The systematic search of both published and unpublished literature resulted in a total of 1192 records (see Supplementary File, Appendix 2). After the deletion of duplicates, 752 studies were screened in abstracts and titles, resulting in 101 studies. After full-text screening of the 101 studies, 48 studies (including 3 databases) were included in the review; the remaining 53 studies were excluded as illustrated in Figure 1. The included 48 studies contained quantified information on stock-out rate at CHW and/or HF levels and/or reasons for stock-outs (see Appendix 4).
3.1 Analysis of Stock-out Rates
We computed descriptive statistics of stock-out rates among CHWs and HFs, based on the numbers reported by various studies (See Table 1. Also see Supplementary File, Appendix 5 for the extracted values). Out of 48 included studies, 46 studies (including 3 databases) stated the number or percentage of CHWs and/or HFs stocked-out. Data analysis contained reported data from the following 19 Sub-Saharan African (SSA) countries.
Countries: Benin, Burkina Faso, Cameroon, Democratic Republic of Congo, Ethiopia, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda and Zambia.
We conducted a hypothesis test to understand if a statistical link existed between the CHW and HF stock-out rates. The resulting P-value [(0.0734) > 0.05] indicated there was no significant difference in the stock-out rates between CHWs and HFs (see Supplementary File, Appendix 6).
3.2 Percentage of Medicines Stocked-out and Stock-out Duration
Out of the included studies, only seven studies documented the percentage of managed commodities stocked-out among CHWs or HFs. The average percentage of managed commodities stocked-out ranged from 8.4% to 58%. Managed commodities varied by country and included products for iCCM and reproductive health.
Reporting on durations of stock-outs lacked standardization across studies (see Table 2). Studies reported differing periods for stock-outs. This variation is to be expected as the period reported depends on the original data collection method (e.g. through the logistics management information system (LMIS), or review of documents, or through survey/observation on the day of visit).
3.3 Reasons for stock-outs
In this review, a bottleneck is defined as “an obstacle that impedes the availability of essential and program health commodities at the CHWs level”.
28 of the 48 studies listed reasons for stock-outs. Semi-structured interviews with domain experts were conducted from October 2018 to December 2018 to gather information on CHW stock-out causes, to identify bottlenecks in SC systems, and to verify findings from the studies. Information regarding reasons for stock-out were extracted and categorized into different themes. The themes were coded to perform a frequency count. The following SC bottlenecks were mentioned most frequently (Please see Chart 1).
3.3.1 Financial Issues
Budgetary constraint is one of the major barriers to efficient SC functioning, ultimately leading to stock-out of community-level commodities. Reviewed studies19,20 and domain experts also specified that inadequate finances for procurement led to national and regional level stock-outs, which reduce community-level stock availability. Lack of financial resources to procure the entire package of iCCM medicines, particularly non-malaria commodities, was a commonly reported problem. Budgetary constraints also hinder distribution, transportation, supervision, and implementing improved data systems. No details were available on whether financial constraints were due to the budget development process, allocation of funds, funding flows to subnational level, budget utilization, or a combination of all—highlighting the need for more information.
3.3.2 Transportation
CHWs typically work in rural locations, with difficult terrains. Commuting to resupply points is usually arduous due to poor roads, limited public transportation, or lack of transportation fund. The majority of CHWs in countries, such as Rwanda and Ethiopia21, travel by foot for resupply. Lack of funding for transportation to collect supplies from HFs is an impediment limiting product availability. Furthermore, trips to the HF are often linked with monthly supervisor meetings at the HF, which become challenging to hold, for the same reasons.
3.3.3 Data Related Issues
Lack of information systems to capture community-level data, lack of data visibility, and lack of data reporting procedures and tools result in poor inclusion of CHW supply requirements in resupply calculations at all levels. In some cases, MNCH medicines are not even included in the national LMIS. According to some domain experts, several existing systems do not allow for the disaggregation of stock information between CHW and HF levels. There are exceptions: the cStock system in Malawi provides stock data at the community-level.22 Good SC data is vital to understand consumption patterns, to inform resupply, to improve quantification and management of products.
At HF and CHW levels, poor data collection and use makes it difficult to accurately estimate needs, which are due to lack of capacity among CHWs and poor supervision. Trainings on reporting and data collection processes are limited, as per domain experts, resulting in sparse and low-quality data in those countries that capture data from CHWs.
3.3.4 Human Resource Issues
Human resource challenges include: 1) lack of adequate resources, 2) inadequate staff trainings, and 3) improper remuneration. Inadequate training and limited resources hamper proper data collection and utilization, which often leads to poor demand-forecasting. Although, CHWs have been found to follow procedures and perform simple tasks correctly, given sufficient orientation and supervision, most CHWs are either inadequately paid or unpaid, resulting in low motivation. In countries such as Rwanda, more than one-third of CHWs have mentioned remuneration as the major constraint in managing health products.23
3.3.5 Stock Management and Storage
Limited ability of CHWs and HFs to manage stock efficiently, either due to limited knowledge of stock management practices, or inadequate or improper storage space, also leads to CHW stock-outs. The issue of inadequate storage space is not only confined to CHWs, who typically store supplies in a box in their home but is more relevant for HFs and regional warehouses. Absence of basic stock management practices and poor storage conditions can affect the quality of medicines or lead to expired or overstocked commodities.24
3.3.6 Poor Forecasting
Poor quantification at the national level leads to inadequate stock levels, which impact CHW stock-outs. In some countries, CHW requirements are not included in the national forecast. For example, while the cStock system tracks consumption and resupply of CHWs, this information is not considered during the annual national-level quantification process.
3.3.7 Issues at Resupply Points
Inadequate supplies at resupply points, absence of or unclear resupply procedures and policies also result in stock-outs. When HFs don’t receive enough supplies for their own consumption, they prioritize their needs over CHWs, resulting in CHWs stock-out.25 Detailed explanations for inadequate supplies at resupply points were not mentioned in the reviewed studies.
3.3.8 Supervision
Effective management of inventory and supply orders require regular supervision. Budgetary constraints often lead to inadequate supervision, due to lack of human resources, capacity building activities, trainings and/or transportation to conduct supervision. Lack of clear guidance also leads to irregular supervisory activities.
3.3.9 Coordination
Communication gaps and weak coordination across SC levels are also the reasons for stock-outs and can often lead to transparency and accountability issues. These issues limit CHWs from knowing whether or when products are available for resupply.26 In some countries, donor-funded organizations facilitate coordination among SC levels. In certain donor-funded projects, CHWs are restocked during monthly meetings27, which are used as a platform to enhance coordination and communication.
3.3.10 Priority/Recognition of CHWs
Some studies and domain experts indicated that CHWs are not fully recognized as a unit of the formal health system (integrated in the national health system). HFs are seen as the “last mile”, therefore, CHW stock is, in some cases, viewed as HF stock, rather than separately. Poor recognition of and attitudes towards CHWs from formal health workers, along with the lack of formal policies on the products that CHWs are permitted to distribute, are major challenges in task shifting, despite the fact that some CHWs are experienced and effectively lead medicine distribution.28
3.3.11 High Consumption and Distribution
Inability to stock adequately during increased demand due to recurrence of epidemics and/or utilization of commodities, also contributes to CHW stock-outs, especially if long time lags exist between the consumption, reporting, and resupply. Varying capacity in distribution at HFs and higher levels and inaccurately captured consumption data at community-level compound this issue. Improper distribution could result in a surplus of commodities at a central level but stock-out at a community-level.