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Open Access 01-12-2019 | Tuberculosis | Research article

Effects and determinants of tuberculosis drug stockouts in South Africa

Authors: L. E. M. Koomen, R. Burger, E. K. A. van Doorslaer

Published in: BMC Health Services Research | Issue 1/2019

Abstract

Background

The frequent occurrence of medicine stockouts represents a significant obstacle to tuberculosis control in South Africa. Stockouts can lead to treatment alterations or interruptions, which can impact treatment outcomes. This study investigates the determinants and effects of TB drug stockouts and whether poorer districts are disproportionately affected.

Methods

TB stockout data, health system indicators and TB treatment outcomes at the district level were extracted from the District Health Barometer for the years 2011, 2012 and 2013. Poverty terciles were constructed using the Census 2011 data to investigate whether stockouts and poor treatment outcomes were more prevalent in more impoverished districts. Fixed-effects regressions were used to estimate the effects of TB stockouts on TB treatment outcomes.

Results

TB stockouts occurred in all provinces but varied across provinces and years. Regression analysis showed a significant association between district per capita income and stockouts: a 10% rise in income was associated with an 8.50% decline in stockout proportions. In terms of consequences, after controlling for unobserved time invariant heterogeneity between districts, a 10% rise in TB drug stockouts was found to lower the cure rate by 2.10% (p < 0.01) and the success rate by 1.42% (p < 0.01). These effects were found to be larger in poorer districts.

Conclusions

The unequal spread of TB drug stockouts adds to the socioeconomic inequality in TB outcomes. Not only are stockouts more prevalent in poorer parts of South Africa, they also have a more severe impact on TB treatment outcomes in poorer districts. This suggests that efforts to cut back TB drug stockouts would not only improve TB treatment outcomes on average, they are also likely to improve equity because a disproportionate share of this burden is currently borne by the poorer districts.

Available only for authorised users

A poverty threshold of R575 (South African Rand) per month per household was used. This is an inflation adjusted lower-bound poverty line, estimated with the cost-for-basic needs poverty line suggested by Özler [34, 35]). Table 8 in the Appendix lists the districts by poverty category.

An example of a potential unobserved district characteristic is ‘bad governance’. This can influence TB drug stockouts, because stock management might be inadequate. And it can influence TB treatment outcomes, because TB treatment guidelines might not be implemented in health facilities.

See Health Systems Trust [36].

Genexpert is a molecular TB test detecting the presence of TB bacteria. Its main advantages are that it can give a result in less than two hours (accurate culture tests can take weeks); that it is more sensitive than sputum microscopy for HIV-positive patients; and, that it also tests for resistance to the drug Rifampicin. It was endorsed by the WHO in 2010. One of the main downsides is that it cannot be used to monitor treatment progress given that it detects both live and dead bacteria.

For an example of such an experiment, see e.g. the Central Chronic Medicine Dispensing and Distribution Programme (CCMDD) available at http://www.hst.org.za/hstconference/hstconference2016/Presentations/roma_ramphal_hst_conf_final_04.05.2016.pdf.

American Hospital Association. AHA survey on drug shortages. 2011.

Besançon L, Chaar B. Report of the international summit on medicines shortage [internet]. 2013. Available from: https://fip.org/files/fip/publications/FIP_Summit_on_Medicines_Shortage.pdf

Masters SH, Burstein R, Decenso B, Moore K, Haakenstad A, Ikilezi G, et al. Pharmaceutical availability across levels of care: evidence from facility surveys in Ghana, Kenya, and Uganda. PLoS One. 2014;9(12):1–12.CrossRef

Hedman L. Medicines shortages. WHO Drug Inf Bull. 2016;30(2):180–5.

World Health Organization (WHO). South Africa tuberculosis profile [Internet]. 2017. Available from: https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=ZA&LAN=EN&outtype=html

Seunanden T, Day C. The extent and impact of TB drug stock-out. South African Heal Rev. 2014:173–89.

Leibbrandt M, Finn A, Woolard I. Describing and decomposing post-apartheid income inequality in South Africa. Dev South Afr. 2012;29(1):19–34.CrossRef

Auditor General South Africa. Performance audit of the management of pharmaceuticals [Internet]. 2016. Available from: http://www.agsa.co.za/Portals/0/Downloads/AGSA%20Performance%20Audit%20Management%20Pharmaceuticals%20-%20Part%201.pdf Performance Audit Management Pharmaceuticals - Part 1.pdf.

Yadav P. Health product supply chains in developing countries: diagnosis of the root causes of underperformance and an agenda for reform. Heal Syst Reform [Internet]. 2015;1(2):142–54 Available from: http://www.tandfonline.com/doi/full/10.4161/23288604.2014.968005.CrossRef

10.

Fox ER, Sweet B V., Jensen V. Drug shortages: A complex health care crisis. Mayo Clin Proc [Internet]. Elsevier Inc; 2014;89(3):361–373. Available from: https://doi.org/10.1016/j.mayocp.2013.11.014.

11.

Gagnon MA. Drug shortages: searching for a cure. Healthc Policy. 2012;7(4):10–7.PubMedPubMedCentral

12.

Bateman C. Drug stock-outs: inept supply-chain management and corruption. South African Med J. 2013;103(9):600–2.CrossRef

13.

Reid S. Monitoring the effect of the new rural allowance for health professionals. Heal Syst Trust [Internet]. 2004:1–7 Available from: https://www.researchgate.net/publication/322273005_Monitoring_the_effect_of_the_new_rural_allowance_for_health_professionals.

14.

Barnett BS, Chaweza T, Tweya H, Ngambi W, Phiri S, Hosseinipour MC. Assessment of non-standard HIV antiretroviral therapy regimens at lighthouse Trust in Lilongwe, Malawi. Malawi Med J. 2016;28(1):6–9.CrossRef

15.

Pasquet A, Messou E, Gabillard D, Minga A, Depoulosky A, Deuffic-Burban S, et al. Impact of drug stock-outs on death and retention to care among HIV- infected patients on combination antiretroviral therapy in Abidjan, cote d’ivoire. PLoS One. 2010 Oct 15;5(10):e13414. https://doi.org/10.1371/journal.pone.0013414.

16.

Jensen V, Rappaport B. The reality of drug shortages—the case of the injectable agent propofol. N Engl J Med [Internet]. 2010;28:806–7 Available from: https://www.researchgate.net/publication/44679864_The_Reality_of_Drug_Shortages_-_The_Case_of_the_Injectable_Agent_Propofol.CrossRef

17.

Metzger ML, et al. The impact of drug shortages on children with Cancer — the example of Mechlorethamine. N Engl J Med [Internet]. 2012;363(26):1–3 Available from: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle: New+engla+nd+journal#0.

18.

Tan YX, Moles RJ, Chaar BB. Medicine shortages in Australia: causes, impact and management strategies in the community setting. Int J Clin Pharm Springer International Publishing; 2016;38(5):1133–1141.

19.

Kranzer K, Ford N. Unstructured treatment interruption of antiretroviral therapy in clinical practice: a systematic review. Trop Med Int Heal. 2011;16(10):1297–313.CrossRef

20.

Shiotani R, Hennink M. Socio-cultural influences on adherence to tuberculosis treatment in rural India. Glob Public Health [Internet]. Taylor & Francis; 2014;1–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25223868

21.

TB DOTS Strategy Coordination. National Tuberculosis Management Guidelines 2014 [Internet]. 2014. 19–28 p. Available from: http://www.tbonline.info/media/uploads/documents/ntcp_adult_tb-guidelines-27.5.2014.pdf.

22.

Gelmanova IY, et al. Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: non-adherence, default and the acquisition of multidrug resistance. Bull World Heal Organ [Internet]. 2007;85(10):703–11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636414/.

23.

Wells et al. HIV infection and multidrug-resistant tuberculosis—the perfect storm. J Infect Dis [Internet]. 2007;196(s1):S86–107 Available from: https://academic.oup.com/jid/article-lookup/doi/10.1086/518665.CrossRef

24.

Massyn N, Peer N, Padarath A, Barron P, Day C, Trust HS, et al. District health barometer 2015/16. Heal Syst Trust [Internet]. 2016;626. Available from: http://www.hst.org.za/publications/Pages/-District-Health-Barometer-201516.aspx

25.

South African Census 2011. Pretoria: Statistics South Africa, 2011. http://www.statssa.gov.za

26.

Harries AD, Hargreaves NJ, Gausi F, Kwanjana JH, Salaniponi FM. High early death rate in tuberculosis patients in Malawi. Int J Tuberc Lung Dis. 2001;5(11):1000–5.PubMed

27.

Davies PD. Drug-resistant tuberculosis. J R Soc Med. 2001;94(6):261–3.CrossRef

28.

Kennedy SB, Campbell J, Hester RA. HIV-associated tuberculosis among a cohort of heterosexual discordant couples in Lusaka, Zambia. J Health Popul Nutr. 2002;20(4):289–96.PubMed

29.

Stop Stockouts. Stock outs in South Africa – a National Crisis, vol. 36; 2013. Available from: https://stockouts.org/Download/stop_stockouts_report_2013pdf_1.pdf

30.

Stop Stockouts. Stock outs in South Africa second. Annu Rep. 2014; Available from: https://stockouts.org/Download/stockouts_2014_final_online.pdf.

31.

Stop Stockouts. 2015 Stock Outs National Survey - Third Annual Report – South Africa. p. 2015. Available from: https://stockouts.org/Download/2015_stock_outs_national_survey.pdf

32.

Auditor General South Africa. Corrective actions and initiatives implemented by management. Performance audit on the management of pharmaceuticals at departments of Health [Internet]. 2016. Available from: http://www.agsa.co.za/Portals/0/Downloads/AGSA%20Performance%20Audit%20Management%20Pharmaceuticals%20-%20Part%202.pdf.

33.

Health systems Trust. District health information system [Internet]. 2016. Available from: http://www.hst.org.za/publications/Pages/-District-Health-Barometer-201516.aspx.

34.

Özler B. Not separate, not equal: poverty and inequality in post-apartheid South Africa. Econ Dev Cult Change [Internet]. 2007;55(3):487–529 Available from: http://www.journals.uchicago.edu/doi/10.1086/511191.CrossRef

35.

Statistics South Africa. CPI history South Africa. Vol. 2016:1.

36.

Health systems Trust. Health systems Trust [Internet]. 2016. Available from: http://www.hst.org.za/aboutus

Title: Effects and determinants of tuberculosis drug stockouts in South Africa
Authors: L. E. M. Koomen
R. Burger
E. K. A. van Doorslaer
Publication date: 01-12-2019
Publisher: BioMed Central
Keywords: Tuberculosis
Tuberculosis
Published in: BMC Health Services Research / Issue 1/2019
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-019-3972-x

At a glance: The STEP trials

Springer Medicine

Effects and determinants of tuberculosis drug stockouts in South Africa

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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