Top

What Are Stock-outs?

stockout-shelf

When a pharmacy (in a medical store or health facility) temporarily has no medicine on the shelf, it is known as a “stock-out”. It may affect one medicine or many medicines, or in the worst case, all medicines. A stock-out can be documented at one point-in-time or over a period of days, weeks or months. When there is good stock management systems in place, the stock-out duration will be minimal or, ideally, never.

The consequences of stock-outs for patients are grave:

  • They have to travel to other health facilities or private sector which may be far away and often many times more expensive… or
  • They may go without the medicines they need.
  • They may get an alternative, appropriate or not, medicine.
  • They lose confidence in the health facility to meet their needs.

The supply chain in developing countries:
Getting medicines to patients

  • The government makes a “forecast” of how many medicines will be needed to manage and treat the population, based on the major public health challenges in the country.
  • Orders and tenders are generated;
  • Medicines are purchased and stored centrally;
  • Medicines are distributed to regional stores and local health facilities;

    • In a push system, health facilities receive “kits” containing a set amount of medicines. The central and regional stores prepare and send these kits on a regular schedule.
    In a pull system, the health facility decides the quantity of medicines needed and then they place orders for the medicines at the district, regional or central store.

  • Medicines are dispensed to patients in health facility pharmacies.

Inefficiencies at any stage of the supply chain cause stock-outs.

  • Inadequate funds for procurement of medicines
  • Inaccurate and non-participatory forecasting
  • Inadequate buffer stock of essential medicines at all levels of the supply chain
  • Inefficient distribution systems at national and regional levels.
  • Inadequate record-keeping

Is there information on stock-outs in my country?

WHO conducts surveys of countries’ pharmaceutical sectors to measure various aspects of the sector’s functioning, including the stock-out duration of medicines. This is done through retrospective analyses of stock-cards from the pharmacy records.

The graph shows the number of days a list of key essential medicines were out-of-stock in middle-level public health facilities in a year. The stock-out duration ranges from 25 to 89 days.

WHO and HAI monitor the availability (and price) of medicines in many African countries. This provides information on which medicines are, and which are not, on the shelves on the day of the survey. This gives useful information about the immediate availability situations, although it does not provide information about the duration which the medicine is off the shelves.

Taking action to eliminate stock-outs

  • District health management teams should be participatory to encourage transparency and accountability in the supply chain
  • Monitoring of availability of medicines at the health facilities
  • Advocacy for 100% availability of essential medicines
  • Advocacy for increased funding for essential medicines

References:
1.WHO and HAI (2008). Measuring medicine prices, availability, affordability and price components http://haiweb.org/medicineprices/
2.Community Case Management (CCM) Essentials: A Guide for Program Managers http://www.coregroup.org/ccm/ccm_field.html
3.Using indicators to measure country pharmaceutical situations. Fact book on WHO level I and level II monitoring indicators; available from http://www.who.int/medicinedocs/index/assoc/s14101e/s14101e.pdf
4.WHO (2000). Promoting Rational Use of Medicines: Core components
5.WHO and MOH (2002). Baseline Survey of the Pharmaceutical sector in Tanzania
6.WHO, HAI, MOH (2002). Uganda Pharmaceutical sector Baseline Survey
7.WHO and MOH (2003). Assessment of the pharmaceutical sector in Ethiopia
8.WHO, HAI, MOH (2003). Assessment of the pharmaceutical sector in Ghana
9.WHO, HAI, MOH (2002). Assessment of the pharmaceutical situation in Kenya: a baseline survey
10.Gray, A (1998). Using stock cards to improve drug management http://www.hst.org.za/uploads/files/kwiksk13.pdf

What are Essential Medicines

Original definition

Essential medicines were originally defined by the World Health Organization (WHO) as those which:

satisfy the needs of the majority of the population and therefore should be available at all times, in adequate amounts, in appropriate dosage forms and at a price the individual and community can afford.

Development of the concept

The idea of defining essential medicines – and establishing a list of them – was developed from a report made to the 1975 World Health Assembly. These efforts were aimed to increase the range and availability of medicines for populations with poor access.

The Expert Committee on the Use of Essential Medicines was established to assist member states to select and procure essential medicines. In 1977, the first report of the Expert Committee included (a) criteria for determining if a medicine fit the definition of an essential medicines and (b) the first model essential medicines list (EML) as two examples of how the concept of essential medicines could be implemented.

Since then WHO has updated the model EML every two years. In 2007, thirty years after introduction of the essential medicines concept, a model EML for children was also introduced.

Adapting the concept at national level

There should be clear links between the national EML, standard treatment guidelines, national expenditure on essential medicines, and procurement practices within the country.

The model EML is expected to be adapted at national level based on the local public health context of the country. Most countries have published a national EML. Most lists have been updated in the past five years; this exercise is crucial to reflect new therapeutic options and changing therapeutic needs.

Selection of medicines for the national EML

Within a country, the selection of essential medicines is usually a two-step process. The first involves regulatory approval, which is based on a review of efficacy, safety, and quality of medicines (without comparison between medicines). From these registered products, essential medicines within a therapeutic class are then selected on the basis of comparative efficacy, safety, and cost. To best ensure the widest acceptance of the list, the selection process for essential medicines needs the involvement of a number of stakeholders, including prescribers, dispensers, academics, health facilities, civil society, professional organizations, and others.

Before 2002, relatively expensive medicines were basically not found on the WHO model EML. This was successfully challenged by public health advocates and treatment activists. With the issue abolished, traditionally more expensive medicines (such as antiretrovirals) were quickly included on the WHO model EML and the official definition of essential medicines was updated to:

Essential medicines are those that satisfy the priority health care needs of the population. They are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility.

It is also important to stress that essential medicines are not second rate medicines for poor people, but that they represent the most cost effective treatments for a given condition

Weaknesses in the concept

The essential medicines concept and the model WHO EML have often been credited for establishing priorities for developing countries on selection of, and expenditure on, medicines to meet the needs of their populations. However, there is a concern that the process has eliminated some key medicines which, although they might not be needed for the majority of the population, may be crucial for the treatment of certain diseases (such as cancer) and specific age groups (such as the elderly).

Although considerable progress has been made in the 30 years since the WHO introduced the essential medicines concept, the benefits have been inequitable. Only two-thirds of the world’s population has access to the medicines they need, leaving one-third — about 2 billion people — without access. And in the poorest parts of Africa and Asia, more than half of the population lacks access.

A renewed commitment to the essential medicines concept is urgently needed in order to realize the spirit and intention of the deliberations of 1977.

References
1.World Health Organization. The selection and use of essential medicines. Report of the WHO Expert Committee, 2002 (including the 12th Model List of Essential Medicines). Technical Report Series No 914. Geneva: WHO,
2.Hans V Hogerzeil The concept of essential medicines: lessons for rich countries
3.Laing R, Waning B, Gray A, Ford N, ‘t Hoen E. 25 years of the WHO essential medicines lists: progress and challenges. Lancet 2003 May 17;361(9370):1723-9
4.Stolk P,Willemen MJC, Leufkens HGM. “Rare essentials” : drugs for rare diseases as. Essential Medicines. Lancet 2003;361:1723-9. 4.
5.J Robertson1 and SR Hill2 The Essential Medicines List for a Global Patient population
6.Backgrounder and Facts for launch of the United Nations report Delivering on the Global Partnerships for Achieving the Millennium Development Goals: WHO
7.World medicines situation

Bottom