WeeklySA_AdminDELIVERY: Is South Africa’s primary healthcare system, the backbone of a healthy nation, threatening to collapse due to a shortage of medicines at our health facilities? …
By Sonti Maseko
Lack of access to contraceptives continues to pose a problem as South Africa’s public healthcare facilities, with latest research revealing that the Eastern Cape and KwaZulu-Natal provinces were hardest-hit by the shortages
Almost all women and girls surveyed in the two provinces did not receive the contraceptives they requested, according to a study by Stop Stockouts Project and civil society organisation Section 27.
The crisis in access to contraception products, methods and services may arguably have contributed to higher rates of adolescent pregnancy, a network of no-governmental organisations (NGO) in the health sector have made this shocking and damning charge to the Government.
The report by the alliance of NGOs in the health sector, under the banner of Section 27, last week reported a widespread shortage of a variety of contraceptives at health facilities, in particular the injectable contraceptives being the least accessible, followed by external condoms.
However, the response by the Department of Health spokesperson Foster Mohale this week seemed to pooh-pooh the revelations or toning them down, in a comment suggesting, “Crisis? What crisis?” This, perhaps in a bid to avoid being pitted against a broad alliance network in the NGO sector and the dire implications of the report.
The findings contained in the report, titled “Contraceptive Supply Chain: Stockouts and their Causes”, have driven the NGO sector to face-off with Government, stating that: “Access to contraceptive is a crucial component of the enjoyment of the right to sexual and reproductive health rights as well as the right to bodily autonomy. Contraceptives enable women and adolescent girls to exercise the right to decide whether to be pregnant, the number and spacing of their children and to have pleasurable and safe sexual experiences without the risk of unintended pregnancies. Moreover, contraception enhances socioeconomic opportunities for women and opens up more educational opportunities for adolescent girls”.
The statement issued by Section 27, goes further to state: “Failure to ensure access to contraceptives therefore violates various constitutionally guaranteed rights”.
The report was published on the back of a research project conducted by members of the alliance, the Stop Stockouts Project in partnership with the Ritshidze project, understanding in 2022 that contraceptive made up the largest share of pharmaceutical medicine stockouts in SA.
The organisations launched a survey aimed, not only at tracking the stockout phenomenon, but also at understanding the driving factors behind the shortages which amounted to “a denial of women’s reproductive rights”.
The organisations are part of a larger consortium of civil society organisation including Doctors without Borders (MSF), Rural doctors Association of South Africa (RuDASA), Rural Health Advocacy Project, Section 27 and the Treatment Action Campaign (TAC) that aim to monitor and report on medicines and vaccine shortages and stockouts at primary healthcare facilities.
Ritshidze is a project being implemented by a broad network of organisations drawing from organisations representing people living with HIV, community based and religious organisations, AIDS research organisations, foundations and public sector initiatives engaged in monitoring and active in the primary healthcare facilities across the country.
Going as far back as 2015, the findings of the report identify poor procurement planning as the main driver of depletion and contraceptive stockouts between 2015 up to 2020, citing as a reference a particular randomised three-year clinical trial, in which the department failed to anticipate a depletion in national stock due to donating contraceptive methods to the trial, named as ECHO 2019. The problem included not anticipating market anxiety relating to the anticipated outcomes of the research examining the relationship between the use of three-month injectable Depo Provera and a potential increased risk of acquiring HIV.
The stockouts impacted the supply of all contraceptives, including after July 2019, when the trial announced the lack of a link between Depo Provera and HIV acquisition.
“All contraceptive stock was impacted’, the report goes on to say, “because Depo Provera is the most commonly used and there was increased reliance on (an alternative brand) NET-EN and the oral pill”. This resulted in the depletion of national stock, according to the research findings.
“Suppliers of contraceptives that were not part of the ECHO trial increased their prices and would not compromise in the absence of competition,” says the report.
Additionally, this poor planning related to not anticipating widespread contraceptive stockouts, a lack of supplier competition, and a weakened national position to negotiate contracts.
In the opening statement of the report, an argument is made that the “prolonged decrease in access to a variety of contraceptive methods (also) indicates a departure from a human rights approach to health care”.
The key findings of the report were based on surveys conducted in three provinces; KwaZulu-Natal, Eastern Cape and the North West as they had the largest percentage of contraceptive stockouts out of the 7 provinces surveyed between April 2022 and June 2023.
The survey conducted interviews with patients visiting health facilities, who were asked whether or not they received the medicines they needed and if they were informed the unavailability or shortages were due to a stockout or shortages, in a three month period. Facility staff surveys were also conducted with managers on the availability of medicines, particularly contraceptives, as well as their responses to contraceptive shortages or stockouts.
Injectable contraception was reported as the largest and most consistent contraceptive stock shortage across all three provinces, over five quarters. External condoms were found to be the second least accessible contraceptive in KwaZuluNatal and the Eastern Cape. In the North West however, the implant was the second most often reported short of stock.
Evidence identified stockouts of external condoms were chronic in the Eastern Cape, and due to international manufacturers and poor concentration of local suppliers. Almost all women and girls surveyed did not receive the contraception they requested, in KwaZulu-Natal and the Eastern Cape. Interestingly, the survey pointed out, the majority surveyed in the North West did.
Importantly, the drivers of contraceptive stockouts, outlined by the report, were not unique, the study found, and that they also caused limited access to other medical supplies and medicines.
Across all three provinces, the study found common patterns and causes, from the responses by managers and staff at health facilities that listed causes of chronic shortages as
Reliance on monopolies of international manufacturers and suppliers and poor information and data systems compounded this cause. In addition to poor national procurement planning at the national level, at the provincial level we found on-going causes of stockouts to include:
· budgetary limitations
· incompatible electronic information systems
· dependence on manual paper-based systems
· poor management of payment systems, stock controls, ordering, contracts and
· Inadequate human resources, and storage.
Budgetary constraints were raised as a particular challenge for the Eastern Cape, North West and Kwa-Zulu, and were exacerbated by poor management of payment and ordering systems. Poor planning that resulted in five years of limited access to contraception for women and girls, is a consequence of inadequate national leadership, and deficits in accountability and transparency.
In a statement that did not do much to hide its severe criticism of the government for the state and quality of health services, the Section 27 report summed up its key findings as a bold indictment of the health department in these terms; “The situation points to a lack of prioritization of gender equality and women’s sexual and reproductive health”.
RESPONSE BY DEPARTMENT OF HEALTH
• As the Department of Health we have noted the media reports Section27’s findings regarding what has been described as shortage of contraceptives and reproductive health services in our hospitals. We would to confirm that there is no shortage of contraceptives in the country based on the system used to monitor the availability of contraceptives and other health commodities across public health system. Unless, the responsible authorities did at the facility level did not place an order through a local depot.
• The Department has introduced online monitoring called Stock Visibility System (SVS) in 2016, to enable managers and pharmacists to monitor medicine stock.at health facilities to overcome the challenges of shortages. However, we take these reports about shortages seriously, we have good and healthy relations with NGOs working in the Health sector and their oversight activities help us to close the gaps identified to swiftly address some of the shortcomings.
• Though we acknowledge that the public health system is overburdened and less funded serving about 86% of the population as compared to highly funded private sector. Thus, it undisputable that some challenges are experienced from time to time, but we dismiss a notion that the system has collapsed. Even the private health sector does experience challenges which unfortunately don’t make to the headlines.
• The challenges facing the public healthcare are complex, and the private health sector is not immune from some of these. The Health Market Inquiry findings in fact suggest that private patients are often getting bad health care with plenty of unnecessary procedures and medicines.
