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Grocery stockpiling is a common behavioral response to the emergence of disasters or heightened uncertainty. Nonetheless, the phenomenon and methods for mitigating it are not well understood. Using a model of household shopping and inventory management, we conceptualize stockpiling as a result of an increase in the fixed cost of making grocery shopping trips, or the opportunity cost of time associated with shopping. In a laboratory experiment, we find that stockpiling increases (decreases) by 78 and 41% (22%) with an increase in fixed costs and price reductions (imposition of purchase limits), respectively. We also find that stockpiling leads to fewer (more) grocery trips by 33 and 22% (36%) under the same three conditions, respectively. Our experiment and subsequent cluster analysis suggest that loss aversion suppresses stockpiling. Our experiment shows that imposing purchase limits, a common retail response to stock‐outs, can trigger stockpiling during shopping trips without purchase limits. Although we do not claim external validity, our study suggests that store managers and policymakers should be careful about solutions during a stockpiling event, such that they do not exacerbate stockpiling, which may disproportionately affect vulnerable groups and disrupt supply chains. [ABSTRACT FROM AUTHOR]

Introduction: The large number of deaths among children with HIV is driven by poor antiretroviral treatment (ART) coverage among this cohort. The aim of the study was to assess the availability and stock‐outs of paediatric and adult ART formulations in Kenya and Uganda across various regions and types of health facilities. Methods: A survey on availability and stock‐outs of paediatric ART at health facilities was adapted from the standardized Health Action International–WHO Medicine Availability Monitoring Tool. All preferred and limited‐use formulations, and three phased‐out formulations according to the 2021 WHO optimal formulary list were included in the survey, as well as a selection of adult ART formulations suitable for older children, adolescents, and adults. Availability data were collected in June–July 2022 and stock‐out data were obtained over the previous year from randomly selected public and private‐not‐for‐profit (PNFP) facilities registered to dispense paediatric ART across six districts per country. All data were analysed descriptively. Results: In total, 144 health facilities were included (72 per country); 110 were public and 34 PNFP facilities. Overall availabilities of preferred paediatric ART formulations were 52.2% and 63.5% in Kenya and Uganda, respectively, with dolutegravir (DTG) 10 mg dispersible tablets being available in 70.2% and 77.4% of facilities, respectively, and abacavir/lamivudine dispersible tablets in 89.8% and 98.2% of facilities. Of note, availability of both formulations was low (37.5% and 62.5%, respectively) in Kenyan PNFP facilities. Overall availabilities of paediatric limited‐use products were 1.1% in Kenya and 1.9% in Uganda. At least one stock‐out of a preferred paediatric ART formulation was reported in 40.0% of Kenyan and 74.7% of Ugandan facilities. Nevirapine solution stock‐outs were reported in 43.1% of Ugandan facilities, while alternative formulations for postnatal HIV prophylaxis were not available. Conclusions: Recommended DTG‐based first‐line ART for children across all ages was reasonably available at health facilities in Kenya and Uganda, with the exception of Kenyan PNFP facilities. Availability of paediatric ART formulations on the limited‐use list was extremely low across both countries. Stock‐outs were reported regularly, with the high number of reported stock‐outs of neonatal ART formulations in Uganda being most concerning. [ABSTRACT FROM AUTHOR]

Background With countries moving towards reaching the UNAIDS 90-90-90 goal to achieve HIV epidemic control, there are going to be an unprecedented number of persons who will need to be tested, treated, and regularly monitored for viral suppression. However, most of the countries with the greatest burden of HIV/AIDS experience regular stock outages which could be detrimental to reaching these targets. ART and other commodities such as HIV test kits and laboratory supplies need to be readily and consistently available to achieve these targets. The main objective was to improve access to HIV/AIDS related commodities and strengthening institutional capacity for the management of HIV/AIDS logistics services through the MAUL procurement and supply chain strengthening project (PSSP) that rolled out four interventions on mentorship and support supervision, stock level monitoring, spatial visualization of stock indicators using GIS, and using WhatsApp to submit order reports as photo images. Methods Medical Access Uganda Limited, a private-not-for-profit supply chain management company in Uganda, implemented these interventions as part of a procurement and supply chain strengthening project (PSSP). These interventions were evaluated using performance monitoring indicators from 2011–2016. We tested for the significance in the change in scores of performance monitoring indicators using the test for difference in proportions. Health facilities were scored on 6 categories and accredited as bronze, silver or gold based on their total scores. Kaplan–Meier estimates were computed for time to silver, and gold ranking and univariate and multivariate Cox proportional hazards models were computed for time to gold ranking. Results We observed a significant reduction in reported stock-outs from 46 to 4% (p 10 aHR: 5.78, p = 0.003) were associated with better stock management ranking scores. Conclusions Improvements in supply chain management in countries committed to achieving the 90-90-90 goals are crucial to achieving HIV epidemic control. Health system strengthening and mentorship investments in Uganda were feasible and are essential for sustainable disease control efforts.

Background: With countries moving towards reaching the UNAIDS 90-90-90 goal to achieve HIV epidemic control, there are going to be an unprecedented number of persons who will need to be tested, treated, and regularly monitored for viral suppression. However, most of the countries with the greatest burden of HIV/AIDS experience regular stock outages which could be detrimental to reaching these targets. ART and other commodities such as HIV test kits and laboratory supplies need to be readily and consistently available to achieve these targets. The main objective was to improve access to HIV/AIDS related commodities and strengthening institutional capacity for the management of HIV/AIDS logistics services through the MAUL procurement and supply chain strengthening project (PSSP) that rolled out four interventions on mentorship and support supervision, stock level monitoring, spatial visualization of stock indicators using GIS, and using WhatsApp to submit order reports as photo images. Methods: Medical Access Uganda Limited, a private-not-for-profit supply chain management company in Uganda, implemented these interventions as part of a procurement and supply chain strengthening project (PSSP). These interventions were evaluated using performance monitoring indicators from 2011–2016. We tested for the significance in the change in scores of performance monitoring indicators using the test for difference in proportions. Health facilities were scored on 6 categories and accredited as bronze, silver or gold based on their total scores. Kaplan–Meier estimates were computed for time to silver, and gold ranking and univariate and multivariate Cox proportional hazards models were computed for time to gold ranking. Results: We observed a significant reduction in reported stock-outs from 46 to 4% (p < 0.001) in the analysis period. Accurate stock card inventory rose from 79 to 91% (p < 0.001); adequate stock levels rose from 54 to 71% (p = 0.002) and stock reporting rates from 91 to 100% (p < 0.001). The stock order fill rate improved from a high of 93% to 97% (p = 0.375). Patient load (medium vs low adjusted hazard ratio (aHR): 2.19, p = 0.026; high vs low aHR: 2.97, p = 0.034) and number of support supervision visits (6–10 aHR: 3.33, p = 0.024; > 10 aHR: 5.78, p = 0.003) were associated with better stock management ranking scores. Conclusions: Improvements in supply chain management in countries committed to achieving the 90-90-90 goals are crucial to achieving HIV epidemic control. Health system strengthening and mentorship investments in Uganda were feasible and are essential for sustainable disease control efforts. [ABSTRACT FROM AUTHOR]

An uninterrupted supply of vaccines at different supply chain levels is a basic component of a functional immunization programme and care service. There can be no progress toward achieving universal health coverage and sustainable development without continuous availability of essential medicines and vaccines in healthcare facilities. Shortages of vaccines, particularly at health facility level is an issue of grave concern that requires urgent attention in South Africa. The causes of vaccine stock-outs are multifactorial and may be linked to a broader systems issue. These factors include challenges at higher levels such as delays in the delivery of stock from the pharmaceutical depot; health facility level factors, which include a lack of commitment from healthcare workers and managers; human resource factors, such as, staff shortages, and lack of skilled personnel. Therefore, there is a compelling need to address the factors associated with shortages of vaccines in health facilities. This paper highlights the challenges of vaccine availability in South Africa, the associated factors, the available interventions, and recommended interventions for the expanded programme on immunization in South Africa. We propose a system redesign approach as a potentially useful intervention.

Abstract Background Despite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on ‘upstream’ or national-level drivers of ARVs stock-outs with less empirical attention devoted ‘down-stream’ or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chronic stock-outs of ARVs. Methods This was a qualitative research design nested within a larger mixed-methods study. We purposively selected 16 health facilities from across Uganda (to achieve diversity with regard to; level of care (primary/ tertiary), setting (rural/urban) and geographic sub-region (northern/ central/western). We conducted 76 Semi-structured interviews with ART clinic managers, clinicians and pharmacists in the selected health facilities supplemented by on-site observations and documentary reviews. Data were analyzed by coding and thematic analyses. Results Participants reported that facility-level contributors to stock-outs include untimely orders of drugs from suppliers and inaccurate quantification of ARV medicine needs due to a paucity of ART program data. Internal stock management solutions for mitigating stock-outs which emerged include the substitution of ARV medicines which were out of stock, overstocking selected medicines and the use of recently expired drugs. The external solutions for mitigating stock-outs which were identified include ‘borrowing’ of ARVs from peer-providers, re-distributing stock across regions and upward referrals of patients. Systemic drivers of stock-outs were identified. These include the supply of drugs with a short shelf life, oversupply and undersupply of ARV medicines and migration pressures on the available ARVs stock at case-study facilities. Conclusion Health facilities devised internal stock management strategies and relied on peer-provider networks for ARV medicines during stock-out events. Our study underscores the importance of devising interventions aimed at improving Uganda’s medicines supply chain systems in the quest to reduce the frequency of ARV medicines stock-outs at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes.

Background: Although adverse drug reactions resulting from the use of nevirapine (NVP) are well described in adults (estimated frequency of 6% – 10%), it has previously been considered less common in children (0.3% – 1.4%). Stock-outs of antiretroviral agents occur frequently in South Africa and result in interruptions in therapy and drug substitutions. Objectives: To report on a case series of paediatric patients who suffered cutaneous drug reactions to NVP at rates not previously described in children. Method: We describe a retrospective observational case series of six children living with HIV who developed Stevens-Johnson Syndrome (SJS) following exposure to NVP because of a prolonged stock-out of efavirenz 200 mg tablets in South Africa. Results: Of the 392 paediatric patients receiving antiretroviral therapy at the institution, 172 were affected by the efavirenz stock-out. Of these, 85 children were changed to NVP of which six developed NVP-induced SJS (7.1% incidence rate). The median time between initiating NVP and developing symptoms was 27 days (range 12–35 days). All patients responded well to NVP cessation and symptomatic treatment. One patient was referred for specialist care. Two patients were successfully rechallenged with efavirenz after developing SJS and three continued lopinavir/ritonavir. Conclusions: This is the second largest case series of NVP-induced SJS in children to date and raises the possibility that the incidence of SJS in children may be higher than previously described. Further research is required to explore the risk factors associated with NVP-induced SJS in children. This case series highlights the negative impact of drug stock-outs on patient health outcomes.

Objective Our objective through this work is to study a certain number of indicators according to the type of hospital facility in order to determine the consequences of the diversity of management methods and of the impact of each management mode on the pharmaceutical services provided. Methods For the data collection method, we used a survey. This latter is intended for the pharmacists of the State Services Managed Autonomously, the University Hospitals, and Private Clinics; the survey was validated by a team of hospital pharmacists and managers. For the elaboration of our questionnaire, we used the Sphinx tool, and for quantitative data, we processed them on a computer medium using the Statistical SPSS. Results In terms of results, the difference in most of the criteria studied is significant depending on whether what is under study is a university hospital, a State Services Managed Autonomously hospital, or a private clinic. Conclusion Logistics is a discipline that is characterized by its cross-cutting character, or even its universality, because it applies to all scientific disciplines and all lines of business. As a result, logistics has a strong presence in the health sector, whether in hospitals or in the pharmaceutical industry. [ABSTRACT FROM AUTHOR]

No abstract available.

INTRODUCTION: The year 2017 marked a transition period with the end of the implementation of Cameroon´s 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target. METHODS: we conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access. RESULTS: a total of 137 staff and 642 people leaving with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04 - 4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16 -7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs "HIV test kits (21%), ARVs (71.4%), viral load testing reagents (100%)" are the major barriers to service delivery and uptake along the cascade. CONCLUSION: we identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target.

At the margins of the global scale‐up of antiretroviral treatment for HIV, the Democratic Republic of the Congo has experienced severe regional stock‐outs of essential medicines. Usually framed by global health actors as signs of technical, logistical, and professional deficiency, antiretroviral scarcity is – perhaps surprisingly – rarely considered to be an exceptional event. Attention to the local consequences of scarcity in the east of the country, however, suggests that stock‐outs arise from far more than mere infrastructural failings. Drawing on an investigative ethnography conducted in the province of South Kivu between 2016 and 2018, this paper examines how stock‐outs in the region have political functions rooted in the calculated denial of medicine to geopolitically significant communities and individuals. Informed by extant research on the geopolitics of health, I begin by conceptually framing the geographical significance of stock‐outs and locate in their origins and functions the discriminate use of scarcity as a biopolitical tool. Then, drawing on interviews and the analysis of previously unpublished and uncollated stock records, I demonstrate the technical and political origins of stock‐outs at six dispensaries in the province. The supply of essential medicines, I argue, has become weaponised and their denial represents a strategic gambit for armed actors seeking territorial footholds in the region. Focusing on the cases of two out‐of‐stock towns in the south of the province, I then examine patients′ agonising experiences of stock‐outs, the poisoning and distortion of local moral economies that scarcity gives rise to, and the profoundly ambiguous transformations of therapeutic citizenship birthed by denial of treatment. I conclude by returning to the scale‐up of antiretroviral treatment and review the critical avenues opened up for health geographers by a focus on the provisioning, scarcity, and denial of essential medicines. [ABSTRACT FROM AUTHOR]

Objective: In 2011, the government of Cameroon launched its performance-based financing (PBF) scheme. Our study examined the effects of the PBF intervention on the availability of essential medicines (EM).Methods: Randomised control trial whereby PBF and three distinct comparison groups were randomised in a total of 205 health facilities across three regions. Baseline data were collected between March and May 2012 and endline data 36 months later. We defined availability of multiple EM groups by assessing stock-outs for at least one day over the 30 days prior to the survey date and estimated changes attributable to PBF using a series of difference-in-difference regression models, adjusted for relevant facility-level covariates. Data were analysed stratified by region and area to assess effect heterogeneity.Results: Our estimates suggest that PBF intervention had no effect on the stock-outs of antenatal care drugs (P = 0.160), vaccines (P = 0.396), integrated management of childhood illness drugs (P = 0.681) and labour and delivery drugs (P = 0.589). However, the intervention was associated with a significant reduction of 34% in stock-outs of family planning medicines (P = 0.028). We observed effect heterogeneity across regions and areas, with significant decreases in stock-outs of family planning products in North-West region (P = 0.065) and in rural areas (P = 0.043).Conclusions: The PBF intervention in Cameroon had limited effects on the reduction of EMs stock-outs. These poor results were likely the consequence of partial implementation failure, ranging from disruption and discontinuation of services to limited facility autonomy in managing decision-making and considerable delay in performance payment. [ABSTRACT FROM AUTHOR]

To describe vaccine stock-outs at national, district, and health facility levels in the WHO African region. We conducted a systematic review to identify studies reporting on vaccine stock-outs at national, district, and health facility levels in 47 African countries. We searched both published and unpublished literature, including the WHO/UNICEF Joint Reporting Form (JRF), for eligible studies. Countries within the WHO African region continue to face the challenge of vaccine stock-outs at national, district, and health facility levels and this impacts on the delivery of immunization services. The frequency and the proportion of stock-outs vary between countries and between regions within a country. Countries need to put more efforts toward finding lasting solutions to vaccine shortages. We look forward to having more countries reporting vaccine stock-outs especially at the health facility level. Furthermore, countries are currently exploring different approaches for improving vaccine stock management. It is expected that in half a decade from now, more well-designed studies will be available that will inform decision-making [ABSTRACT FROM AUTHOR]

Poor stock management has been identified as one of the causes of vaccine stock-outs in health facilities. This study assessed the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care facilities in OR Tambo district of the Eastern Cape province, South Africa. Descriptive cross-sectional study design was used in this study to assess both the stock management practices and the availability of vaccines in the facilities. The study was conducted in 64 primary health care facilities across all sub-districts in OR Tambo. Data were collected using a questionnaire administered by the researcher, record checks and through observation. The occurrence of stock-outs of six tracer vaccines on the day of the visit and in the preceding 24 months were assessed. The data were captured into REDCap tool and analysed using STATA version 14. Most standard stock management procedures were not adhered to, as these procedures were mostly handled by health care workers who either required formal training or refresher training on vaccine management. Cold chain capacity was not adequate and some vaccines were exposed to freezing. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which contributed to stock-outs. A total of 49 (77%) health facilities had at least one stockout for at least one vaccine on the day of the visit. Furthermore, BCG and OPV were the most affected vaccines in 37 (58%) and 28 (44%) of facilities, respectively. Interventions for improving vaccine availability should be considered, especially those targeting human resources and the entire stock management system. [ABSTRACT FROM AUTHOR]

Introduction: the year 2017 marked a transition period with the end of the implementation of Cameroon's 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target. Methods: we conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access. Results: a total of 137 staff and 642 people living with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04-4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16-7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs "HIV test kits (21%), antiretrovirals (ARVs) (71.4%), viral load testing reagents (100%)" are the major barriers to service delivery and uptake along the cascade. Conclusion: we identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target. [ABSTRACT FROM AUTHOR]

Background. South Africa (SA) has experienced several stock-outs of life-saving medicines for the treatment of major chronic infectious and non-communicable diseases in the public sector. Objective. To identify the causes of stock-outs and to illustrate how they undermine access to medicines (ATM) in the Western Cape Province, SA. Methods. This qualitative study was conducted with a sample of over 70 key informants (frontline health workers, sub-structure and provincial health service managers). We employed the critical incident technique to identify significant occurrences in our context, the consequences of which impacted on access to medicines during a defined period. Stock-outs were identified as one such incident, and we explored when, where and why they occurred, in order to inform policy and practice. Results. Medicines procurement is a centralised function in SA. Health service managers unanimously agreed that stock-outs resulted from the following inefficiencies at the central level: (i) delays in awarding of pharmaceutical tenders; (ii) absence of contracts for certain medicines appearing on provincial code lists; and (iii) suppliers’ inability to satisfy contractual agreements. The recurrence of stock-outs had implications at multiple levels: (i) health facility operations; (ii) the Chronic Dispensing Unit (CDU), which prepacks medicines for over 300 000 public sector patients; and (iii) community-based medicines distribution systems, which deliver the CDU’s prepacked medicines to non-health facilities nearer to patient homes. For instance, stock-outs resulted in omission of certain medicines from CDU parcels that were delivered to health facilities. This increased workload and caused frustration for frontline health workers who were expected to dispense omitted medicines manually. According to frontline health workers, this translated into longer waiting times for patients and associated dissatisfaction. In some instances, patients were asked to return for undispensed medication at a later date, which could potentially affect adherence to treatment and therapeutic outcomes. Stock-outs therefore undermined the intended benefits of ATM strategies. Conclusion. Addressing the procurement challenges, most notably timeous tender awards and supplier performance management, is critical for successful implementation of ATM strategies.

Abstract Backrgound Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs. Methods Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively. Results Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms. Conclusions While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers’ accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods.

Background. Immunisations are one of the most cost-effective public health interventions available and South Africa (SA) has implemented a comprehensive immunisation schedule. However, there is disagreement about the level of immunisation coverage in the country and few studies document the immunisation coverage in rural areas. Objective. To examine the successful and timely delivery of immunisations to children during the first 2 years of life in a deeply rural part of the Eastern Cape Province of SA. Methods. From January to April 2013, a cohort of sequential births (N=470) in the area surrounding Zithulele Hospital in the OR Tambo District of the Eastern Cape was recruited and followed up at home at 3, 6, 9, 12 and 24 months post birth, up to May 2015. Immunisation coverage was determined using Road-to-Health cards. Results. The percentages of children with all immunisations up to date at the time of interview were: 48.6% at 3 months, 73.3% at 6 months, 83.9% at 9 months, 73.3% at 12 months and 73.2% at 24 months. Incomplete immunisations were attributed to stock-outs (56%), lack of awareness of the immunisation schedule or of missed immunisations by the mother (16%) and lack of clinic attendance by the mother (19%). Of the mothers who had visited the clinic for baby immunisations, 49.8% had to make multiple visits because of stock-outs. Measles coverage (of at least one dose) was 85.2% at 1 year and 96.3% by 2 years, but 20.6% of babies had not received a second measles dose (due at 18 months) by 2 years. Immunisations were often given late, particularly the 14-week immunisations. Conclusions. Immunisation rates in the rural Eastern Cape are well below government targets and indicate inadequate provision of basic primary care. Stock-outs of basic childhood immunisations are common and are, according to mothers, the main reason for their children’s immunisations not being up to date. There is still much work to be done to ensure that the basics of disease prevention are being delivered at rural clinics in the Eastern Cape, despite attempts to re-engineer primary healthcare in SA.

This paper examines the stock-outs of medicines and diagnostic devices inUganda. Our aim is to trace and compare interruptions in the supply ofantiretrovirals and Rapid Diagnostic Tests in order to provide anethnographic account of the complex role that improvisations playwithin global health infrastructures. We will argue that the fragmentedand mobile infrastructures of these key global health technologiesrequire and necessitate improvisations by the different actors involvedas well as on almost all levels of the Ugandan health-care system. Theextent and abundance of improvisations in itself works to acquireinfrastructural capacities, a process that we will call the infrastructuringof care and treatment. We will also show how this process ofinfrastructuring of care and treatment – here rendered visible throughimprovisations – produces new dilemmas and uncertainties. Ourapproach to infrastructure challenges technocratic overtones prevalentin current debates around the much-needed strengthening of healthsystems. Our study of stock-outs aims to show how the infrastructure ofunder-resourced health systems is maintained by a complex nexus ofsocio-material practices and improvisations. [ABSTRACT FROM AUTHOR]

Over the past decade, several countries across all regions, income groups and procurement methods have been unable to secure sufficient BCG vaccine supply. While the frequency of stock-outs has remained rather stable, duration increased in 2014–2015 due to manufacturing issues and attracted the attention of national, regional and global immunization stakeholders. This prompted an in-depth analysis of supply and demand dynamics aiming to characterize supply risks. This analysis is unique as it provides a global picture, where previous analyses have focused on a portion of the market procuring through UN entities. Through literature review, supplier interviews, appraisal of shortages, stock-outs and historical procurement data, and through demand forecasting, this analysis shows an important increase in global capacity in 2017: supply is sufficient to meet forecasted BCG vaccine demand and possibly buffer market shocks. Nevertheless, risks remain mainly due to supply concentration and limited investment in production process improvements, as well as inflexibility in demand. Identification of these market risks will allow implementation of risk-mitigating interventions in three areas: (1) enhancing information sharing between major global health actors, countries and suppliers, (2) identifying interests and incentives to expand product registration and investment in the BCG manufacturing process, and (3) working with countries for tighter vaccine management. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this exploratory study was to investigate how management practices and processes contribute to stock-outs in the warehouse retail liquor sector in Johannesburg. Research design: A pragmatic research philosophy was used in a multi-case approach to determine the association between business management practices and stock-outs. The unit of analysis of the study is the highest turnover outlets. Findings: The results revealed that retailers base demand forecasting on judgement and naïve or simple moving average forecast methods. There is little consideration of variability, lead time or targeted customer service levels when determining optimal inventory levels. Product breakages are common, implying that data inaccuracies and stock-outs are highly probable. Information sharing between the retailers and suppliers is limited and formal collaboration programmes do not exist. The respondents revealed that frequent stock-outs resulted in poor business performance characterised by declining sales, customer retention and competitive advantage. Limitations: Although the sample selected represented a significant portion of the top 50% contributors to the sector’s sales, the sample is small and the focus of the study is limited, which decreases the generalisability of the results. Practical implications: Retailers can reduce stock-outs by investing in improvements in demand forecasting, synchronisation through collaboration and training of employees. Originality or value: This study provides empirical evidence of the linkages between poor management practices and processes, stock-outs, customer service and business performance.

The under-performance of supply chains presents a significant hindrance to disease control in developing countries. Stock-outs of essential medicines lead to treatment interruption which can force changes in patient drug regimens, drive drug resistance and increase mortality. This study is one of few to quantitatively evaluate the effectiveness of supply chain policies in reducing shortages and costs. This study develops a systems dynamics simulation model of the downstream supply chain for amikacin, a second-line tuberculosis drug using 10 years of South African data. We evaluate current supply chain performance in terms of reliability, responsiveness and agility, following the widely-used Supply Chain Operation Reference framework. We simulate 141 scenarios that represent different combinations of supplier characteristics, inventory management strategies and demand forecasting methods to identify the Pareto optimal set of management policies that jointly minimize the number of shortages and total cost. Despite long supplier lead times and unpredictable demand, the amikacin supply chain is 98% reliable and agile enough to accommodate a 20% increase in demand without a shortage. However, this is accomplished by overstocking amikacin by 167%, which incurs high holding costs. The responsiveness of suppliers is low: only 57% of orders are delivered to the central provincial drug depot within one month. We identify three Pareto optimal safety stock management policies. Short supplier lead time can produce Pareto optimal outcomes even in the absence of other optimal policies. This study produces concrete, actionable guidelines to cost-effectively reduce stock-outs by implementing optimal supply chain policies. Preferentially selecting drug suppliers with short lead times accommodates unexpected changes in demand. Optimal supply chain management should be an essential component of national policy to reduce the mortality rate. [ABSTRACT FROM AUTHOR]

Backrgound: Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs.Methods: Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively.Results: Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms.Conclusions: While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers' accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods. [ABSTRACT FROM AUTHOR]

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Objective: Using data from four public sector clinics in South Africa, we sought to investigate provider- and patient-level outcomes, to understand how the 2012 tenofovir stock shortage affected the HIV care and monitoring of ART patients.Methods: Prospective cohort analysis of ART-naïve, non-pregnant, HIV-infected patients >18 years initiating first-line ART between 1 July 2011-31 March 2013. Linear regression was used for all outcomes (number of ART initiates, days between pharmacy visits, transfers, single-drug substitutions, treatment interruptions, missed pharmacy visits, loss to follow-up and elevated viral load). We fit splines to smooth curves with knots at the beginning (1 February 2012) and end (31 August 2012) of the stock shortage and displayed results graphically by clinic. Difference-in-difference models were used to evaluate the effect of the stock shortage on outcomes.Results: Results suggest a potential shift in the management of patients during the shortage, mainly fewer average days between visits during the shortage vs. before or after at all four clinics, and a significant difference in the proportion of patients missing visits during vs. before (RD: 1.2%; 95% CI: 0.5%, 2.0%). No significant difference was seen in other outcomes.Conclusion: While South Africa has made great strides to extend access to ART and increase the quality of the health services provided, patient care can be affected when stock shortages/outs occur. While our results show little effect on treatment outcomes, this most likely reflects the clinics' ability to mitigate the crisis by continuing to keep patient care and treatment as consistent as possible. [ABSTRACT FROM AUTHOR]

We make the case for why continuous pharmaceutical manufacturing is essential, what the barriers are, and how to overcome them. To overcome them, government action is needed in terms of tax incentives or regulatory incentives that affect time. [ABSTRACT FROM AUTHOR]

Stock-outs, also known as shortages or complete absence of a particular inventory, in public health facilities have become a hallmark in Uganda's health system making the notions of persistent doubt in access to healthcare – uncertainty , and doing more with less – ‘ improvisation ’, very pronounced. The situation becomes more critical in post-conflict areas with an over whelming burden of preexisting and conflict-related ailments amidst weak health systems. Particularly in the war-torn Northern Uganda, the intersection between the effects of violent conflict and shortage of medications is striking. There are problems getting the right type of medications to the right people at the right time, causing persistent shortages and uncertainty in access to healthcare. With reference to patients on Antiretroviral Therapy (ART), we present temporal trends in access to healthcare in the context of medication shortages in conflict-affected areas. We examine uncertainties in access to care, and how patients, medical practitioners, and the state – the key actors in the domain of supplying and utilizing medicines, respond. Our observation is that, while improvisation is a feature of biomedicine and facilitates problem solving in daily life, it is largely contextual. Given the rapidly evolving contexts and social and professional sensitivities that characterize war affected areas, there is a need for deliberate healthcare programs tailored to the unique needs of people and to the shaping of appropriate policies in post-conflict settings, which call for more North-South collaboration on equal terms. [ABSTRACT FROM AUTHOR]

Stock-outs are one of a retail chains' biggest problems because they lead directly to lost sales, reduced profits, and the potential loss of customers. This research applied probit regression to determine the relationship between various stock-keeping unit (SKU) attributes and retail stock-out performance. The data sample came from a large grocery retailer in Serbia and included two high-risk product categories consisting of a total of 115 SKUs and 98 stores. For the identification of stock-outs, a perpetual inventory aggregation method was used. Regardless of the category observed, the variables that were identified as having a detrimental impact on stock-out performance include stock-out at the distribution center, promotion, and high sales speed. On the other hand, a beneficial effect in terms of a reduced number of stock-outs was observed when the ordering process was performed using an automated ordering system. [ABSTRACT FROM AUTHOR]

An uninterrupted supply of vaccines at different supply chain levels is a basic component of a functional immunization programme and care service. There can be no progress toward achieving universal health coverage and sustainable development without continuous availability of essential medicines and vaccines in healthcare facilities. Shortages of vaccines, particularly at health facility level is an issue of grave concern that requires urgent attention in South Africa. The causes of vaccine stock-outs are multifactorial and may be linked to a broader systems issue. These factors include challenges at higher levels such as delays in the delivery of stock from the pharmaceutical depot; health facility level factors, which include a lack of commitment from healthcare workers and managers; human resource factors, such as, staff shortages, and lack of skilled personnel. Therefore, there is a compelling need to address the factors associated with shortages of vaccines in health facilities. This paper highlights the challenges of vaccine availability in South Africa, the associated factors, the available interventions, and recommended interventions for the expanded programme on immunization in South Africa. We propose a system redesign approach as a potentially useful intervention.

Background: Malaria rapid diagnostic tests (RDTs) are particularly useful in low-resource settings where follow-through on traditional laboratory diagnosis is challenging or lacking. The availability of these tests depends on supply chain processes within the distribution system. In Mozambique, stock-outs of malaria RDTs are fairly common at health facilities. A longitudinal cross-sectional study was conducted to evaluate drivers of stock shortages in the Cabo Delgado province. Methods: Data were collected from purposively sampled health facilities, using monthly cross-sectional surveys between October 2011 and May 2012. Estimates of lost consumption (consumption not met due to stock-outs) served as the primary quantitative indicator of stock shortages. This is a better measure of the magnitude of stock-outs than binary indicators that only measure frequency of stock-outs at a given facility. Using a case study based methodology, distribution system characteristics were qualitatively analysed to examine causes of stock-outs at the provincial, district and health centre levels. Results: 15 health facilities were surveyed over 120 time points. Stock-out patterns varied by data source; average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost consumption percentage were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each ten-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage indicating that higher rates of stock-outs occurred at higher levels of observed consumption. Causes of stock-outs included inaccurate tracking of lost consumption, insufficient sophistication in inventory management and replenishment, and poor process compliance by facility workers, all arguably stemming from inadequate attention to the design and implementation of the distribution system. Conclusions: Substantially high levels of RDT stock-outs were found in Cabo Delgado. Study findings point to a supply chain with a commendable degree of sophistication. However, insufficient attention paid to system design and implementation resulted in deteriorating performance in areas of increased need. In such settings fast moving commodities like malaria RDTs can call attention to supply chain vulnerabilities, the findings from which can be used to address other slower moving health commodities. [ABSTRACT FROM AUTHOR]

Abstract: This paper describes a ‘simheuristic’ algorithm – one which combines simulation with heuristics – for solving a stochastic variant of the well-known Inventory-Routing Problem. The variant discussed here is integrated by a vehicle routing problem and several inventory problems characterized by stochastic demands. Initial stock levels and potential stock-outs are also considered, as well as a set of alternative refill policies for each retail center. The goal is to find the personalized refill policies and associated routing plan that minimize, at each single period, the expected total costs of the system, i.e., the sum of inventory and routing costs. After motivating it, a detailed description of the problem is provided. Then, a review of the related literature is performed and our simulation–optimization approach is introduced. The paper presents a set of numerical experiments comparing the proposed method against different refill strategies and discusses how total costs evolve as the level of system uncertainty and the inventory-holding costs per unit are varied. [Copyright &y& Elsevier]

This study tested the hypothesis that retail customers' drive to assimilation or differentiation moderates the effect on their initial preference for a particular product of their discovery in the store of a previously unconsidered comparable alternative, which happens to be presently out of stock. The results revealed that new awareness of alternative options has an impact on customers' preferences, even if they are unavailable when the choice is being made. Participants who were more concerned with differentiation exhibited a stronger preference for the option originally under consideration if they were told that the alternative was out of stock due to heavy demand rather than short supply. By comparison, those more concerned with assimilation had a weaker preference for the initial product when they learnt that its unavailability was said to be due to heavy demand, not supply shortfall. The article concludes with theoretical implications and areas for future research. [ABSTRACT FROM AUTHOR]

Background To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. Methods We combined weekly ACT stock data for the period 2009-2011 from six health facilities in he Ulanga District in Tanzania, together with household data from 333 respondents on the ost of fever care-seeking in Ulanga during the same time period to establish how health eeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. Results rrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were ligible for free service or referring patients to the private sector despite ACT stock), which ncreased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock- outs were considered to be the result of non-compliant behaviour of others in the health ystem and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. Conclusion System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to nsure a stable supply of ACT in the public sector and increase health worker accountability. [ABSTRACT FROM AUTHOR]

Empirical studies in retailing suggest that stock-out rates are quite high in many product categories. Stock-outs result in demand spillover, or substitution, among items within a product category. Product assortment and inventory management decisions can be improved when the substitution rates are known. In this paper, a method is presented to estimate product substitution rates by using only Point-Of-Sale (POS) data. The approach clusters POS intervals into states where each state corresponds to a specific substitution scenario. Then available POS data for each state is consolidated and the substitution rates are estimated using the consolidated information. An extensive computational analysis of the proposed substitution rate estimation method is provided. The computational analysis and comparisons with an estimation method from the literature show that the proposed estimation method performs satisfactorily with limited information. [ABSTRACT FROM AUTHOR]