3.3 Qualitative Findings: Reasons for stock-out at different levels of the supply chain
Reasons for stock-out were grouped under four segments of the supply chain drawing from international descriptions of the supply chain (24, 25). We present these reasons in the order products move from the central level of the supply chain to CHWs: procurement, distribution, storage and community-level stock management. Overall, issues relating to distribution were the most frequently reported.
Less than half (n = 19) of included papers with qualitative findings described procurement challenges as reasons for stock out (Appendix 3). The challenges include:
a. Financial issues: There were challenges with inadequate funding from limited domestic budgetary allocation, delayed disbursements (26–34) and an overreliance on unpredictable external funding, especially as termination of donor agreement often leads to disruption in supply (32, 34, 35).
Furthermore, direct financial allocations to health centers often ignore the population size they cater for and the demands of the community health service provision and disbursement is often delayed and lower than the amount allocated (36).
b. Governance and coordination of national procurement: A key reason for stock-out was delays in procurement from lack of or inadequate governance structure (37). Other governance-related challenges were lengthy and unclear procurement process (26, 32, 33), frequent changes in key leadership positions within the Ministry of Health with resultant delay in obtaining approval to import medicines into the country (38), and delay in receiving international and domestic orders (39, 40).
c. Logistic management: Insufficient medicine procurement at the central store (41–44) was explained by poor forecasting at district and national levels (37) and unanticipated increased demand, especially with an influx of internally displaced persons (IDPs) during crisis situations (28).
More than half (n = 40) of included papers with qualitative findings described distribution challenges as reasons for stock-out (Appendix 3). The challenges include:
a. Policies: Lack of or delay in implementing formal policies that stipulate the products that CHWs are permitted to manage and dispense, and policies that formally integrate CHWs into the national supply chain, contribute to CHW stock-outs (34, 40, 45–47). This includes failure to disseminate policies to health centers resulting in refusal or reticence to supply CHWs with stock (26, 48). Health centers were often considered to be the "last mile"; therefore, CHW stock is, in some cases, compiled with and viewed as health center stock. Furthermore, restrictive guidelines were preventing the distribution of medicines such as zinc supplement to CHWs (49).
b. Logistic management: Logistic-related stock-out was explained by weak supply chain systems (28, 29, 34, 44, 50–52) from complex and multi-level supply chains (34, 36, 53, 54), fragmentation and duplication from stand-alone supply chains for vertical health programs that work independently of the national supply chain (28, 31, 36, 49).
Consequently, there was mismanagement of supplies (32), including suspected theft of medicines at different levels of the chain (32, 43, 55), insufficient deliveries (43) and delays (56) from central stores.
c. Information management: Poor communication and coordination between different levels of the supply chain made obtaining information to inform supply chain decisions difficult, especially distribution (34, 57). This included poor visibility of consumption data due to irregular submission of logistics reports of CHW link health center (58) and no system to track that supply reached the last mile (36, 59). This may explain the frequently used push system of distribution with a fixed supply that is not data-driven, and which ignores increased demand from awareness campaigns and consequently can result in wastage in some centers and shortage in others (34, 43, 60, 61) and expiry of medicine in centers with supply in excess of their demand (48, 49).
d. Transportation: Delays were often reported in transportation from the district to the health center and subsequently the community. The distance and time required to reach the health centers for resupply (26, 31, 37, 41, 52, 59, 62–66) was also an issue, explained in part by difficult road conditions or terrain (28, 31, 32, 34, 53, 54, 57, 59, 66), especially during the rainy season (28, 50, 59) with floods making some places unreachable (28). Relatedly, insecurity during travel was often a concern, especially in conflict-affected areas (28, 39).
CHWs had limited motivation to travel to pick up medicines (52) as they often lacked enough time and transport fare for collection (30, 31, 65). Lack of dedicated funding for collection was limiting product availability at the community level (26, 28, 34, 36, 48, 53, 54, 62, 67–69). Where third-party logistic companies were considered for distribution to centers including CHW link health centers, engagement was often delayed by bureaucracy (28).
e. Human resource management: CHW stock-out resulted from lack of responsiveness to stock-out reports by health centers or district stores (69), perhaps due to a lack of technical competence for managing logistics activities (31, 32, 54) and poor supervisory support (58, 68). While in general CHWs have been found to follow procedures and perform simple tasks correctly given sufficient orientation and supervision, CHWs were not always guaranteed supplies at the link health center, as this was sometimes threatened by "power tussle" and tense relationship between them and health center workers (28). Additionally, link health centers delay in processing CHWs' refill requests (28), prioritize their own needs over those of CHWs (35) and may use medicines meant for CHWs to top up their supply especially if availability is tracked at health center level but not CHW level (26, 28, 39, 57, 70). Additionally, link health center often experience stock-out too (48, 65, 66), partly explained by over-prescription of free medicines (28) and may be pressured to appropriate CHWs’ stock.
Less than half (n = 7) of included papers with qualitative findings describing storage challenges as reasons for stock-out at CHW and health center levels (Appendix 3). These include limited or inadequate or improper storage space, which led to CHW stock-outs. The issue of inadequate storage space is not unique to CHWs, who typically store supplies in a box in their homes but also relevant for health centers (35, 36, 66, 71). Inadequate or inefficient use of space at health center often meant they are unable to keep enough stock to resupply CHWs.
The poor storage conditions have tendencies to compromise the stability and potency of medicines (31, 34, 66, 68, 72). Furthermore, insecure storage space has the potential for theft (34).
3.3.4. Community-level stock management
Less than half (n = 29) of included papers with qualitative findings described challenges relating to community-level stock management as reasons for stock-out (Appendix 3). The challenges include:
a. Human resource management: Human resource challenges include shortage of trained staff dedicated to stocktaking and forecasting (26, 34, 35, 43, 53), limited training opportunities and supportive supervision on supply chain management at the health center level (29, 31, 41, 42, 49, 53, 59, 73–76). CHWs with low literacy/numeracy capacity experienced challenges in reporting and submitting data (57). This challenge was aggravated when they managed many products, leading to inadequacy in stock management (53). Hence, data from CHWs may be sparse and of low-quality. Also, complicated, data-intensive stock-taking was unmanageable for the capacity available at health center and time constraints limit the ability of health center staff to adequately manage logistics (36). Overall, inadequate training, supervision and poor numeracy skills constrain proper data collection, and utilization, which often leads to poor demand-forecasting, and poor data visibility of community-level consumption data for consolidation into district-level quantification and decision making (34, 36, 52, 57, 59, 65, 67, 74, 77). Data were often not accurate or, where accurate, did not support decision making (28, 67). At health center and CHW levels, poor data collection and use make it difficult to accurately estimate needs, contributing to expiry of medicines at the community level (32).
b. Logistic management: There were often no standard procedures or formulas for calculating resupply quantities for CHWs and who should be notified if centers are understocked (31, 57, 67, 68). Insufficient amounts of medicines from poor forecasting (28, 39, 40, 44, 69, 70) do not respond to increased demand for services, including the provision of medicines (27). CHWs and health center staff report to multiple places using lengthy non-standardized forms that are not user-friendly, thereby creating a slow flow of data necessary to inform supply planning (54, 57, 73). Additionally, poor communication between the health center and central store limits effective planning for stock needs (36).
3.4 Qualitative Findings: Consequences of stock-outs of essential medicines on stakeholders
3.4.1 Program: Five articles described consequences of stock-out on the program, including limited program performance and impact (33, 69, 75, 78) with some programs experiencing stalled implementation (28). Overall, stock-outs reduce acceptability and confidence of the population in CHW programs (69).
3.4.2 Health center: Seven articles described how stock-out affect CHW link health centers. These consequences include increased workload (demand) from case referrals that CHWs couldn't treat due to stock-out (28, 29, 50). Health centers with stockout function poorly or are unable to provide services (44, 55, 60). They may be accused of theft by end-users (55), forced to improvise with other (non-ideal) materials when a medicine is unavailable (45).
3.4.3 CHWs: Fifteen articles considered the consequences of stock-out on CHWs to include demotivation from community members' complaints about lack of medicines (46, 56, 69, 79, 80) and consequent loss of reputation and recognition (81), with some CHWs incurring out-of-pocket expenses to preserve reputation (31, 61). Ultimately, this may result in job attrition (28, 46, 50).
Stock-out at national levels led to CHWs experiencing a long wait for medicine supply after training (26), thereby limiting their service delivery (51, 78, 81–83) and led to depreciation of CHW competency in medicine administration (46).
3.4.4 End-users: Twenty-six papers considered the consequences of stock-out on end-users. Community-level stock-outs meant end-users were not offered services and were referred to the health center by CHWs (28, 32, 66, 72, 84). Some family planning end-users were uncomfortable with these referrals as health center services were not as discreet as those offered by CHWs (66), resulting in change of contraceptive methods while others stopped usage (61). End-users self-referred themselves from a health centers without stock to those with stock (85, 86) based on dissatisfaction from consultations without medicines (87), delay in accessing care within the community due to referrals (69), incurring out-of-pocket cost to buy unavailable medicines (28, 45, 56, 66, 88, 89). End-users on routine medicines had poor compliance to medicine regimens when they lost access to free medicines (29, 89), others received inappropriate treatment (90), including underdosing with a resultant incomplete recovery and development of medicine resistance (58). Overall, end-users had a poor perception of and little confidence in CHWs implementing programs with a medicine stock-out. Consequently, this accounted for low utilization of services (28, 29, 39, 46, 50, 54, 61, 75, 78, 87).
Some end-users resorted to alternative vendors (rather than CHWs and health centers) (91) including herbalists, and hawkers (92), which could put them at risk of receiving counterfeit and substandard medicines.
3.5 Risk of bias and quality of evidence
Using ROBINS-I, 12 of the 28 studies with quantitative findings were evaluated to have a serious overall risk of bias, nine moderate, six low and one had no information for assessing risk of bias.
As shown in (Appendix 6), the “confounding domain” was a significant contributor to the increased risk of bias of the seven domains of ROBINS-I. The major confounding issue being the co-interventions such as community-focused programs that may have improved availability of essential medicines in the intervention communities. Therefore, the extent of stock-out described in this review may be lower than what obtains in many communities in LMICs, and stakeholders may benefit from primary research to assess the level of local stock-out.
Of the 67 studies with qualitative findings, 12 were considered to have high quality of evidence, 48 moderate quality and seven have low quality. The overall CERQual assessment, explained in a Summary of Qualitative Findings table (Appendix 7), includes a narrative explanation of the CERQual assessment that highlights issues on methodological limitation and adequacy of data. In light of what we can describe as moderate level of evidence, stakeholders may conduct methodologically sound primary research to identify and quantify the context-relevant reasons and consequences of stock-out in their environment which would guide future interventions.