Shortages of essential medicines in healthcare in low- and middle-income countries

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Access to medicines is a basic human right. Yet nearly two billion people experience shortages or lack of essential medicines and medical supplies. This means that they are unavailable, inaccessible or unaffordable for one of four people in the world. Many developed countries experience this problem, but it escalates in low- and middle-income nations. Access to medicine means that people have the right medicines of the right quality, at the right price, time and place. This right place in most of the cases means hospitals, clinics and pharmacies operating in these facilities. And this stage frequently fails in poor countries.

Poor countries rely on expensive import of medicines

Many undeveloped countries, like those in Africa, do not have the technical, financial or human resources needed for high-scale drug production. They depend on imported medical products.

Photo: Assorted medicines in pill form.

Before a drug reaches a market, it has to be approved in a country in demand. Registration costs and complicated regulatory rules require companies to invest significant amounts of money to get through this process. Complex regulations may prevent some manufacturers from entering the market if operational costs are overly high. Many companies operating in Africa pointed to high registration, maintenance, and inspection costs as the main reasons for deciding against entering some African markets. Partially, this cost can be passed to consumers, but many companies, particularly for generic medicine, withdraw from supplying the drug at all. Thus, competition is limited, and branded drug costs stay high. This leads to market domination by a single or small number of suppliers and inflates the prices paid by the public sector. This adds up to low- and middle-income countries financial and healthcare problems, and dependence on donor funding for purchasing medicines.

Complicated supply chain adds up to delays in medicine delivery

Once the drug is approved in a country, it has to change a lot of hands between getting from the producer into the hands of healthcare personnel and patients. The supply chain includes suppliers of raw material, manufacturers, regulators, distributors, bulk purchasing organizations and the end users in the healthcare system. The distribution of medicines is very complex and inefficient in poor countries in comparison to highly developed ones. In the public sector, like hospitals and clinics, it can take months between placing an order and its delivery to the central medical store or distributor. Then medicines are transported to regional storage locations which may take weeks. Further, more days or weeks pass over to deliver medicines to the local storage places and at last, from there to healthcare facilities. These numbers rise quickly if we add more stages involved. Each stage has a time and cost consequences and disruption at any point will result in medicines stock-out. Additionally, hospital and clinics can be limited by the fact that drugs in demand can be just ordered in bulk from general stores. This exceeds the financial capacities of local healthcare providers leaving them reliant on time-consuming supply chain machinery.

Limited infrastructure and shortage of healthcare personnel

Decisions regarding the number of medical supplies to be sent to a lower stage in the public sector are made based on storage conditions and capacity, demand and available transportation. Medicines, depending on the country, have specific storage requirements like temperature or humidity. Tropical climate of many low- and middle-income countries counts here against and limits the amount of storage facilities for medical products. Added to this is the poor transportation system. Medicines distributions are usually made by road networks restricted by limited infrastructure, like road conditions or number of vehicles. As a consequence, many medicines in demand do not reach those in need on time, or never.

Another cause of medicines shortages is the limited number of trained healthcare staff. Primarily, the stock-outs were experienced by hospitals with no pharmacy support personnel, as the role of pharmacist is to manage and monitor a medical stock, ensuring medicine availability.

Consequences for healthcare systems and patients

Lack of timely delivered medicines negatively impacts therapeutic outcomes for patients. They tend to receive no or delayed therapy, and this results in loss of disease control or even death. Moreover, sudden treatment interruptions lead to increased illness, spreading resistant forms of HIV and tuberculosis, increased immunosuppression for HIV-positive patients and risk of accompanying infections. In addition, medicine shortages result in high levels of frustration and stress for everyone involved, including pharmacists, nurses, doctors and patients. This leads to unhealthy work relations and poor performance, in consequence reflecting on healthcare quality.

Medicines’ shortages in hospitals and clinics lead some patients to buy a drug through out-of-pocket payments. This can be a heavy financial burden, as even prices of generic products stay beyond the reach of poor people. Not infrequently, a family is forced to sell its only cow to afford medicine for one of the children, burying themselves even deeper in poverty. The other side of a coin is when people, due to financial reasons and stock-outs, turn to fake drugs sellers. This substandard or falsified medical products flood the market in countries facing medicine shortages. Illegitimate medicines can worsen the medical problems by not resolving them and lead to hundreds of deaths, due to containing harmful substances.

Lack of medicines, affecting various classes of products, causes a cascade of suffering, from no relief for the pain of a child’s broken leg, to deaths from diseases that are easily cured. Although the causes of drugs’ stock-out are complex, seeking improvement and ensuring access to medicines can be measured by the number of prevented deaths.

References:

Ozawa et al. Access to medicines through health systems in low- and middle-income countries. Health Policy and Planning. 2019.

Barton et al. Unintended consequences and hidden obstacles in medicine access in Sub-Saharan Africa. Frontiers in Public Health. 2019.

Silverman et al. Tackling the triple transition in Global Health Procurement. 2019

Ndzamela and Burton. Patients and healthcare professionals’ experiences of medicine stock-outs and shortages at community healthcare center in the Eastern Cape. South African Pharmaceutical Journal. 2020.

Bhattacharya and Lam. Overcoming shortages of essential medicines: perspectives from industrial and systems engineering and public health practice. Transforming Global Health. 2020.

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