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Stock-outs of Essential Medicines Continue to Place Lives at Risk

CHIC research.

Community health workers (CHWs) play a key role in achieving health for all and pandemic preparedness and response. And professional CHWs (proCHWs) must be salaried, skilled, supervised and supplied. But a new research paper released by the Coalition details a concerning trend of essential medicine stock-outs hampering the efforts in low- and middle-income countries.

The care provided by CHWs, which the CHIC study defines as “paraprofessionals or lay individuals based in the community who provide health services to urban and rural communities,” is proven to improve health outcomes in a variety of settings. As an example, we note that the delivery of Integrated Community Case Management (iCCM), a cornerstone of the work of CHWs, has been shown to reduce child deaths from malaria, pneumonia, and diarrhoea by up to 60%.

Yet, to do their work effectively, CHWs must have reliable access to essential medicines.

To assess the extent of, consequences, and causes of stock-outs at the CHW level, CHIC analyzed 1083 peer-reviewed articles and grey literature.

Essential Medicine Stock-Outs

In the entire time period considered in the study (2006-2021), CHWs experienced stock-outs 28.93% of the time. This was substantially higher than the health centers to which they were affiliated, which were impacted 9.17% of the time.

Perhaps the biggest concern, however, is that essential medicine stock-outs in low- and middle-income countries (LMICs) appear to be on the rise.

When researchers looked at just the data during the period 2016-2021, stock-outs for CHWs increased to 48.65%.

Clearly, essential medicine stock-outs for CHWs are a growing concern that requires immediate attention.

A Community Health Worker extracting liquid from a vial with a syringe

Community Health Impact Coalition

The Impact of Stockouts

Essential medicine stock-outs led to several adverse outcomes for patients.

The consequences of stockouts included:

end-users not being offered CHW services and being referred to health centers, despite this often not being a viable option.
delays in patients accessing community care.
people incurring out-of-pocket expenses to obtain medicines usually available at no cost (resulting in poor medication compliance).
inappropriate and insufficient treatment being provided.
dosing practices that increased the risk of medicine resistance.

The paper makes clear that patients “had a poor perception of and little confidence in CHWs implementing programs with a medicine stock-out.” This resulted in lower utilization of the program, undermining the ongoing effectiveness of CHWs in affected regions.

Unsurprisingly, stock-outs also contributed to CHW demotivation, primarily due to community members’ complaints and workers’ loss of reputation and recognition. Some CHWs even incurred out-of-pocket expenses to preserve their reputation, which is a significant concern considering around 60% of CHWs receive no salary at all.

Causes of stockouts.

CHIC identified supply chain issues as the primary cause of stock-outs for CHWs. Findings were grouped into four segments, presented in the order medicines move from the central level of the supply chain to CHWs. A list of the main causes in each segment is presented below.

Procurement
- Inadequate funding from limited domestic budgetary allocation, delayed disbursement, and unpredictable external funding.
- Delays in procurement due to lack of or inadequate governance structure of national procurement.
- Insufficient supplies at central medicine stores due to poor forecasting at district and national levels.
Distribution
- Lack of policies stipulating what products CHWs are permitted to manage and dispense, resulting in CHWs not being formally integrated into the national supply chain.
- Weak, overly complex, and fragmented supply chain systems, leading to problems with suspected theft, insufficient deliveries, and delays from central stores.
- Poor communication and coordination between different levels of the supply chain. Supplies were often fixed, not determined by data-related consumption patterns.
- Large distances, difficult road conditions, weather events, bureaucracy, and conflict delayed transport at all levels of the supply chain.
- Myriad human resource issues contributed to essential medicine stock-outs, including lack of technical competence for managing logistics, poor supervisory support, “power tussles” between CHWs and health center staff, and over-prescription of free medicines.
Storage
- Inadequate or improper storage space for essential medicines was reported in several of the papers analyzed. CHWs often had to keep medicines at home, which increased risks of theft, deleterious effects on potency from improper storage, and limits to how much stock could be kept on hand.
Community-level stock management
- Inadequate training, supervision, and poor numeracy skills resulted in poor demand-forecasting and inadequate consumption data, making it difficult to accurately estimate needs at the community level.
- There were often no standard procedures or formulas for calculating resupply quantities for CHWs, nor who should be contacted if centres were understocked.

A group of people lining up for their babies to be vaccinated by a Community Health Worker

Community Health Impact Coalition

A Challenging Road Ahead

While most causes of essential medicine stock-outs were related to supply chain issues, contributing factors are wide-ranging and require a comprehensive and coordinated response.

In conclusion, Coalition researchers noted:

“The reasons for stock-out are multi-dimensional and would require multi-sectorial and system approach, including coordination of government and donor financing, building quantification into the routine health information system and leveraging mobile technology, enacting and governing policies that support last-mile distribution, capacity building, supervision and motivation of the health workforce on supply chain management, and design of simplified stock management tools for CHWs.”

To learn more, read the full paper on Stock-outs Of Essential Medicines Among Community Health Workers, listen to this interview with CHIC CEO, Madeleine Ballard and Dickson Nansima Mbewe, a senior health surveillance assistant (or CHW) with the Malawi Ministry of Health, and watch this webinar from Child Health Task Force.

Support the proCHW movement by joining the #SupplyCHWs campaign.

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