The adherence to effective vaccine stock management protocols in the government facilities, the availability of vaccines, and the effectiveness of the stock visibility system in OR Tambo District of the Eastern Cape Province of South Africa

Iwu, Chinwe Juliana (2019-12)

Thesis (PhD)--Stellenbosch University, 2019.

Thesis

ENGLISH SUMMARY : Effective vaccine stock management is one of the criteria for a functional vaccine supply chain. It ensures that the quality of vaccines is maintained and that vaccines are continuously available at service delivery points. The continuous availability of vaccines is a vital component of the health system which is required to achieve public health goals such as improved immunisation coverage, and universal health coverage. Reports on vaccine availability and stock management of vaccines in OR Tambo district of the Eastern Cape Province are scarce. Also, since the implementation of the mobile device for stock reporting, stock visibility solution (SVS), no study has explored the experiences of the health care workers in order to identify potential barriers and facilitators to the implementation of the system. This study was therefore aimed at assessing the vaccine stock management status as well as availability of vaccines in the OR Tambo district, in Eastern Cape Province, South Africa. As part of the literature review, we firstly gathered evidence on occurrence of vaccine stock -outs at different levels of the supply chain; the national, district, health facility level in the WHO African region. A systematic search of the literature was conducted to identify studies reporting on vaccine stock-outs at these levels. Furthermore, a cross-sectional study was conducted to assess the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care settings in the Eastern Cape province, South Africa. Data was collected from a total of 64 PHC facilities using a researcher administered questionnaire, record checks and direct observation. This was followed by a qualitative study to explore the perceptions and experiences of the SVS system amongst healthcare workers (HCWs) who are involved with managing stock levels of medicines in primary health care facilities in the Eastern Cape Province. Consequently, a scoping review was conducted to summarise currently available information on interventions for vaccine stock management. Quantitative data was managed using an electronic data capturing tool, REDCap, and descriptive statistics, and Pearson’s chi-squared test, were conducted using STATA® Version 14. The qualitative data was analysed using thematic analysis. Based on the JRF data, approximately 50% of the countries in Africa reported stock-outs of at least one vaccine for at least one month at national and district levels, in 2017. Fourteen (30%) countries reported vaccine stock-outs in 2017 at the national level. BCG vaccine is the most affected vaccine, with an increase from five countries in 2010 to 16 counties in 2015. There is an 86% chance of stock-out at the district level is caused by stock-out at the national level being linked to national level stock-outs and a 62% chance of this leading to interruption of immunisation services at the facility level. At the facility level stock-outs reports from Africa were few. We found a total of eight studies that reported vaccine stock-outs across Africa; South Africa (5); Nigeria (1); Guinea (1) and Kenya (1) and Ethiopia (1). Poor stock management, disease outbreaks, poor supply chain structure, delays in deliveries and lack of trained health personnel are possible causes of facility level stock-outs. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. However, the health care workers were reluctant to fill in the stock cards. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. The ordering system was weak; as only about half 31(49%) of the respondents understood the concept of maximum and minimum stock levels, which are needed for proper quantification of needs. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which could have contributed to stock-outs. Common reasons for delays from the depot include staff shortages at the pharmaceutical depot causing a backlog of orders, delay from the suppliers, procurement delays and possibly lack of proper communication between the depot and the facilities. 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 commonly affected vaccines in 37 (58%) and 28 (44%) facilities, respectively. Within the last two years (between February 2017- February 2019), BCG and OPV had the most prolonged median duration of 167 and 103 days, respectively. PCV experienced the most prolonged duration of stock-outs amongst the newer vaccines with a median duration of stock-outs of 85 days. Four studies met our inclusion criteria (three before-after studies and one randomised trial). Three studies were conducted in low- and middle-income countries, while one was conducted in Canada. All the studies had various limitations and were classified as having a high risk of bias. Study findings suggest that use of digital information systems to improve information and stock visibility, coupled with other interventions (such as training of health care workers on the use of innovative tools and redesign of the supply chain to tackle specific bottlenecks) have the potential to increase vaccine availability, reduce response times, and improve the quality of vaccine records. Although more of well-designed studies are needed to strengthen the evidence base. The SVS system was well understood by most HCWs, as a system for reporting stock levels to managers. They also displayed high commitment to ensuring the systems works. However, some factors were identified as potential barriers for efficient usage of the system. This includes staff shortages and high staff turnover, lack of responses from the managers, the extra workload that comes with the system, amongst others. The HCWs made various suggestions for how the system might be improved, most pertinently the need for more pharmacists and pharmacy assistants and for these cadres to be primarily in-charge of stock management and the use of the SVS. The OR Tambo district of South Africa, just like in other countries, suffers from vaccine stock-outs especially BCG, and OPV. Similarly, the lack of proper stock management linked to the use of manual stock cards, long response time from the pharmaceutical depot and inadequate fridge capacity may be responsible for stock-outs in the primary health care facilities in OR Tambo district. Interventions for improving vaccine availability should be considered, especially those focused on the factors highlighted above.

AFRIKAANSE OPSOMMING : Geen opsomming beskikbaar.

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