Why stock-out and expiration of medicines occur in developing countries – a conceptual view

This month, February 2018, the Ministry of Health in Uganda announced a major operation to collect and dispose of expired medicines from all over the country – including public health facilities and private not for profit health facilities. The revelation that over the previous years, expiration of medicines occurred in both public and private health facilities partly explains the poor availability of health commodities in the country. Indeed a 2015 report by the Uganda Ministry of Finance, Planning and Economic Development noted that the Government of Uganda is concerned about “continuous stock out” of essential medicines. The concurrent stock-out and expiration of essential medicines has undesirable public health consequences and merits systematic inquiry, more so because the phenomenon is seen in many other developing countries.

As a pharmacist, I have been asked why I did not have a medicine in stock by a patient at the dispensing window, by fellow managers throughout my career and by the public through Members of Parliament when we appeared before the relevant Parliamentary Committees when I worked at the Uganda National Medical Stores (NMS)  – and no matter who asks the question, explaining why you are stocked out of an essential medicine is an embarrassing experience! But the most challenging is when you must explain why some of the medicines expire under your watch while you are stocked out of the others. In one of the daily papers then, the columnist asked whether we should switch the managers of pharmaceutical supply chains with the attendants in our local kiosks because they appeared to know better how to keep appropriate stock levels than we did! I thought the columnist was too harsh, but I also appreciated his frustration.

It is against such background that my Doctoral research at Maastricht School of Management, Netherlands aims to explicate why stock-out and expiration of medicines occur in developing countries. I am therefore interested to offer a theoretical view on the public question of why the medicines expire in our supply chains. I hope that our views could contribute to policy interventions to minimize expiration amidst stock-out of essential medicines in Uganda and indeed other countries. In sharing this view, I also seek public opinion on what they see as the cause of stock-outs and expiration of medicines in Uganda and other developing countries – for the purpose of improving relevancy of our research.

So far, we find that pharmaceutical supply chains are complex undertakings that need to be optimally set to attain desired performance. Assessing performance requires dis-aggregated data to be collected and analyzed to show what happens in each segment of the supply chain at any specified moment in time. However, such performance measures are none existent and supply chain performance is depicted through extreme occurrences like stock-out and expiration of essential medicines.

Optimizing the supply chain requires collaboration and integration of supply chain members to deliver value for the end user. Unfortunately, there is minimal understanding and conceptualization of how collaboration and supply chain integration may be applied to pharmaceutical supply chains. Consequently, practitioners lack a plausible framework to guide interventions in the quest to improve performance. Interventions are therefore either not directed on the key performance determinants or critical aspects of the supply chain are excluded from the investments made. This results into continued under-performance despite investments made to improve the supply chains.

We then argue that gaps in performance measurement, supply chain collaboration and supply chain integration undermine flow of information, products, funds, and management decisions across the supply chain. Disruptions in flow exhibit as stock-outs, stock accumulation, and expirations in the medicines supply chains of developing countries.

To understand why stock-out and expiration of medicines occur in Uganda and other developing countries, we should be asking the following questions:

• Do we have appropriate supply chain performance indicators to inform a root cause analysis of the stock-out and expiration? If we had such indicators, we would better anticipate and prevent the occurrence of stock-out and expiration.
• How well are the key players (Ministry of Health, Central Medical Stores, Health Facilities and Financing agencies) collaborating to anticipate and prevent the occurrence of the stock-out and expiration?
• What disrupts flow of products in our pharmaceutical supply chains?
• What disrupts flow of information in our pharmaceutical supply chains?
• What disrupts flow of money in our pharmaceutical supply chains?
• What disrupts flow of decisions in our pharmaceutical supply chains?

Therefore, as we get rid of existing expired medicines from our pharmaceutical supply chains, let us ask and ponder over those questions to prevent a recurrence of stock-out and expirations. One critical intervention should be policy inquiry to answer the above questions.

Thank you.