2013 and 2014. Raw
data for the survey can be found at www.stockouts.org.

2014 Survey Results: Similarly to the 2013 survey, there was
There were frequent stock outs of other 1st line HIV a high participation rate by respondents in the 2014 survey, medicine, 2nd line HIV medicine, paediatric HIV medicine, indicating a willingness from facility staff to resolve the issues. isoniazid preventive treatment (IPT) for TB, and medicine Over 80% of facilities in every province, except for Free State, for complicated TB. Patients who require medicine other were willing to participate in this survey.
than FDCs are often already more vulnerable because they have clinical complications such as resistance, side effects, HIV and TB: Nationally, more than one in four (614/2,454 –
and/or other co-existing conditions such as renal failure, or 25%) facilities reported any ARV or TB medicine stock out in the because they are children or adolescents. three month survey period compared to one in five (459/2,139 – 21%) in 2013. Resolving stock outs requires clear and strong commitment at the provincial and district levels. The five provinces with Availability of Fixed Dose Combinations (FDCs) was the largest proportion of facilities reporting stock outs available in more facilities in 2014, an improvement were Mpumalanga (40%), North West (39%), Limpopo compared to 2013. While 75/614 facilities reported FDC (29%), Eastern Cape (28%) and Free State (28%). The stock outs, only 18 facilities sent patients home with a lower response rate in the Free State suggests this smaller supply and 9 facilities sent patients home with no figure probably underestimates the true rate of facilities affected by stock outs.
Second Annual Report 6
Stop Stock Outs Report: 2014
Proportion (%) of facilities by province for 2013 & 2014 reporting at least one ARV/TB stock out in the three months prior to
contact.

Northern Cape KwaZulu-Natal Western Cape Six provinces had an increase in the number of facilities reporting ARV/TB medicine stock outs in 2014 compared to 2013 - Eastern Cape, Gauteng, KwaZulu-Natal, High Impact /
Mpumalanga, North West and Northern Cape. No medication
given (175
Limpopo and the Western Cape had a decrease in the proportion of facilities reporting stock outs in 2014. (270 facilities) Free State had a significant drop in participation by facilities in 2014. In 2013, 87% facilities shared information on stock outs, while in 2014 only 63% did so. This suggests a change in context, where healthcare workers are unable to report stock outs. In 22% (175/779) of the cases where an ARV/TB medicine was reported out of stock, the patient was sent home with no medication (high impact). In 35% (230/779) of cases the patient was either given a smaller supply, their pill Patient Impact of ARV/TB stock outs
burden was increased or a less than optimal medicine was given (medium impact). In 43% (334/779) of stock Measles vaccine stock outs occurred most frequently outs reported the facility was able to borrow medicine in Mpumalanga, where 8% (15/182) of facilities were and the patient went home with their full supply of treatment (low impact). Other essential medicines
Childhood Vaccines (Rotavirus, Pentaxim, Measles): 12%
Salbutamol inhaler (asthma) was most often out of stock (249/2157) of facilities reported a stock out of at least one in North West, where 43% (92/214) of facilities were Sodium valproate (epilepsy) was most often out of stock Pentaxim stock outs were most frequently reported in in KwaZulu-Natal, where 22% (78/345) of facilities were Limpopo, where 28% (67/238) of facilities were affected.
Enalapril/perindopril (hypertension) was most often out Rotavirus vaccine stock outs most often reported of stock in Northern Cape where 20% (21/104) of facilities in Eastern Cape, where 10% (42/428) of facilities were were affected.
7 Second Annual Report
Stop Stock Outs Report: 2014
Collaboration with the Department of Health:
seven most severely affected districts, with over
The findings of this survey have been presented to the 40% of facilities reporting ARV/TB stock outs, are: National Department of Health (NDoH) and the Provincial Departments of Health (DoH) in the Free State, Gauteng, Joe Gqabi 46% (16/35), Eastern Cape
Limpopo, North West, Northern Cape and Western Cape. Alfred Nzo 50% (28/56), Eastern Cape
The aim of this report is to contribute to a constructive dialogue between civil society, DoH and its partners. Bojanala 44% (34/77), North West
Therefore, all departments were invited to include in the report a response to the report or plan of action to address Nkangala 44% (25/57), Mpumalanga
the crisis quantified in the report. Gert Sibande 41% (23/56), Mpumalanga
The Gauteng, Limpopo, Northern Cape, North West, and
Western Cape
provincial Departments of Health have
Lejweleputswa 42% (13/31), Free State
engaged with civil society on causes of stock outs and
potential solutions to improve the supply chain. We applaud
Fezile Dabi 42% (11/26), Free State.
their committed action plans to resolve stock outs and
An emergency task force is needed to resolve urgent stock have included them in this report.
outs to respond to the crises in these districts. The NDoH Strong commitment and political are necessary for the should assist provinces with the formation of this task force implementation of these action plans. Despite repeated attempts to discuss the findings of the report and plans to
resolve stock outs, the Eastern Cape, KwaZulu-Natal and
Mpumalanga provincial departments of health have not

II. Provincial and National health departments must work responded. Free State has opted not to contribute to this
together to establish and implement national minimum
report. We call on these provincial departments to follow the standards for supply chain management and resolution
example set by the national department of health and the of stock outs in all provinces.
other provincial departments and engage constructively with civil society to implement action plans to ensure that their facilities have the medicines patients' require. III. Provincial health departments should develop and Recommendations and Way Forward:
implement provincial action plans to resolve and
I. Urgent action is needed in the worst-affected seven
prevent stock outs in every province, with clear timelines districts and two provinces where close to 40% of
and evaluation of these action plans and provision for facilities reported stock outs.
emergencies, and focus on worst-hit districts. SSP offers North West and Mpumalanga had 40% and 39%
to work with provincial departments to develop these respectively of facilities reporting an ARV or TB stock out.
1 Pentaxim is a combination vaccine against diphtheria, tetanus, pertussis, poliomyelitis and Haemophilus influenzae type b. Second Annual Report 8



Stop Stock Outs Report: 2014
I'm a 45-year-old single lady. I live in an informal settlement close to the Lilian Ngoyi clinic called Aaron Motsoaledi. The majority of the people who live there are from rural areas in provinces outside of Gauteng. I was diagnosed with HIV 16 years ago and started ARV treatment in September 2014. In February 2015, after taking FDC for 5 months I experienced what it is like to not be able to take treatment because of stock outs. When I arrived at my clinic, I was told that my treatment was not in stock and sent home with no medicine. I am not formally employed and I rely on informal employment, which comes about irregularly. Regular visits to the clinic to check if the medication is available negatively impact my chance at employment. Employers started seeing me as unreliable and am paid less due to being late for work after checking to see if my FDC was available yet. The stock out lasted for 3 weeks until I was able to get my treatment. I was very happy when I finally received my treatment." -Maria from Michael Maponya Clinic, Soweto, Gauteng 9 Second Annual Report
Stop Stock Outs Report: 2014
2014 Stock Outs Survey
in South Africa
Second Annual Report
With approximately 3 million people on antiretroviral therapy (ART) and more than
300 000 people treated for tuberculosis (TB) every year, South Africa puts incredible
demands on its health system. Well-functioning supply chains to deliver medicines
and vaccines are critical for its ability to respond to the needs of the population
and have effective treatment programmes. As a civil society coalition that ensures
transparency and accountability exists along the supply chain, the Stop Stock Outs
Project (SSP) was formed to ensure that all patients have access to the medicines
they require.

On a day to day basis, the SSP receives reports of essential medicine stock outs
from patients and health care workers through a confidential hotline. Using these
reports, the SSP liaises with the Department of Health (DoH) along different levels of
the supply chain to facilitate and monitor the resolution of each case. Additionally,
the SSP aims to engage with government in its efforts to improve procurement,
distribution and management of essential medicine stocks in the longer term. In
2014, the SSP received 614 reports of essential medicine stock outs from the
general public through the hotline.

To systematically assess and quantify the extent of medicine (ARV) and/or tuberculosis (TB) medicines over a three-month stock outs in public health facilities across South Africa, the time period. 403 (19%) facilities reported stock outs of ARVs SSP also undertakes annual national surveys. Thus far, two compared to 68 (3%) facilities that reported stock outs of TB surveys have been conducted, in the fourth quarters of 2013 medicines. In 20% of affected facilities, patients were sent home or referred elsewhere without medicines. To re-assess the extent of stock outs one year later, a second survey was The first, conducted in 2013, was the largest survey at that conducted in 2014, with modification in the methodology time on stock outs in South Africa. In 2013, 21% of facilities made in consultation with the National Department of Health (459/2139) reported a stock out or shortage of antiretroviral (NDoH) and stakeholders in the consortium.
Second Annual Report 10



Stop Stock Outs Report: 2014
I suffer from an inflammation in my stomach and in my chest. I have been suffering with this condition for 10 years. In July 2014, I was sent to Baragwanath Hospital for a full check–up. After the check–up I was put on treatment called Ranitidine, this medicine helped me a lot. I was referred to Lilian Ngoyi clinic and that is where I started getting my treatment. But I have been having problems getting my medicine. In January and February 2015 I did not get my treatment and the nurse told me I must buy my own medicine from the pharmacy. In March the nurse gave me treatment for 10 days. Now, in April again I was told I must buy my own medicine. I borrowed money from my friend so that I could buy the treatment. " - Patient (32 years) from Lilian Ngoyi Clinic, Soweto, Gauteng This telephonic survey was conducted over six weeks, from For the purposes of this survey, a stock out was defined as no October to November 2014. Survey assistants were recruited medicine on the facility shelf. A stock out in the preceding 3 and trained to use the same questionnaire to enable the months was an event occurring during the 90 days before the collection of standardised information from all facilities day of the phone call and an ongoing stock out was an event contacted. Upon calling a facility, the surveyor asked to speak occurring on the day of the phone call. Facilities reporting a to, in order of preference, the pharmacist, pharmacy assistant stock out on the day of the call were asked if they were willing for or person who orders the facility's medicine. The motivations their facility name to be identified for follow-up. 77% (314/410) and aims of the survey were explained to respondents who of facilities agreed and details were forwarded weekly to NDoH. were then asked to respond anonymously to questions about A facility was deemed unreachable if no correct phone number medicine stock outs at their facility. could be obtained or if after four attempts to phone the facility, the call remained unanswered. 11 Second Annual Report
Stop Stock Outs Report: 2014
Adjustments to the survey methodology were made in 2014 in order to gather more refined information. The following
changes were made:
Table 1: 2013 and 2014 – Changes in Methodology
Respondent Sister in Charge Pharmacist, Pharmacy Assistant or Person who orders the facility's medica- Type of rupture ARV/TB stock outs and ARV/TB stock outs only Medicines that are out of stock Dosage not requested Dosage requested (e.g.150mg, 300mg) Patient impact Open-ended response Categorized into 3 categories based on 2 other categorical questions (See Table 2 for more details) Any vaccine stock outs Rotavirus, Pentaxim, and Measles vaccine stock outs Other Essential Salbutamol Inhaler (asthma), Metformin Tablets (diabetes), Sodium Valproate Tablets (epilepsy), Enalapril/Perindopril Tablets (hypertension), Ceftriaxone Injection (antibiotic) stock outs In 2014, to define high, medium and low impact stock 2 below. Between 2013 and 2014, changes in the definition outs, respondents were asked about the action taken by the of the patient impact of reported stock outs in the survey facility and the subsequent effects of their actions on affected were made. The comparable figure between 2013 and 2014 patients. Stock outs were then categorized as high, medium is the number of patients leaving the facility without any and low impact according to the definitions described in Table medication, defined as a high impact stock out in the 2014 survey and as left with no medication in the 2013 survey. Table 2: 2014 Patient Impact Definitions
Patient Left Facility With:
Referred and/or turned patients away Referred and/or turned patients away Switched to a different dosage, pill burden increased A smaller or full supply Received a less optimal medicine or regimen A smaller or full supply Switched appropriately to a different medicine Second Annual Report 12
Stop Stock Outs Report: 2014
Between October and November 2014, the survey team contacted 2865 (77%) of the 3732 facilities identified nationwide by telephone. In the remainder of cases a telephone number for that facility was not obtainable, or the number called was unreachable after four attempts. Table 3 below shows by province the number of facilities identified, the number of facilities that were contacted by phone, and the number of facilities that provided information. Of the facilities that were contacted, 87% (2499/2865) provided information; 45 facilities did not treat HIV or TB patients and were removed from the denominator. In the other 13% (365/2865) of cases, the individual answering the phone declined to participate. Respondent rates were above 84% in most provinces (except in the Free State) indicating willingness of facility staff to collaborate and resolve the problem.
Table 3: Facilities that were contactable and provided information on stock outs of ARV and/or TB medicines. Results by province
Number of Facilities
% (Number)
% (Number)
Facilities Contactable by Phone
Facilities Providing Information
Table 4: Proportion (%) of facilities participating in survey, 2013 & 2014
13 Second Annual Report
Stop Stock Outs Report: 2014
ARV and TB Stock Outs
In 2013, 21% (459/2139) of facilities and in 2014, 25% day of the call (ongoing). The results for 2014 compared to (614/2454) of facilities reported at least 1 ARV/TB stock 2013 are illustrated in Table 5 and 6 below. In 2014, with out in the three months prior to contact. In 2013, 11% improved methodology, the implications of these proportions (242/2239) of facilities and in 2014, 17% (410/2454) of in terms of their effect on patients can be understood.
facilities reported at least one ARV/TB stock out on the Table 5: Proportion (%) of facilities by province for 2013 and 2014 reporting at least one ARV/TB stock out in the three month
period prior to contact.
Northern Cape KwaZulu-Natal Western Cape Table 6: Proportion (%) of facilities by province for 2013 and 2014 reporting at least one ARV/TB stock out on the day of contact
(ongoing)

There was wide variation in the extent of stock Mpumalanga reported the largest proportion of facilities outs between provinces and between districts (district with stock outs, with 40% (82/205) of facilities reporting breakdown located in graphs of the provincial a stock out of at least 1 ARV/TB medication in the overview section below). In 2014, six provinces preceding three months and 30% (62/205) of facilities (Eastern Cape, Gauteng, KwaZulu-Natal, Mpumalanga, in Mpumalanga reporting a stock out on the day of the North West, and Northern Cape) had an increase in survey call. North West province had the most significant facilities reporting a stock out compared to 2013. Free State, Limpopo and Western Cape had a decrease increase from 4% (8/182) in 2013 to 39% (86/222) in in the proportion of facilities reporting stock outs 2014 in facilities reporting stock outs.
in 2014 compared to 2013. However, the lowered respondent rate of 63% in the Free State could lead to an underestimation of the extent of the problem.
Second Annual Report 14
Stop Stock Outs Report: 2014
I was given alternative treatment because Tenofovir tablets were out of stock. I don't remember the name now, but my system did not agree with it and I reacted very badly to the medicine. I could not take it anymore. I phoned the Stop Stock Outs Project hotline in February 2015, after getting their contact number from a friend of mine, to see how they can help me. After reporting this incident, a week later I received a call from the clinic to let me know that my treatment was available. I am happy to be on my treatment again because that other one was making me feel very depressed." - Patient (46 years old) from Matsulu CHC, Nelspruit, Mpumalanga Breakdown of ARV and TB Stock Outs
The majority of reported ARV/TB stock outs were for treatment, 6% (154/2454) for paediatric HIV treatment and treatment of adult HIV patients. Nationwide, 14% 6% (140/2454) for TB treatment. Table 6 on the next page (351/2454) of facilities reported a stock out of medicine shows the provincial breakdown of facilities reporting stock used for adult HIV treatment, 3% (78/2454) for PMTCT outs for the different patient groups.
15 Second Annual Report
Stop Stock Outs Report: 2014
Table 7: Proportion (%) of facilities reporting adult ARVs, PMTCT, paediatric ARVs and TB stock outs in the three month period
prior to contact.

Eastern Cape Northern Cape KwaZulu-Natal Western Cape
Table 8: Seven most commonly reported medicines nationwide in 2014. Breakdown of the 867 instances where ARV and/or TB
medicines were reported out of stock.

Nevirapine solution (79 facilities) Zidovudine 300mg (77 facilities) FDC (75 facilities) Abacavir (63 facilities) Isoniazid tablets (53 facilities) Lamivudine (53 facilities) Aluvia 200mg/50mg (45 facilities) A total of 867 instances of ARV/TB medicines were of 43 different ARV or TB medicines were reported out reported out of stock in 614 different facilities as of stock, with some medications reported out of stock some facilities reported more than 1 item out of stock. in only 1 facility and some medications reported out of Table 8 above shows the breakdown of the seven most stock in 79 facilities nationwide. During this period, the commonly reported individual medicines. Review of known medicines that were out of stock at a national individual medicines reported indicates that no one level were Nevirapine solution and Isonaizid tablets (INH) single item was disproportinately out of stock. A total as picked up by this survey. Second Annual Report 16
Nationwide, in 19% of the stock out cases patients were sent away without any medication. 30% of adult HIV stock outs lasted more than one month, 41% between one to four weeks and 28% less than one week. A 3 month supply as opposed to monthly supply of ARV treatment (as supported by a DoH circular (July 2010) can be used which would decreased patient burden at facilities and could lead to improved medicine availability. Stop Stock Outs Report: 2014
Adult HIV2 Stock Outs: Nationwide, 351 of 2454 (14%)
by province. The three most commonly reported adult ARV facilities reported a stock out of at least 1 adult ARV, the stock outs were of (AZT) Zidovudine 300mg for adults (77 majority of which are used in first line adult HIV treatment facilities), (FDC) Fixed Dose Combination (75 facilities), and regimens according to South African national protocols. Table (ABC) Abacavir for adults (63 facilities). 9 below shows the reported stock outs of adult ARV regimens Table 9: The proportion (%) of facilities by province in 2014 reporting ARV stock outs in the three month period prior to contact.
1st line adult HIV (188 facilities) 2nd line adult HIV (172 facilities) Exceptional adult HIV cases (81 facilities) Impact
There were 75 facilities that reported stock outs of the FDC.
However only 9 of 75 facilities sent patients home with no
FDC, and only 18 out of 75 facilities sent patients home with
a smaller supply.
Treatment with FDC is advantageous as it reduces the pill burden on patients from three or four to one tablet a day which can positively influence treatment adherence. Until the end of 2014, FDC was the treatment of choice for initi-ation of all adult patients without contra-indications and a CD4 count lower than 350 copies/ml. From 2015 on, nation-al guidelines have changed the criteria for initiation to all patients with a CD4 count lower than 500 copies/ml. If the country aims to have 4.6 million people on HIV treatment by the end of 2016, facilities need to closely monitor their FDC as FDC stock outs will impact a large number of patients. * 1st Line ARVs: (D4T) Stavudine 30mg , (EFV) Efavirenz 600mg , (TDF) Tenofovir 300mg , (TDF/FTC/EFV (FDC))Tenofovir/Emtricitabine/Efavirenz 300/200/600mg , (TDF/FTC) Tenofovir/ Emtricitabine 300mg/200mg, (3TC) Lamivudine 150 or 300 mg; **2nd Line ARVs: (AZT) Zidovudine 300mg , (LPV/r) Lopinavir/Ritonavir200mg/50mg , (ATV) Atazanavir 300mg , (ddi)(Didanosine), (RTV) Ritonavir 100mg; *** Exceptional Cases: (NVP) Neviarapine 200mg, and (ABC) Abacavir 600mg 17 Second Annual Report
Stop Stock Outs Report: 2014
Table 10: Provincial breakdown of 75 facilities reporting FDC stock outs by province in 2014.
1 December 24, 2014. NDOH Press Release. Various Pharmaceutical Companies Gets Tender to Supply ARV's In South Africa I am a Professional Nurse and I work in the HIV chronic section of my clinic. Part of my duties is to dispense medication to patients. As a Professional Nurse who treats chronic HIV patients, I find stock outs to be very frustrating. Due to HIV been an infectious disease, patients are more prone to being infected with other infectious diseases making their immune systems vulnerable. For this reason it is important that patients are stable on their medication. Stock outs disrupt this process. This is frustrating because when I treat an HIV positive patient I cannot provide them with all the medication they need. This angers patients very much and means the patient is not stabilized on their treatment. Members of our HIV support group have contacted the Stop Stock Outs project before when they don't receive their medicine. One of these patients didn't receive her FDC treatment in January 2015. I give them the list of treatment out of stock. They tell me that the SSP is reliable when it comes to helping patients have access to their treatment. They trust the SSP" - Professional Nurse, Johannesburg, Gauteng Second Annual Report 18
Stop Stock Outs Report: 2014
Paediatric ARVs3 and Prevention of Mother to Child Transmission (PMTCT)
Stock Outs:
Nationally, 6% (154/2454) of facilities reported a stock facilities in KwaZulu-Natal reporting more than 1 paediatric out of ARVs required for the treatment of paediatric HIV ARV out of stock (43 items from 24 facilities reporting a and 3% (78/2454) of facilities reported a stock out of paediatric ARV out of stock). Mpumalanga had the highest medication required for PMTCT. 190 paediatric ARVs proportion with 10% (20/205) of facilities reporting a stock were reported out of stock in 153 facilities, with most out of paediatric ARVs.
Table 11: The proportion (%) of facilities by province for 2013 and 2014 reporting paediatric ARVs and PMTCT stock outs in the
three month period prior to contact.
(ABC) Abacavir 60mg or 20mg/ml (3TC) Lamivudine (AZT) 150mg or 10mg/ml, (AZT) Zidovudine 100mg, (AZT) Zidovudine solution 50mg/5ml (D4T) Stavudine 15mg or 20 mg (EFV) Efavirenz 200mg (EFV) Efavirenz 50mg (LPV/r) Lopinavir/Ritonavir Aluvia 100mg/25mg tablets, LPV/r) Lopinavir/Ritonavir Kaletra 80/20mg/ml solution, (RTV)Ritonavir 100mg 19 Second Annual Report
Stop Stock Outs Report: 2014
PMTCT stock outs were due to a national stock out of Nevirapine solution over that time period; a national circular was issued asking the facilities to switch to alternatives. Limpopo province reported the highest stock outs of ARVs used for PMTCT with 10% (26/266) of facilities affected, while the least affected provinces had less than 1% of facilities reporting such stock outs (Northern Cape, Free State and Western Cape). The provincial variations indicate that stock outs of paediatric HIV and PMTCT medicines in less than 1% of facilities are achievable within the country.

Consequences/Impact: In 24% of reported paediatric HIV
and PMTCT stock outs patients were sent home without
treatment (high impact). 31% of paediatric HIV and PMTCT
stock outs lasted more than one month, 51% between one to
four weeks and 18% less than one week.
HIV positive children should not interrupt treatment, as it increases the risk of treatment failure and resistance. When children develop resistance against first line treatment, second line treatment options with paediatric regimens are limited. Effective PMTCT reduces the risk of transmission of HIV from HIV positive mothers to their children. Nevirapine Stock outs are a big inconvenience to the role I solution is given to babies born from HIV positive mothers to play. In February 2015, more than 14 drugs were lower the risk of transmission after birth while breastfeeding. out of stock at my facility including Amphotericin B, Uninterrupted access to PMTCT treatment is therefore Sodium valproate, Ampicillin and Gliclazide. When stock outs indispensable to give newborns the best possible protection occur, I cannot provide patients with the necessary treatment they need and secondly clinicians cannot perform their roles against a life with HIV.
adequately. Stock outs do compromise patient treatment and sourcing alternative treatment can be time consuming, TB4 Stock Outs: Stock outs of TB treatment were reported less
sometimes resulting in having to put everyday tasks on hold. frequently than stock outs of ARV treatment. 6% (140/2454) The Stop Stock Outs Project assisted me by following up on treatment I ordered that was not being delivered to my facility. My advice to clinicians who are faced with stock outs; don't give up searching, go the extra mile and keep trying to get treatment from other facilities or seek alternative treatment, keep knocking on other doors." - Pharmacist in the Eastern Cape Second Annual Report 20
Stop Stock Outs Report: 2014
TB4 Stock Outs: Stock outs of TB treatment were reported less
commonly reported out of stock as illustrated in table 12 below. frequently than stock outs of ARV treatment. 6% (140/2454) INH used as prophylaxis in the prevention of TB amongst HIV of facilities reported a stock out of at least one TB medication. positive patients was the most common TB related medicine First line TB treatment was most often reported in Eastern Cape reported out of stock in 47 out of 2454 facilities.
while in Mpumalanga, treatment for complicated TB was most Table 12: The proportion (%) of facilities by province for 2014 reporting TB stock outs in the three month period prior to contact.
1st line (59 facilities) IPT (INH) (47 facilities) Complicated TB cases (41 cases) In 29% of facilities reporting TB stock outs patients were sent home without treatment. 33% of TB stock outs lasted more than one month, 42% between one to four weeks and 25% less than one week. The use of INH for the prevention of TB in HIV infected individuals is national policy. The stock of this drug is concerning as IPT is one of the pillars for TB control. As a Professional Nurse, I do patient consultations every day. I also order medication as we do not have an assistant pharmacist. As a Professional Nurse you cannot allow a patient to leave the facility without treatment. When the treatment a patient needs is out of stock, then alternative treatment needs to be identified and this can take a long time to do. I contacted the Stop Stock Outs Project, because I thought they could advise me on what to do in such a situation when Abacavir tablets for adults and Abacavir solution for children were out of stock in March 2015. I was informed that there was a national stock out of the treatment and was provided with a circular for alternatives to be used during the stock out. I also asked the Stop Stock Outs Project for help when medication was being phased out and we didn't know what to replace the medication with, like Adalat and Beclomethasone inhalation spray. It would be helpful if I could receive this information from the Department of Health. " - Professional Nurse, Mpumalanga *1st line TB: (R/H) Rifampicine/Isoniazid 150/75mg -Rifinah/Rimactazid, (R/H) Rifampicine/IsoniazidH 300/150mg -Rifinah/Rimactazid, RH R/H) Rifampicine/Isoniazid 60/60mg (Rimactazid) for Children, (RHZE) Rifampicine/Isonaizid /Pyrazinamid/Ethambutol– Rifafour **IPT: (INH) Isoniazid tablets 300mg ***Complicated TB: (PZAZ) Pyrazinamide 150mg, (Z PZA) Pyrazinamide 500mg, ( E) Ethambutol 400mg, (Eto) Ethionamide, (Km) Kanamycin, (Lvx) Levofloxacin, ( R) Rifampicin capsules, ( R)Rifampicin suspension 21 Second Annual Report
Stop Stock Outs Report: 2014
Length of ARV/TB Stock Outs
Respondents were asked about the length of time one and four weeks and 25% were resolved in one week. taken to resolve the incident of stock out incidents that occurred during the three month survey period. There was wide variation in the length of time it took for Of all stock outs reported nationwide, 32% of stock stock out cases to be resolved in different provinces as seen outs lasted more than one month, 43% lasted between Table 13: Proportion (%) of stock outs lasting i. more than one month, ii. one to four weeks or iii. less than one week. Results by
province for 2014
Eastern cape Mpumalanga North West Northern Cape KwaZulu-Natal Western cape Impact on patients
In 2014, 22%(175/779) of ARV/TB stock outs, patients left the facility with NO medication (high impact). In 2013, 20% of ARV/TB stock outs led to patients leaving without their medicine. These patients will face the most severe consequences of stock outs. Individual patients can be forced to interrupt treatment which can undermine their adherence and lead to increased illness. 35% (270/779) of ARV/TB stock outs resulted in a medium impact stock out where the majority of patients left with a smaller supply. While these patients did not have a treatment interruption, having to return to the clinic more frequently adds to the patients' costs and may result in poor adherence. In 43% (334/779) of stock outs reported the facility was able to borrow medicine and the patient went home with their full supply of treatment (low impact). Second Annual Report 22
Stop Stock Outs Report: 2014
Table 14: Reported impact of medicine stock outs upon patients. 2013 & 2014. (In 2013, fewer facilities provided information on
given (72 facilities) medication given (175 facilities) (270 facilities) Borrowed medication (135 facilities) 35% 175 high impact stock outs, where patients left with no I am a 40 year old mother of two, living in Nelspruit medication, were reported nationwide. The majority of high Mpumalanga. Originally home for me is in Pienaar impact stock outs lasted over a month in 40% (70/173) of Msogwaba. I work a part time job. In January 2010 I was cases, one to four weeks in 37% (64/173) of cases and less diagnosed HIV positive. I started taking FDC in September of than a week in 23% (39 /173) of cases (in two cases, length the same year; it is now 5 years that I am on this treatment. I also of stock out was not reported). The seven most common belong to a support group for people living with HIV at Eziweni medicines where patients were sent home with no treatment clinic. It is here that I got information about the Stop Stock were Zidovudine (AZT) 300mg, Abacavir (ABC) solution for Outs Project from the chairperson of the group. Since August children, Aluvia 200mg/50mg, Kaletra solution, Tenofovir 2014 to February 2015, I have been receiving two months' HIV (TDV), Isoniazid (INH) tablets, and Nevaripine solution. treatment. Getting two months' treatment is a problem for me, because I work a part time job and I have to use my second child's grant money for transport to get to the clinic. At least with 3 months' treatment I am able to extend my budget and only use the child's grant for what the child needs. Also, the nurse kept on telling me that the problem is with supply." - Mother of two (40 years old) from Eziweni clinic, Nelspruit, Mpumalanga 23 Second Annual Report
Stop Stock Outs Report: 2014
Second Annual Report 24
Stop Stock Outs Report: 2014
25 Second Annual Report
Stop Stock Outs Report: 2014
Provincial Overview
(ARV & TB)
Eastern Cape
District breakdown: % faciliities reporting ARV/TB stock out
Length to resolution
Joe GqabiOR Tambo 7 most commonly reported medicines
% facilities reporting stock out of:
(AZT) Zidovudine 300mg (INH) Isoniazid tablets Nevirapine solution RH 60/60 (Rimactazid) Second Annual Report 26
Stop Stock Outs Project: National Survey – 2014 FREE  STATE  
District  breakdown:  %  Facili es  repor ng  ARV/
Length  to  resolu on  
TB  stock  out  
Stop Stock Outs Report: 2014
Free State
7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
(ABC)  Abacavir   District breakdown: % faciliities reporting ARV/TB stock out
Length to resolution
(TDF)  Tenofovir   (EFV)  Efavirenz  50mg  for   (AZT)  Zidovudine  300mg   Kaletra  soluhon   Aluvia  200mg/50mg   7 most commonly reported medicines
% facilities reporting stock out of:
(EFV) Efavirenz 50mg for (AZT) Zidovudine 300mg Aluvia 200mg/50mg 27 Second Annual Report
Stop Stock Outs Project: National Survey – 2014 GAUTENG  
District  breakdown:  %  Facili es  repor ng  ARV/TB  
Length  to  resolu on  
stock  out  
Stop Stock Outs Report: 2014
7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
Aluvia  200mg/50mg   District breakdown: % faciliities reporting ARV/TB stock out 12%  
16%   Length to resolution
(AZT)  Zidovudine  300mg   Nevirapine  soluhon   (ABC)  Abacavir  for  children   (3TC)  Lamivudine   Kaletra  soluhon   PMTCT  42% Paediatric   7 most commonly reported medicines
% facilities reporting stock out of:
Aluvia 200mg/50mg (AZT) Zidovudine 300mg Nevirapine solution (ABC) Abacavir for children Second Annual Report 28
Stop Stock Outs Project: National Survey – 2014 District  breakdown:  %  Facili es  repor ng  ARV/TB  
Length  to  resolu on  
stock  out  
Stop Stock Outs Report: 2014
19%   18%   18%   7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
(EFV)  Efavirenz  200mg   District breakdown: % faciliities reporting ARV/TB stock out
Length to resolution
Nevirapine  soluhon   (ABC)  Abacavir  adults   (3TC)  Lamivudine  adults   (INH)  Isoniazid  tablets   18% 18% 14% 6%   (AZT)  Zidovudine  300mg   7 most commonly reported medicines
% facilities reporting stock out of:
(EFV) Efavirenz 200mg Nevirapine solution (ABC) Abacavir adults (3TC) Lamivudine adults (INH) Isoniazid tablets (AZT) Zidovudine 300mg 29 Second Annual Report
Stop Stock Outs Project: National Survey – 2014 LIMPOPO  
Length  to  resolu on  
District  breakdown:  %  Facili es  repor ng  ARV/
TB  stock  out  
Stop Stock Outs Report: 2014
7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
District breakdown: % faciliities reporting ARV/TB stock out 23%  
Length to resolution
Nevirapine  soluhon   (3TC)  Lamivudine  adults   (AZT)  Zidovudine  300mg  adul (TDF)  Tenofovir   Aluvia  200mg/50mg  adults   (ABC)  Abacavir  children   Adult  ARV   PMTCT   Paediatric   Less than 1 week, 7 most commonly reported medicines
% facilities reporting stock out of:
Nevirapine solution (3TC) Lamivudine adults (AZT) Zidovudine 300mg adults Aluvia 200mg/50mg adults (ABC) Abacavir children Second Annual Report 30
Stop Stock Outs Project: National Survey – 2014 Length  to  resolu on  
District  breakdown:  %  Facili es  repor ng  ARV/
TB  stock  out  
Stop Stock Outs Report: 2014
G  Sibande     7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
District breakdown: % faciliities reporting ARV/TB stock out
Length to resolution
Nevirapine  soluhon   (ABC)  Abacavir  adults   44% (ABC)  Abacavir  children   (3TC)  Lamivudine  adults   (EFV)  Efavirenz  600mg  adults   Less than 1 week, 7 most commonly reported medicines
% facilities reporting stock out of:
Nevirapine solution (ABC) Abacavir adults (ABC) Abacavichildren (3TC) Lamivudine adults (EFV) Efavirenz 600mg adults 31 Second Annual Report
Stop Stock Outs Project: National Survey – 2014 NORTH  WEST  
Length  to  resolu on  
District  breakdown:  %  Facili es  repor ng  ARV/
TB  stock  out  
Stop Stock Outs Report: 2014
North West
Bojanala   Ngaka  Modiri  Dr  K  Kaunda     7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
District breakdown: % faciliities reporting ARV/TB stock out
28%   Length to resolution
(AZT)  Zidovudine  300mg   (TDF)  Tenofovir   (3TC)  Lamivudine  adults   (ABC)  Abacavir  adults   Aluvia  200mg/50mg  adults   (EFV)  Efavirenz  600mg  adults   Bojanala Ngaka Modiri 7 most commonly reported medicines
% facilities reporting stock out of:
(AZT) Zidovudine 300mg (3TC) Lamivudine adults (ABC) Abacavir adults Aluvia 200mg/50mg adults (EFV) Efavirenz 600mg adults Second Annual Report 32
Stop Stock Outs Project: National Survey – 2014 NORTHERN  CAPE  
Length  to  resolu on  
District  breakdown:  %  Facili es  repor ng  
ARV/TB  stock  out  
Stop Stock Outs Report: 2014
Namakwa   Mgcawu   Frances   Northern   Seme     Gaetsewe     (Siyanda)   Baard     7  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
District breakdown: % faciliities reporting ARV/TB stock out
Length to resolution
(INH)  Isoniazid  tablets   (EFV)  Efavirenz  50mg  children   (ABC)  Abacavir     (D4T)  Stavudine  30mg  adults   (3TC)  Lamivudine  adults   Namakwa Mgcawu Frances 7 most commonly reported medicines
% facilities reporting stock out of:
(INH) Isoniazid tablets (EFV) Efavirenz 50mg children (D4T) Stavudine 30mg adults (3TC) Lamivudine adults 33 Second Annual Report
Stop Stock Outs Project: National Survey – 2014 WESTERN  CAPE  
Length  to  resolu on  
District  breakdown:  %  Facili es  repor ng  
ARV/TB  stock  out  
Stop Stock Outs Report: 2014 3%  
Western Cape
5  most  commonly  reported  medicines    
%  Facili es  repor ng  stock  out  of:  
District breakdown: % faciliities reporting ARV/TB stock out
Length to resolution
(INH)  Isoniazid  tablets   Atazanavir  tablets   (EFV)  Efavirenz  200mg  for   RH  60/60  (Rimactazid)  for  3% west Coast Cape Town OverbergCentral Karoo Western Cape 5 most commonly reported medicines
% facilities reporting stock out of:
(INH) Isoniazid tablets Atazanavir tablets (EFV) Efavirenz 200mg for children RH 60/60 (Rimactazid) for children Second Annual Report 34
Stop Stock Outs Report: 2014
Key Provincial Findings:
There have been differences observed between as well as within provinces, with some districts disproportionately affected by stock outs. Some of the key findings are highlighted below. Eastern Cape:
- 50% (28/56) of facilities in Alfred Nzo and 46% - 36% (9/25) of facilities in Umkhanyakude and 39% (16/35) of facilities in Joe Gqabi districts reported (13/33) of facilities in Uthukela districts reported ARV/TB stock outs while only 14% (13/96) of facilities ARV/TB stock outs while only 11% (5/44) of facilities in Amathole and 16% (8/50) of facilities in Cacadu in Uthungulu and 12% (6/49) facilities in Zululand districts respectively were affected during the same reported ARV/TB stock outs during the same time - 39% of stock outs took over one month to resolve, the - The highest number of paediatric ARVs reported out second lengthiest in the country.
of stock occurred in this province. - FDC was the most common medicine reported out of - 22% (76/345) of facilities reported stock outs of Sodium Valproate tablets (epilepsy).
- 16% (79/501) of facilities reported Salbutamol inhaler (asthma) stock outs. - 28% (67/238) of facilities reported Pentaxim vaccine Free State
- 31% (17/55) of facilities in Mopani and 37% (23/62) - Urgent assessment of and intervention by DoH in of facilities in Vhembe districts reported ARV/TB stock Fezile Dab and Lejweleputswa is needed where 42% of facilities in both districts report ARV/TB stock outs. - 46% of stock outs reported lasted for over one month, the lengthiest in the country.
- Adult ARVs were the most commonly reported treatment out of stock. - 41% (23/56) and 44%(25/57) of facilities in Gert Sibande and Nkangala districts respectively reported - Second line ARVs were more often reported out of a stock out of ARV/TB medicines during the survey. stock than first line ARVs. - 33% of stock outs lasted over one month.
- 42% of stock outs lasted between one and four - 19% (35/188) of facilities reported stock outs of Salbutamol Inhalers (asthma).
35 Second Annual Report
Stop Stock Outs Report: 2014

North West

- A very significant increase in facilities reporting stock outs was noted in this province from 4% (8/182) in 2013 to 39% (86/222) in 2014.
- Assessment of the reasons for this drastic change should be done. Bonjanala district was the most - Adult ARVs were the most commonly reported treatment out of stock. Ordering, forecasting and other procurement processes related to adult ARVs should be assessed.
- 30% (6/20) of facilities in JT Gaetsewe and 38% (11/29) of facilities in Pixley ka Seme districts reported ARV/TB stock outs while only 7% (1/15) of facilities in Frances Baard and 10% (2/20) of facilities in Siyande reported ARV/TB stock outs - 22% (21/96) of facilities reported Enalapril/ Perindopril tablets (hypertension) out of stock. - FDC was the most common ARV reported out of Western Cape
- 6% (3/53) and 4% (3/64) of facilities in Eden and Cape Winelands districts reported ARV/TB stock outs.
- Of all stock outs reported, INH stock outs made up 60% of the medicines out of stock.
Second Annual Report 36
Stop Stock Outs Report: 2014
Vaccine Stock Outs - Rotavirus, Pentaxim and Measles

Primary healthcare facilities were asked to report if Rotavirus, Pentaxim or Measles
vaccines were in stock, out of stock or not stocked by the facility on the day of the
call. 2157 PHC facilities provided responses about all three vaccines. Across the
country, 11.5% (249/2157) of facilities reported at least one vaccine out of stock.

Pentaxim was most frequently reported out of stock in facilities were affected. Rotavirus stock outs were most often 10% (219/2194) of facilities. 6% (122/2198) of facilities reported in the Eastern Cape, where 10% (42/428) of facilities reported a Rotavirus stock out and 4% (78/2198) a were affected. Measles vaccine stock out occurred most Measles vaccine stock out. Pentaxim stock outs occurred frequently in Mpumalanga, where 8% (15/182) of facilities most frequently in Limpopo, where 28% (67/238) of 37 Second Annual Report
Stop Stock Outs Report: 2014
Table 15: The proportion (%) of facilities by province for 2014 reporting Pentaxim, Rotavirus and Measles vaccine stock outs on
the day of the call (ongoing).

% Pentaxim vaccine % Rotavirus vaccine % Measles vaccine Pentaxim is a combination vaccine for the immunisation booster in the 2nd year. A vaccine stock out could be of infants after 6 weeks of age. It protects against responsible for anything from increased numbers of diphtheria, tetanus, pertussis, poliomyelitis and unnecessary hospital admissions for severe cases to invasive infections caused by Haemophilus influenza outbreaks of preventable diseases, putting an immediate type B. It is given three times in a primary vaccination strain on existing health services and causing death and series at 6, 10 and 14 weeks of age and a 4th dose as a disability in the long term.
OTHER ESSENTIAL MEDICINE STOCK OUTS - Salbutamol Inhaler (asthma),
Metformin Tablets (diabetes), Sodium Valproate Tablets (epilepsy), Enalapril/
Perindopril Tablets (hypertension), Ceftriaxone Injection (antibiotic)

Five other essential medicines that are required at primary Salbutamol inhaler was most often reported out of stock healthcare level were included in the survey: Salbutamol nationally in 12% (287/2426) of facilities. Sodium valproate Inhaler (asthma), Metformin Tablets (diabetes), Sodium tablets and Ceftriaxone injection were the second and third Valproate Tablets (epilepsy), Enalapril/Perindopril most commonly reported items out of stock with 7% of facilities reporting both out of stock nationally. Sodium Tablets (hypertension), Ceftriaxone Injection (antibiotic) valproate stock outs primarily occurred in only two provinces, for intravenous or intramuscular use. As with vaccines, 22% (78/354) of facilities in KwaZulu-Natal and 15% (21/140) respondents were asked to report if the medication was in facilities in North West with a stock out. Ceftriaxone injection stock, out of stock or not stocked by the facility on the day of was most often out of stock in in 13% (35/264) of facilities in Limpopo and 10% (27/280) of facilities in Gauteng. Second Annual Report 38
Stop Stock Outs Report: 2014
Table 16: The proportion (%) of facilities by province for 2014 reporting five other essential medicine stock outs on the day of
the call (ongoing).

Sodium valproate inhaler stock outs: 43% of stock outs: 22% of Perindopril stock facilities in KZN outs: 20% of facilities in NC % Salbutamol Inhaler % Metformin Tablet % Sodium Valproate Tablet % Enalapril/Perindopril Tablet % Ceftriaxone Injection The treatment of chronic non-communicable diseases such as asthma, diabetes,
hypertension and epilepsy also depends on patient adherence on the one hand and a
reliable, ongoing supply of medication on the other, to prevent morbidity and mortality
due to these diseases. In some cases such as Enalapril/Perindopril (antihypertensive)
and Sodium valproate (anti-epileptic), these drugs may be substituted with others
at primary healthcare level if there is a stock out, but there is no substitute in the
public sector for Salbutamol inhalers dispensed to asthmatic patients for acute relief
of a tight chest. When patients have no access to first-line medication, they may
either go without treatment causing their disease to become uncontrolled or they are
given substitutes which give rise to additional risks and side-effects. Both of these
consequences result in increased morbidity and mortality due to chronic diseases.

Ceftriaxone is an injectable antibiotic that can be used of childhood infections according to the South African intravenously or intramuscularly as first-line treatment Integrated Management of Childhood Infections (IMCI) primarily for bacterial meningitis, severe pneumonia protocol. In certain cases, Ceftriaxone can be substituted and sepsis, as well as first-line treatment for a number with another antibiotic if available, but the substitute is unlikely to be as effective. 39 Second Annual Report
Stop Stock Outs Report: 2014
Key findings
The objective of the survey is to determine the extent of stock outs in order
to bring the problems faced by patients and healthcare workers alike to
those responsible for their resolution. While recommendations on how to fix
ongoing problems are not the primary objective of this report, there are some
overlapping issues that might contribute to sustainably resolving stock outs.

Wide variation amongst provinces,
Urban and rural areas
districts and facilities
• There was a differential distribution of the stock outs • This survey highlights the wide variation in types of between rural and urban areas. medicines out of stock, length of stock outs and patient • Rural districts in KwaZulu-Natal and Eastern Cape are impact both between and within provinces. The diffuse notably affected, as well as many urban districts in Free nature of the situation indicates that there are complex State, Mpumalanga and North West underlying reasons that differ by province and even district. Hence analysis of root causes and identification • Rural areas are particularly hard hit as it is already hard of solutions are needed at all levels of the supply chain, to ensure an uninterrupted supply to them. The scale of from facilities, to district teams, to provincial and national the number of patients in urban areas also has a marked level. Co-ordinated efforts are necessary, especially impact on stock outs.
between district health and pharmaceutical services.
• Assessing various features of these areas and facilities, • Stock outs vary from facility to facility. Root causes analysis such as their delivery and transport system, varied should be focused at facility level. District health and demand for services, human resources capacity, storage pharmaceutical services teams should support facilities space for medicines and buffer stocks, stock management with supply processes such as ordering and forecasting.
systems and infrastructure (e.g. phone lines, fax machines to place orders) can lead investigators to root causes • Urgent action is needed in areas most severely affected. leading to effective solutions.
• Improved visibility of medicines at facility level is • It is critical to assess and identify what factors contribute • The number and duration of high impact stock outs to and prevent stock outs in different areas. Examples of (where patients leave without any medication) should these key factors include adequate and trained human be minimized. DoH can issue timely communication resources, district support with ordering and forecasting, on time payment of manufacturers, and accountable and (circulars/memos) for alternative medicines and ensure responsive facility, district and provincial managers. consequences for non-compliance by manufacturers are implemented. Facilities can switch to a different dosage • The varied results of the survey demonstrate that well- of the same medication (e.g. provide two 150mg tablets functioning systems are possible in South Africa and to achieve a 300mg dose), monitor stock levels closely, targets should be set against those standards.
place emergency orders, borrow medication from other • Even though Pentaxim, Measles and Rotavirus vaccines facilities, and ensure they escalate stock outs to district are supplied by the same manufacturer, the different teams, depots, and province. proportion of stock outs between the different vaccines is surprising and should be investigated. • The long duration of the stock outs in certain provinces could be indicative of a need for more effective mechanisms to react quickly to stock outs. In all provinces, except for Western Cape, more than 20% of stock out cases lasted for over one month.
Second Annual Report 40
Stop Stock Outs Report: 2014
Strengths and Limitations of the
Analysis & Discussion
An ineffective supply chain can weaken the entire health system's ability to provide effective health care. This survey This is the largest survey to date on the extent of stock outs identified a high proportion of facilities, one in four, with in the South African antiretroviral treatment programme. In stock outs of any ARV and/or TB medicines. These stock outs 2014, this survey made contact with 77% of 3732 identified were unevenly distributed across provinces and districts, facilities and a high respondent rate of 87% nationwide, highlighting areas necessitating urgent corrective action.
ensuring robust results. This was a large survey involving facilities that are responsible for providing medicines to South Africans. In 2014, 25% A major constraint of the survey is that respondents can only (614/2454) of facilities contacted had a stock out of ARV/TB report on stock outs they are aware of. Ascertainment bias medicine in the three months prior to contact. This is similar may exist in this type of survey and tends to underestimate to the findings in 2013, when 21% (459/2454) facilities the true proportion of stock outs, as staff are more likely contacted had a stock out in the same time period. to underreport stock outs. Secondly, often in surveys of healthcare staff, individuals wish to create a favourable Stock outs of fixed dose combinations (FDCs) were less impression of where they work. If this occurred in this survey frequent in 2014, improving compared to 2013. While it would lead to an underestimation of the true extent of 75/614 of facilities reported FDC stock outs, only a few stock outs. Additionally, a consequence of a lower response sent patients home with no medicine or a smaller supply. rate in Free State is that results from the province may However, there were frequent stock outs of other 1st line HIV also underestimate the problem as only 63% of Free State medicine, 2nd line HIV medicine, paediatric HIV medicine, respondents agreed to provide information. isoniazid preventive treatment (IPT) for TB, and medicine for complicated TB. Patients who require medicine other than Finally, as individual recall of when the stock out began and FDCs are often already more vulnerable because they have when it was resolved are likely to be more prone to error. The clinical complications such as resistance, side effects, and/or estimated duration of stock outs should be seen as indicative other co-existing conditions such as renal failure, or because rather than exact. However, the survey asked participants to they are children or adolescents. They already have a limited provide stock outs at two different time points, the day of number of options for effective treatment.
the call and in the past three months. Using too short a time frame would underestimate the problem and using too long In 20% of the reported stock out cases in both 2013 and a time frame could overestimate the problem. The two time 2014, patients were turned away from the facility without points used in this survey were stock outs existing on the day medication. These patients are the most affected by the of the call (ongoing) and stock outs occurring during the three adverse impact of stock outs. Facing stock outs, many months prior to contact, to provide a range of outcomes. patients will be at risk of developing and transmitting drug resistance, interrupting and even defaulting treatment, and ultimately increased risk of illness and death. Stock outs can also be demoralising for the health care workers who have to turn patients away without treatment, and determine who does or does not get treatment or how much treatment each patient receives. However, 87% of healthcare workers contacted were willing to participate in this survey, suggesting that health staff in facilities recognize the problem of stock outs and are willing to collaborate to solve it.
41 Second Annual Report
Stop Stock Outs Report: 2014
Collaboration between
DOH and SSP
The aim of this report is to continue to act as a constructive dialogue
between civil society, the Department of Health and its partners. This report
assists in identifying gaps in healthcare delivery, and as a result leads
investigators to diagnosing causes and implementing solutions. This report
is meant to provide warnings for areas that require further assessment.

Collaboration between NDoH, Provincial HODs and HOPS Chief Directorate of District Health and District teams was established after the survey was conducted; diagnosis of engaged in discussion of the results of this survey. causes and development of action plans are underway. A further meeting was held with the Sedibeng pharmaceutical services team. Gauteng's HOD and MEC • NDoH: In December 2014, NDoH and SSP reviewed have committed to providing narratives identifying root results of this survey causes, factors that prevent stock outs in their province • Gauteng: In January 2015, the SSP and the MEC and action plans as part of this report. for Health, Head of Department (HOD), Head of • Free State: In February 2015, Free State, the SSP, the HOD Pharmaceutical Services (HOPS), Depot Managers, and HOPS have met to review the results of this survey. Second Annual Report 42
Stop Stock Outs Report: 2014
FSDoH had committed to providing narratives identifying example set by the national department of health and the root causes, factors that prevent stock outs in their other provincial departments and engage constructively with province and action plans as part of this report. However, civil society to implement action plans to ensure that their in April 2015, FSDoH opted not to provide this and we facilities have the medicines patients require. urge for this and we urge for vital corrective action to • Heads of Pharmaceutical Services (HOPS): In March 2015, SSP and HOPS met to review the results of this survey. • Northern Cape: In March 2015, the SSP, HOPS, and district The ultimate consequence of a malfunctioning supply system pharmacists of Northern Cape engaged in discussion is human loss and illness. Stock outs can lead to unnecessary of the results of the survey. Pharmaceutical services suffering, costly resistance, and in the worst cases, death. and district health services have identified some of the contributing factors to stock outs and have committed to In South Africa, stock outs remain one of the key constraints providing narratives identifying root causes, factors that in the delivery of effective healthcare across the country prevent stock outs in their province and action plans as with 21% of facilities in 2013 and 25% of facilities in 2014 part of this report.
continuing to reporting stock outs of HIV/TB medicines. Persistence of stock outs over time is indicative not just of • North West: In March 2015, the SSP, HOD, HOPS and the complexities of the health system but also of the need district pharmacists of North West engaged in discussion for urgent co-ordinated intervention at different levels of of the results of the survey. The province has identified the supply system to prevent it. Supply chain systems are some of the contributing factors to stock outs and have an ecosystem of people, activities, information, resources, committed to providing narratives identifying root depots and facilities that have to come together to ensure the causes, factors that prevent stock outs in their province delivery of medicine to patients. Improvement of the supply and action plans as part of this report.
chain will only be realized with co-ordinated efforts between district health teams, pharmaceutical services, and provincial • Western Cape: In April 2015, the SSP and pharmaceutical and national health departments. services communicated on the results of the survey, and the province has committed to providing a narrative to In order to address stock outs at the national and provincial level, a concrete high level strategy, with clear timelines, is • Limpopo: In April 2015, the SSP, the HOD's office, HOPS needed. This strategy needs to include: and medicine monitor of Limpopo engaged in discussion of the results of the survey. The province has identified 1. Identifying the problem and causes some of the contributing factors to stock outs and has 2. Creating action plans and timelines committed to providing narratives identifying root causes, factors that prevent stock outs in their province 3. Implementing the action plans and action plans as part of this report.
4. Measuring and evaluating progress At the time of the release of this report, Gauteng, Limpopo,
5. Effective and immediate communication through this North West, Northern Cape and Western Cape have
process, both up and down, between national, provincial, included responses as part of this report.
district and facility level staff, health care workers and most importantly, patients. The need for action to ensure We applaud their committed action plans to resolve stock
adequate access to medicine in South Africa is necessary outs and have included the action plans in this report.
now more than ever. Bold and concerted effort is required to create a system that is responsive to the needs of the Strong commitment and political will is necessary for the implementation of these action plans. Despite repeated attempts to discuss the findings of the report and plans to The need for action to ensure adequate access to medicine resolve stock outs, the Eastern Cape, KwaZulu-Natal and in South Africa is necessary now more than ever. Bold Mpumalanga provincial departments of health have not and concerted effort is requiredto create a system that is responded. Free State has opted not to provide an action responsive to the needs of the patients.
plan. We call on these provincial departments to follow the 43 Second Annual Report
Stop Stock Outs Report: 2014
Recommendations and way
5. Gert Sibande 41% (23/56), Mpumalanga 6. Lejweleputswa 42% (13/23), Free State A. Urgent attention is needed in seven districts
7. Fezile Dabi 42% (11/26), Free State and two provinces.
Action plans are needed that:
B. Establishment of national minimum
1. Address stock outs in the most affected provinces and districts in the immediate term Provincial and National health departments must work together to establish and implement national
2. Put into place functional and effective emergency minimum standards for supply chain management
mechanisms in provinces to react quickly when and resolution of stock outs in all provinces.
stock outs do occur During the survey period, North West and Mpumalanga
C. Provincial Action Plans are required
were the most affected provinces, both with nearly 40%
of facilities reporting an ARV or TB stock out during the Provinces will need to assess, investigate and commit
survey. Additionally, the seven most severely affected
action plans to address stock outs. These action plans
districts with over 40% of facilities reporting ARV/TB stock
should consist of strategies that include:
outs that require urgent ongoing attention are: 1. Surveillance and increased visibility of stock outs 1. Joe Gqabi 46% (16/35), Eastern Cape 2. Rapid response mechanisms for stock outs 2. Alfred Nzo 50% (28/58), Eastern Cape 3. Governance, accountability and transparency along the supply chain 3. Bojanala 44% (34/77), North West 4. Supply chain strengthening and procurement 4. Nkangala 44% (25/53), Mpumalanga Second Annual Report 44
Stock Outs Survey: Second Annual Report –
Stop Stock Outs Report: 2014
Provincial Department
of Health Narratives and
Action Plans
This report has served as part of a
productive dialogue between civil
society, patients and the Department
of Health. Identifying and assessing
problems in healthcare delivery is the
first step to finding solutions and,
in turn, improving quality of care.

As part of this collaboration, Gauteng, Limpopo, North
West, Northern Cape and Western Cape have committed
narratives and action plans to improve access to medicines
for all patients.
Gauteng .46
North West .54
Northern Cape .62
Western Cape .72
45 Second Annual Report
Stop Stock Outs Report: 2014
The volume of the uptake of the new medicines whilst reducing the stock levels of the old medicines has not Report on the stock out situation within the Gauteng Province • some EML items have been advertised on the tender The following have been identified as some of the main reasons and no supplier tendered for the bid and therefore for medication stock outs within the Province: the required volume of the medication cannot be 1. Forecasting (pre-tender)
3. Demand planning and demand planning systems (ICT)
• Only uses consumption based data from the Medical Supplies Depot and the Provincial Medicine • Demand planning is inaccurate without a reliable Procurement Unit; patient treatment information is not inventory management system; fortunately there is a standardised inventory management system that is being installed in all the institutions and the situation • ARV regimen statistics collected by the district should stabilise soon health information system is inadequate for use in quantification process. It does not differentiate if the 4. Supplier issues
regimen 1 is the Stavudine, Tenofovir or fixed dose combination regimen. • Non adherence to the contractual lead times • Time lapse between guideline changes and the • manufacturing challenges due to the fluctuation in tendering process sometimes creates a gap in making the availability of the active pharmaceutical ingredient the new guideline medicines available on tender. (API). This has a global impact as reflected on the Food Thus, procurement is on a quotation system which is and Drug administration (FDA) website.
time consuming and does not guarantee continuous availability of the required volumes.
Strategies have been identified by the Province to minimise out of stocks at institutions and facilities. The strategies are 2. Contract management
included in the action plan on the next page: • The time taken to switch and stabilize patients on the new therapeutic classes varies from patient to patient. Second Annual Report 46
Stop Stock Outs Report: 2014
Main causes of stock Strategies being implemented
• Setting up of a committee with all As per NDOH tender schedule relevant stakeholders to input into the quantification of medication for the 80% of facilities to be using province. Patient information will thus the standardised inventory be included.
management system by end of • Information collection tool on the DHIS to be reviewed so that it accurately identifies the different regimens in use.
• Continue with the installation of a standardised inventory management system at all hospitals and district pharmacies Contract management • Advertise and award provincial tenders MSD to improve on the supply chain processes involved in the procurement of items not on national contracts • All contracted supplier issues and poor performance to be escalated to the main contract management unit at NDOH for inclusion in the national medicine shortage website and appropriate intervention • Strengthen the implementation of the penalty clause in accordance with the general conditions of contract • Strengthen operating the follow up centre at the medical supplies depot to engage suppliers on adherence to contractual lead times 47 Second Annual Report
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Root Causes
The causes of medicines stock outs are very complex and have many
Department of Health Pharmaceutical Services contributing factors. In some instances one factor and in other instances a combination of factors are applicable. Limpopo department is in no denial that there are challenges with regards to availability of medicines From: The Office of Senior Manager Pharmaceutical Services at facilities. Despite the challenges that there are, as Limpopo province, To: Stop Stock Outs Project we are making advances in small pockets and once all complete we should see a turn around. Even where systems are put in place, the issue of stock outs is further compounded by its very dependence on 1. Limpopo province has a central provincial depot that serves 461 human factor for reporting as well as for prevention thereof. clinics and 42 hospitals 2. Facilities follow an ordering and delivery schedule prepared by the As reported above, the Limpopo department of health monitors medicines availability and we found it disturbing in many instances that the stock reported as out of stock during the survey period was in 3. Hospitals order on weekly basis and orders are delivered exactly a actual fact available at the depot. We look into this matter seriously and this calls for us to strengthen our surveillance. We also appreciate the 4. Clinics now order stock directly from the depot on a scheduled roster efforts by the SSP and would welcome partnering in order to create twice in a month. Clinic orders reach the depot via a supporting alerts for us to assist get to the bottom of the problem.
hospital that should assist with order screening. Distribution of medicines from the depot is outsourced.
It is unclear at this stage what could have caused this situation. We would like to believe that there were communication problems between 5. Our province has 5 Districts with long distances between facilities demanders and the depot while we look for ways of preventing such.
6. Clinics lack electronic ordering systems (Orders done manually)7. There is a severe inadequacy of pharmacy personnel at PHC level8. Middle management (supervisor) posts not filled (This imply there is a void between Assistant manager and junior staff) 9. The province performs two-weekly stock availability monitoring through RAQA (Regulatory Affairs and Quality Assurance) office Second Annual Report 48
Stop Stock Outs Report: 2014
Estimates based on data from programs are not always accurate Data is not available timeously Contract transition period Almost always supply challenges are experienced during this time Switches in treatment protocol Poor planning and/or lack of transition plan • Late payment of suppliers resulting in accounts put on hold • Suppliers withhold stock • At the time of survey, the Limpopo department did not have Senior manager and there was backlog and suppliers withheld deliveries • Partial deliveries by suppliers amplify the amount of invoices for • Some suppliers wait to accumulate significant amounts of orders before they could effect deliveries • Example: Order placed in Oct 2014 worth R3880.00 was not delivered. Department placed another order for the same amount in Feb 2015 and only in March 2015 the supplier delivered both orders then worth a total amount of R7760.00 • Currently we do not have policy and capacity in terms of human resources to implement supplier penalties for suppliers deviating from the terms of contract • Limited stock supplied to province requires careful planning and Most of our PHC facilities have inadequate storage space.
This then dictates limited stock to be ordered resulting in frequent orders, frequent receiving at facilities not having dedicated personnel for stock management Non awards for National tenders • Some products where tenders are not awarded imply that provinces must source these through quotation.
• There seem to be more and more products where no supplier bids when NDOH calls for bids.
• These increases workload significantly for provinces as we have to source these on quotation • Limited financial delegation for buy out items • Constraints in sourcing adequate quotations to comply with good financial practices 49 Second Annual Report
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Factors preventing stock outs
• Roll Out Rx Solution (Hospitals) to link up with depot (Real time • Regularized orders • Appropriate staffing for clinics • Roll Out Rx Lite (PHC and CHC) (Stock visibility solution) • Timely payment of suppliers • Supply chain optimization using DTC • Alternate supplier ASAP if one supplier fails • 3-day DTC training conducted 15-17 April 2015 • Penalties for failure to terms of contract • Address leadership and Mx challenges @ district and hospital • Honesty and integrity of suppliers levels (Mentoring and monitoring) • Tender awards prior to current contract expiration • Facilitate appointment of skilled , competent managers • Accurate forecasts • List PHC facilities for community service in 2016 • Adherence to min/max • Risk based approach for optimized procurement • Electronic systems for real time response • Call centre for facilities to log stockouts and monitor closure/ • Improved storage space • Implement penalties for failing suppliers Provincial plan to prevent stock outs
• Supervisory visits by RAQA office • Establish mini depots • Establish Facility improvement Teams to mentor and monitor • We are currently establishing a task team comprising several facility performance stakeholders within the department • Two day provincial Health summit conducted • CSP Adopt a Clinic Project • CSP Ideal clinic project Provincial Perspectives on reported stock outs
Ongoing Stock outs 8 Oct 2014 Excess ARV's at facilities In October 2014 we performed the exercise below in order to prevent medicines expiring. Some of these products were expiring from as early as Feb 2015 and we wanted to prioritise the use thereof.
We asked facilities to provide us with their stock levels for single item ARV's and the facilities had to keep stock for 3 months and declare whatever was in excess of three months to us. The self-explanatory results are in the table below. It is clear from this table that as a province, we did not really have a shortage but the stock was sitting in facilities where it was in excess and there was no communication between facilities. What is being highlighted here, is the deficiency of our communication systems between the facilities and the need to have monitoring systems with early warning indicators to address shortages before they become crisis. The province had excess ARV's yet other facilities experienced shortage
Row Labels
Sum of Quantity
Efavirenz 600mg 28's
Philadelphia 1296 Lamivudine & Zidovudine combo 56's
Lamivudine 150mg 56/60
Philadelphia 1587 Lamivudine 300mg 56/60
Second Annual Report 50
Stop Stock Outs Report: 2014
Row Labels
Sum of Quantity
Stavudine 15mg 60's
Stavudine 20mg 60's
Stavudine 30mg 60's
Tenofovir & Emtricitabine combo 28's Tenofovir & Lamivudine combo 28's
Tenofovir 300mg 28's
Philadelphia 2331 Grand Total
51 Second Annual Report
Stop Stock Outs Report: 2014
The table below shows the items that were surveyed what the stock reported o/S for Ceftriaxone while the depot had 1 279 units. This is an levels were at the depot versus the number of facilities reporting Out of area then that would receive our attention.
stock (O/S). It is obvious from this table that there was yet a supply chain break down between the depot and facilities. For example, 10 facilities Second Annual Report 52
Stop Stock Outs Report: 2014
In the table on the previous page, the ARV's have been blackened out The next table (below) also indicates the number of facilities that because they are accessed through the DDV, meaning, they do not get reported stock outs during the survey period. For example, only 1 handled by the depot at all.
facility reported stock out in relation to Abacavir oral solution on 10 Oct Other products such as Haloperidol had universal outage and the DOH 2014. This was not reported in excess in any of our facilities. This might is aware and looking to source alternative suppliers.
be consistent with the SSP findings. Senior Manager: Pharmaceutical Services 53 Second Annual Report
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Western Cape
• Weekly meetings to discuss and resolve current and impending Medicine availability is reliable in the Western Cape. The Cape Medical Depot (CMD) is the procurement, warehousing and • Alternatives for unavailable products are referred the Provincial distribution arm of the DoH WC for pharmaceuticals and non PTC and clinical pharmacologist for alternatives wherever -pharmaceutical items for DHS. The province has implemented a number of strategies to ensure that medicines are available at all facilities. These strategies include: • Weekly dues out reports circulated to facilities, managers, pharmacists and NDOH. Any other concerns relating to shortages or the omission of items from tenders that will have • Accurate estimates are forwarded to NDoH for the preparation of a material impact on patient care and /or costs are reported to • The CMD has a finance manager on its establishment and • DDV documentation is actively followed up by CMD - original reports to the CMD Manager and RP documentation is collected by a CMD driver on a set route known to all facilities, so as to effect payment to suppliers within • A delivery schedule by the CMD to facilities is circulated and is well known and utilised.
• The CMD pays its suppliers in <30 days - in an average of 15-20 • Orders are placed with suppliers. These are faxed, emailed and confirmation of receipt gained.
• APP indicators measure the internal efficiency relating to the • 2 weeks before supplies are expected, a Medsas report is used resolution of queries by facilities as they relate to orders/stock to confirm the delivery dates of the orders expected.
matters, as well as the 72 hour turnaround time of orders to facilities.
• A Medsas generated letter to suppliers is forwarded informing them that should deliveries to CMD, be outside the obligations • CEOs of suppliers are engaged first hand by visiting to assess contracted for, the relevant penalties will apply as per contract.
what the current situation is regarding stock availability. This has been vitally important in resolving any ongoing issues • Contract penalties applied for late deliveries by suppliers.
regarding any part of the supply chain between the depot and the suppliers (e.g. claims of non-payment etc.) • Any variances in cost as a result of a buyout made from a 2nd supplier, rather than the contracted supplier, are recovered from the contract holder.
Second Annual Report 72
Stop Stock Outs Report: 2014
Appendix Table 1: Facilities that were contactable and provided information on stock outs of ARV and/or TB medicines.
Results by province in 2014 and 2013

Facilities reporting a
Facilities contactable by
Participation: Facilities
Pentaxim stock out
Participation: Facilities
Appendix Table 2: Proportion (%) of facilities reporting at least one ARV/TB stock out on the day of contact (ongoing) by province
for 2013 & 2014 and breakdown of proportion (%) of facilities reporting adult ongoing ARVs, PMTCT, paediatric ARVs and TB
stock outs on the day of contact (ongoing) by province in 2014

Facilities
Facilities
Facilities
Facilities
Facilities
Facilities
reporting at least
reporting at least
reporting at least
reporting at least
reporting at least
reporting at least
one ARV/TB
one ARV/TB
one adult ARV
one PMTCT stock
one paediatric
one TB stock out
stock out
stock out
stock out
ARV stock out
73 Second Annual Report
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Appendix Table 3: Proportion (%) of facilities reporting at least one ARV/TB stock out in the three month period prior to
contact by province for 2013 & 2014 and breakdown of proportion (%) of facilities reporting adult ARVs, PMTCT, paediatric
ARVs and TB stock outs in the three month period prior to contact 2014

Previous three
Facilities
Facilities
Facilities
Facilities
Facilities
Facilities
reporting at least
reporting at least
reporting at least
reporting at least
reporting at least
reporting at least
one ARV/TB
one ARV/TB
one adult ARV
one PMTCT stock
one paediatric
one TB stock out
stock out
stock out
stock out
ARV stock out
Appendix Table 4: Proportion (%) of facilities reporting Pentaxim, Rotavirus and Measles vaccine stock outs on the day of the call (ongoing).
Results by province for 2014

Ongoing Vaccine Stock
Facilities reporting at
Facilities reporting a
Facilities reporting a
Facilities reporting a
least one vaccine stock
Rotavirus vaccine stock
Pentaxim stock out
Measles vaccine stock out
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Appendix Table 5: Proportion (%) of facilities reporting other essential medicine (non-HIV/TB) stock outs on the day of the
call (ongoing). Results by province in 2014

Ongoing Stock Outs
Facilities reporting
Facilities Reporting
Facilities Reporting
Facilities Reporting
Facilities Reporting
a Salbutamol Pump
a Metformin tablet
a Sodium Valproate
a Ceftriaxone Stock
stock out % (#)
Stock Out
(Epilim) Tablet Stock
Perindopril Stock Out
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Source: http://www.rhap.org.za/wp-content/uploads/2015/06/Stop-Stockouts-Report-2014.pdf

Microsoft word - ul lafayette h1n1 prep _2_.docx

UL Lafayette GENERAL PANDEMIC GUIDE Seasonal (common) Flu • Caused by: Human influenza virus • Transmitted: From person to person • Immunity: o Most people have some immunity o Vaccine is available Pandemic flu would describe a new human virus that: • Is easily spread throughout the world

theepisodes.org

The Lilly Suicides by Richard DeGrandpre1 William Forsyth met and married his wife June in 1955. After two years of military service in West Germany, Bill left with June to Los Angeles, where Bill had grown up. Soon after arriving, Bill bought several Volkswagens and started a rental car business near the LA airport. Times were tough at first, but the business