This document discusses innovations in access to essential medicines in South Africa. It provides background on the WHO's Model List of Essential Medicines and South Africa's quadruple disease burden. It then reviews South Africa's essential medicines access challenges and potential for mobile health technologies to improve pharmaceutical supply chain management and patient access. Key findings indicate limited research on these topics and their relationships in South Africa. Mobile phone ubiquity and health policies suggest an enabling environment for mHealth, but challenges around stewardship, leadership and resources must also be addressed.

1. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
1
T u l a n e
U n i v e r s i t y
S c h o o l
o f
P u b l i c
H e a l t h
a n d
T r o p i c a l
M e d i c i n e
Innovations
in
Access
to
Essential
Medicines:
Focus
on
South
Africa
Aimee
Edmondo
MPH
Candidate
Spring
2014
Public
Health
Analysis
Culminating
Experience
Department:
Global
Health
Systems
and
Development
Focus:
Program
Design
and
Implementation
Advisor:
Nathan
Morrow

2. List
of
Acronyms
ANC
–
African
National
Congress
ARV
–
Anti
Retro
Virals
CHW
–
Community
Health
Worker
DoH
–
Department
of
Health
EDL
–
Essential
Drugs
List
EDP
–
Essential
Drugs
Programme
eHealth
–
Electronic
Health
Informatics
EML
–
Essential
Medicines
List
EMR
–
Electronic
Medical
Records
FDC
–
Fixed
Dose
Combination
HIS
–
Health
Information
System
HIM
–
Health
Information
for
Management
HIV
–
Human
Immunodeficiency
Virus
HST
–
Health
Systems
Trust
ICT
–
Information
and
Communications
Technology
iDART
–
Intelligent
Dispensing
of
Anti-­‐Retroviral
Treatment
KEMSA
–
Kenya
Medical
Supplies
Agency
LMIC
–
Low
and
Middle-­‐Income
Countries
LMIS
–
Logistics
Management
Information
System
MatCH
–
Maternal
Adolescent
and
Child
Health
mHealth
–
Mobile
health
technology
MSF
–
Medecins
Sans
Frontieres
/
Doctors
Without
Borders
MSH
–
Management
Sciences
for
Health
NCD
–
Non-­‐Communicable
Disease
NDP
–
National
Drug
Policy
NDoH
–
National
Department
of
Health
NGO
–
Non-­‐governmental
Organization
PHC
–
Primary
Health
Care
PTC
–
Pharmacy
and
Therapeutics
Committee
RCT
–
Randomized
Controlled
Trial
SMS
–
Short
Message
Service
SSA
–
Sub
Saharan
Africa
STG
–
Standard
Treatment
Guidelines
TB
–
Tuberculosis
WHO
–
World
Health
Organization

3. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
1
Abstract
South
Africa
instituted
no
cost
public
healthcare
services
in
1994,
despite
this,
South
Africa
suffers
from
a
quadruple
health
burden,
which
includes
communicable
disease,
non-­‐communicable
disease,
poor
maternal
and
child
health,
and
injury
and
death
due
to
violence.
Additionally,
South
Africa
is
home
to
the
largest
populations
of
HIV
and
TB
infected
individuals
in
the
world.
Satisfactory
health
outcomes
are
dependent
upon
reliable
access
to
health
care
and
uninterrupted
supplies
of
essential
medicines.
Recently,
advocacy
organizations
have
reported
regular
stock
outs
of
essential
medicines,
and
reviews
of
patient
experiences
in
the
public
healthcare
delivery
system
indicate
that
patients
are
required
to
repeatedly
return
to
health
facilities
to
collect
medications.
Consequently,
impoverished
patients
are
often
demoralized
and
experience
catastrophic
out
of
pocket
expenses.
In
this
analysis
mobile
technology
is
explored
as
a
potential
intervention
to
empower
patients
and
simultaneously
improve
access
to
essential
medicines
in
South
Africa.
A
qualitative
review
of
literature
from
the
last
decade
was
conducted
to
explore
essential
drugs
access
and
the
pharmaceutical
supply
chain
management
system
in
South
Africa.
Additionally,
mobile
health
technology
interventions
in
sub
Saharan
Africa
were
reviewed
for
their
feasibility
and
potential
to
improve
supply
chains.
Policy
documents
and
reports
from
advocacy
organizations
were
also
used
to
inform
this
analysis.
Over
20
documents
were
identified
for
this
public
health
analysis.
Findings
related
to
access
to
medicines
and
care,
pharmaceutical
supply
chain
systems,
and
the
role
of
mobile
health
technology
indicate
that
little
comprehensive
research
has
been
conducted
in
South
Africa
on
these
topics
and
the
relationships
between
them.
Furthermore,
few
peer-­‐reviewed
studies
have
explored
the
impact
of
healthcare
access
barriers
and
essential
medicine
shortages
in
South
Africa
on
treatment
adherence
or
overall
health
outcomes.
Widespread
mobile
phone
use,
advanced
ICT
systems,
and
government-­‐initiated
health
technology
policies
suggest
that
South
Africa
has
an
enabling
environment
to
facilitate
the
implementation
mHealth
to
improve
essential
medicines
access.
It
should
be
noted,
however,
that
limited
stewardship,
poor
leadership,
resource
constraints,
and
an
ineffective
culture
of
service
delivery
will
need
to
be

4. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
2
ameliorated
in
order
to
implement
beneficial
mHealth
innovations
to
improve
pharmaceutical
supply
chain
management.
Background
WHO
and
the
Model
List
of
Essential
Medicines
In
1975
global
concerns
about
the
availability
of
important
lifesaving
medicines
in
the
public
sector,
particularly
in
developing
countries,
led
to
a
request
by
the
World
Health
Assembly
for
the
World
Health
Organization
(WHO)
to
establish
a
model
list
of
essential
medicines.
The
first
essential
medicines
list
(EML)
was
released
in
1977.
Challenges
to
the
EML
and
changing
patterns
of
health
and
evidenced-­‐
based
practices
have
led
to
several
revisions
of
this
list
(Laing
et
al.
2003).
Today,
the
WHO
EML
is
in
its
18th
edition.
Essential
medicines
are
defined
by
WHO
as:
“Those
drugs
that
satisfy
the
priority
health
care
needs
of
the
of
the
population.
They
are
selected
with
due
regard
to
public
health
relevance,
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,
appropriate
dosage
forms,
with
assured
quality
and
adequate
information,
and
at
a
price
the
individual
and
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
(2002).”
Accordingly,
South
Africa
also
has
its
own
essential
drugs
list
(EDL)
and
associated
treatment
guidelines,
though
the
evolution
of
this
list
has
been
fraught
with
controversy
and
heavily
influenced
by
a
host
of
growing
epidemics
such
as
HIV
and
TB
(Laing
et
al.
2003).
Primary
Health
Care
and
the
Essential
Drugs
List
in
South
Africa
Following
democratic
transition
in
South
Africa
in
1994,
the
African
National
Congress
(ANC)
proposed
a
plan
for
national
health
services
based
on
the
concept
of
primary
health
care
(PHC)
promoted
at
Alma
Ata.
Through
this
plan,
the
National
Department
of
Health
(NDoH)
sought
to
address
the
unequal
distribution
of
health
services,
infrastructure,
monetary,
and
human
resources
resulting
from
Apartheid.
No
cost
PHC
became
available
to
the
public
though
a
district
health
system
following
the
construction
and
upgrading
of
over
1,500
clinics
(Coovadia
et
al.
2009).
In
1996
South
Africa
released
the
National
Drug
Policy
(NDP),
which
outlined
changes
in
drug
management
and
detailed
a
host
of
legislative
and
regulatory
priorities.
One
of
these
priorities
involved
the
establishment
of
a
representative
committee

5. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
3
to
produce
standard
treatment
guidelines
(STGs)
from
which
the
medicines
to
be
included
in
the
PHC
EDL
would
be
extracted.
The
first
editions
of
these
documents
were
released
in
April
of
1996
(Gray
&
Suleman
2000,
Essack
et
al.
2011).
Though
the
national
PHC
EDL
and
STGs
are
regularly
reviewed
and
updated,
limited
political
will,
patent
policies,
and
inequitable
resources
mean
that
some
essential
drugs
are
less
accessible
than
others.
HIV
has
been
a
prominent
issue
in
the
EDL
process.
Today
there
are
clear
STGs
for
HIV
and
TB
and
policy-­‐
based
strategic
plans
at
the
national
and
provincial
level
in
South
Africa,
but
at
one
time
anti-­‐retrovirals
(ARVs)
were
considered
too
expensive
for
public
use.
For
example,
in
the
1998
PHC
EDL
it
is
noted
that
“these
medicines
are
very
costly
and
cannot
be
provided
on
a
mass
scale
by
the
public
health
services…
they
may
only
be
provided
on
a
limited
and
selected
basis
or
for
academic
and
research
purposes
only”
(Laing
et
al.
2003).
Fortunately,
the
World
Health
Assembly
approved
a
Revised
Drug
Strategy
in
May
of
1999,
which
allows
for
interpretation
of
the
World
Trade
Organization
(WTO)
TRIPS
agreement
based
on
priority
global
health
concerns
(Hoen
et
al.
2011).
This
has
greatly
reduced
the
cost
of
ARVs
and
allowed
South
Africa
to
establish
a
national
ARV
program
in
2003
with
assistance
from
foreign
donors.
With
over
2.1
million
people
initiating
ARV
treatment
in
South
Africa
in
2012,
it
is
the
largest
program
of
its
kind.
Health
Service
Delivery
and
the
Health
Status
of
South
Africa
Multiple
reviews
on
the
process
of
implementing
post-­‐Apartheid
national
health
services
in
South
Africa
have
indicated
that
progress
is
slow,
uneven,
and
faces
multiple
difficulties.
(Gray
&
Suleman
2000,
Coovadia
et
al.
2009,
Levitt
N,
2011).
Major
setbacks
in
implementation
have
included
confusion
about
responsibilities
within
the
district
health
system.
In
the
2004
National
Health
Act,
the
NDoH
is
identified
as
the
sole
responsible
party
for
national
health
policy,
while
public
health
service
delivery
was
deemed
a
provincial
responsibility.
Within
the
national
pharmaceutical
program,
NDoH
is
responsible
for
the
tender
process,
while
provincial
governments
are
responsible
for
ordering,
storage,
and
distribution
of
medicines.
Additional
national
health
care
challenges
include
skilled
human
resource
shortages,
unequal
distribution
of
resources
–
with
very
few
at
the
rural
community
or
primary
level,
and
poor
human
resource
management.
Though
perhaps
more
damaging
has
been
a
historical
lack
of
stewardship
and
leadership
within
the
health
system
at
a
national
level
(Coovadia
et
al.
2009).

6. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
4
Though
South
Africa
is
considered
a
high-­‐middle
income
country,
its
health
outcomes
are
worse
than
many
low-­‐income
countries.
Currently
South
Africa
faces
a
quadruple
epidemic,
which
includes
communicable
disease
(such
as
HIV
and
TB),
injury
and
death
due
to
violence,
diseases
of
poverty
(such
as
poor
maternal
and
child
mortality
and
morbidity),
and
rising
non-­‐communicable
chronic
diseases
related
to
diet
and
lifestyle.
South
Africa
is
home
to
the
largest
number
of
HIV
infected
individuals
in
the
world,
with
an
estimated
6.1
million
infected.
Additionally,
over
60%
of
TB
patients
are
found
to
be
co-­‐infected
with
HIV
(UNAIDS
2012).
The
need
for
uninterrupted
supplies
of
essential
medicines,
particularly
for
South
Africa’s
growing
burden
of
chronic
communicable
and
non-­‐communicable
disease,
is
evident.
Rationale
South
Africa’s
overburdened
and
under-­‐resourced
public
healthcare
system
regularly
struggles
to
meet
the
demands
of
the
public.
In
addition,
poor
pharmaceutical
logistics
and
supply
chain
management
impedes
the
ability
of
patients
to
adhere
to
treatment
regimes,
and
when
combined
with
poverty,
often
deters
highly
vulnerable
households
from
engaging
in
health
seeking
behavior
(Goudge
et
al.
2009).
Regular
stock
outs
of
essential
medicines
at
the
facility
and
depot
level
put
patients
at
risk
of
developing
poor
health
outcomes
and
increase
the
probability
of
drug
resistance.
Moreover,
smaller
rural
clinics
serving
traditionally
impoverished
areas
are
particularly
vulnerable
to
stock
outs
because
they
are
downstream
recipients
of
medicines
from
larger
facilities
such
as
municipal
and
district
hospitals
(MSF
et
al.
2013).
Multiple
reviews
on
access
to
care
in
South
Africa
indicate
that
poverty,
poor
healthcare
service
delivery,
and
a
lack
of
clear
information
from
providers
disempower
patients.
In
order
to
improve
the
disease
burden
in
South
Africa
these
reviews
indicate
that
novel
and
innovative
approaches
to
improve
health
services
are
needed
(Goudge
et
al.
2009,
Coovadia
et
al.
2009,
Mayosi
et
al.
2009,
Schneider
et
al.
2006).
Mobile
health
technology
(mHealth)
is
a
growing
field.
Innovative
uses
of
technology
have
improved
information
flow,
allowed
for
timely
and
accurate
methods
of
data
collection,
and
have
connected
consumers
with
providers.
Recent
pilot
programs
have
looked
at
how
mobile
technology
can
increase
access
to
medicines
by
improving
accountability
within
the
supply
chain
of
pharmaceuticals
(Barrington
et
al.
2010).
Given
that
there
are
29
million
mobile
phone
users
in
South
Africa,
a
noted
increase
from
17%
to
76%
amongst
adults
in
the
past
decade,
it
would
be
advantageous
to
explore
the
ways
in
which

7. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
5
mHealth
can
both
empower
patients
and
improve
access
to
medicines
in
low
resource
settings
in
South
Africa
(KMPG
South
Africa
2013).
Competencies
The
competencies
to
be
developed
by
this
analysis
into
essential
medicines
access
in
South
Africa
are
as
follows:
Program
Design
and
Implementation
competencies:
• Identify
program/project
goals,
objectives,
strategies,
activities
and
resource
requirements
for
interventions
that
target
key
global
health
problems.
• Develop
management
systems
for
interventions
that
address
priority
global
health
problems.
• Identify
information
requirements
for
design,
implementation,
and
evaluation
of
global
health
programs.
• Apply
design
and
implementation
principals
and
approaches
to
a
specific
program
area
within
global
health.
Topic-­‐specific
competencies:
• Develop
an
understanding
of
the
supply
chain
management
system
for
essential
medicines
on
the
national,
provincial,
and
district
level
in
South
Africa.
• Conduct
a
landscape
analysis
of
the
current
health
issues
in
South
Africa
as
they
relate
to
essential
medicines
access.
• Review
the
existing
systemic
and
social
challenges
to
essential
medicine
access.
• Research
and
compile
best
practices
regarding
the
use
of
mobile
technology
in
low-­‐resource
setting
to
improve
health
outcomes
and
access
to
essential
medicines.
Methodology
Literature
in
this
analysis
was
located
utilizing
the
databases
PubMed
and
Google
Scholar.
Peer
reviewed
journal
articles
were
limited
to
the
past
decade
(2004
to
2014),
with
some
exceptions
such
as
those
related
to
policies
implemented
prior
to
2004.
Database
searches
included
the
following
terms
and
phrases:
• South
African
drug
policy
• Pharmaceutical
supply
chain
management
in
South
Africa
• Access
to
essential
medicines
in
South
Africa
• Access
to
health
care
in
South
Africa
• Medication
stock
outs
in
South
Africa

8. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
6
• Mobile
technology
and
medicines
access
• Mobile
health
in
South
Africa
• Monitoring
distribution
of
essential
medicines
• Health
impacts
of
medication
stock
outs
in
South
Africa
Publications
regarding
essential
medicines
and
pharmaceutical
supply
chain
systems
from
multilateral
institutions
such
as
the
World
Health
Organization
(WHO)
and
international
agencies
were
also
considered
in
this
analysis.
In
addition,
applicable
policy
briefs,
news
stories,
information
regarding
mobile
health
technology
programs,
and
government
documents
were
accessed
via
the
online
websites
of
the
South
African
National
Department
of
Health
(NDoH),
associated
press,
private
technology
enterprises,
and
advocacy
organizations.
Results
and
Discussion
Findings
from
a
review
of
literature
related
to
access
to
medicines
and
care,
pharmaceutical
supply
chain
systems,
and
the
role
of
mobile
health
technology
indicate
that
little
comprehensive
research
has
been
conducted
in
South
Africa
on
these
topics
and
the
relationships
between
them.
Furthermore,
few
peer-­‐reviewed
studies
have
explored
the
impact
of
healthcare
access
barriers
and
essential
medicine
shortages
in
South
Africa
on
treatment
adherence
or
overall
health
outcomes.
Topics
that
repeatedly
appeared
in
literature
searches
regarding
access
to
care
in
the
context
of
South
Africa
included
human
resource
challenges
and
the
role
of
leadership
and
stewardship
in
health
systems
strengthening.
Table
1:
Literature
sources
by
topic
Document
Year
Location
Source
Type
Access
to
Care
Access
to
Medicines
Pharmaceutical
Supply
Chain
Mobile
Health
Technology
Health
Outcomes
Aronovich
&
Kinzett
2001
Kenya
Report
X
Barnighausen
et
al
2012
N/A
Peer
Reviewed
Journal
X
Barrington
et
al
2010
Tanzania
Peer
Reviewed
Journal
X
X
X
Demiris
et
al
2008
USA
Peer
Reviewed
Journal
X
X
Embrey
et
al
2009
Global
Peer
Reviwed
Journal
X

9. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
7
Essack
et
al
2011
South
Africa
Peer
Reviewed
Journal
X
Goudge
et
al
2009
South
Africa
Peer
Reviewed
Journal
X
X
Gray
&
Suleman
2000
South
Africa
Report
X
Harris
et
al.
2011
South
Africa
Peer
Reviewed
Journal
X
Hozerzeil
et
al.
2013
Global
Peer
Reviewed
Journal
X
Kaplan
2006
Global
Peer
Reviewed
Journal
X
X
Leon
et
al.
2012
South
Africa
Peer
Reviewed
Journal
X
Levitt
et
al
2011
South
Africa
Peer
Reviewed
Journal
X
X
MSF
et
al
2013
South
Africa
Report
X
X
X
MSF
et
al.
2013
South
Africa
Report
X
X
NDoH
2012
South
Africa
Report
X
NDoH
2011
South
Africa
Report
X
X
Pharasi
&
Miot
2013
South
Africa
Report
X
Schneider
et
al
2006
Souther
n
Africa
Region
Peer
Reviewed
Journal
X
X
X
Steyn
et
al.
2009
South
Africa
Peer
Reviewed
Journal
X
X
Access
to
Medicines
and
Health
Care
in
South
Africa
An
initial
search
for
literature
related
to
access
to
medicines
in
South
Africa
yielded
few
results.
Therefore,
studies
related
to
public
sector
health
care
access
in
South
Africa
have
been
used
as
a
proxy
for
essential
medicines
access.
These
works
have
been
combined
with
reports
from
advocacy
organizations
that
address
nationwide
pharmaceutical
stock
outs.

10. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
8
Despite
the
great
strides
that
South
Africa
has
made
since
its
democratic
transition
from
Apartheid
in
1994,
health
outcomes
remain
unsatisfactory.
While
the
South
African
constitution
assures
state
sponsored
PHC
for
all,
uneven
resource
allocation,
inadequate
infrastructure,
and
skilled
human
resource
shortages
continue
to
plague
the
system.
It
is
recognized
that
equitable
universal
health
care
must
be
affordable,
available,
and
acceptable
to
recipients
of
services.
The
public
health
care
system
in
South
Africa
rarely
meets
these
requirements,
particularly
for
chronically
ill
patients
(Harris
et
al.
2011,
Goudge
et
al.
2009).
Affordability
Affordability
is
a
key
component
of
accessible
health
care.
While
PHC
services
are
offered
to
the
public
at
no
cost,
there
are
often
catastrophic
out
of
pocket
expenses
that
affect
the
most
vulnerable
and
impoverished
populations
in
South
Africa.
Due
to
an
inequitable
distribution
of
infrastructure
and
resources
many
individuals,
especially
those
in
rural
areas,
are
unable
to
access
care
due
to
public
transport
costs.
For
individuals
in
lower
wealth
quintiles
in
South
Africa,
transport
costs
and
distance
to
PHC
clinics
are
likely
to
be
higher
than
those
for
individuals
in
the
uppermost
quintiles
-­‐
who
are
generally
closer
to
secondary
and
tertiary
facilities
and
are
more
likely
to
utilize
private
modes
of
transportation.
With
high
rates
of
unemployment
(currently
24.5%
nationally),
many
households
in
rural
areas
are
reliant
upon
government
funded
social
grants
as
a
sole
source
of
income.
When
transport
costs
are
combined
with
limited
availability
of
services
and
interrupted
drug
supplies,
these
cost
burdens
can
account
for
6%
to
60%
of
household
expenditure
in
any
given
month
depending
on
the
number
of
repeated
trips
to
obtain
medicines
and
care.
Private
healthcare
services
are
also
frequently
secondary
sources
of
out
of
pocket
expenses
for
vulnerable
groups
that
are
dissatisfied
with
publicly
funded
PHC.
In
South
Africa
private
healthcare
services
function
alongside
public
services,
delivering
care
to
those
with
private
insurance
schemes
or
individuals
with
the
ability
to
pay.
These
catastrophic
costs
can
increase
household
vulnerabilities
and
food
insecurity
for
low-­‐income
families.
For
individuals
without
sufficient
financial
resources,
care
is
often
sought
intermittently,
despite
higher
rates
of
infectious
and
non-­‐communicable
disease
(NCD)
within
these
lower
wealth
quintiles
(Harris
et
al.
2011,
Goudge
et
al.
2009,
MSF
et
al.
2013).
Availability
Availability
of
healthcare
refers
to
the
quantity
of
fully
functioning
public
facilities,
goods,
and
services.
In
an
effort
to
bolster
PHC
services,
several
hundred
rural
primary
clinics
were
built
to
improve
access
for
underserved
areas.
Unfortunately,
these
rural
clinics
are
plagued
with
health
system
weaknesses

11. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
9
and
frequently
lack
adequate
infrastructure
and
skilled
service
providers.
In
South
Africa
the
number
of
doctors,
pharmacists,
and
nurses
required
for
the
public
healthcare
system
to
function
outstrip
the
number
of
available
professionals.
Furthermore
many
of
the
national
human
resource
challenges
do
not
reflect
the
disparities
within
South
Africa
–
many
of
these
healthcare
professionals
work
in
urban
areas,
leave
the
government
system
to
provide
care
in
the
for-­‐profit
private
sector,
or
choose
to
practice
outside
of
the
country.
Over
85%
of
the
South
African
population
is
reliant
upon
public
services,
and
yet
the
private
system
employs
70%
of
the
doctors
in
the
country.
Similarly,
only
29%
of
registered
pharmacists
work
in
the
public
sector.
National
public
sector
vacancy
rates
for
doctors
and
nurses
are
currently
56%
and
46%
respectively,
and
there
are
roughly
8
pharmacists
providing
services
per
100,000
people
(George
et
al.
2009,
FIP
2012,
Gray
&
Suleman
2000,
Schneider
et
al.
2006).
Few
studies
have
explored
healthcare
service
availability
from
a
beneficiary
perspective,
of
those
that
have,
drug
stock
outs
were
frequently
noted
as
deterrents
to
care
(Schnieder
et
al.
2006,
Goudge
et
al.
2009,
MSF
et
al.
2013).
Two
of
the
national
core
standards
for
pharmaceutical
services
at
health
facilities
in
South
Africa
ensure
that,
“medicines
and
medical
supplies
are
in
stock
and
their
delivery
is
reliable,
and
that
stock
levels
and
storage
are
managed
appropriately”
(NDoH
2011).
In
surveys
performed
by
patient
advocacy
organizations,
it
was
found
that
21%
of
facilities
nationwide
had
experienced
shortages
or
stock
outs
of
HIV
and
TB
medication,
with
some
rural
provinces
reporting
stock
out
rates
of
over
50%.
Vaccine
availability
was
surveyed
as
a
proxy
for
other
essential
medicines.
Nationally,
14.7%
of
facilities
had
experienced
shortages
and
stock
outs
of
vaccines.
Again,
rural
provinces
experienced
higher
vaccine
stock
out
rates
at
over
30%
(MSF
et
al.
2013).
Similarly,
in
a
2011
baseline
audit
of
national
health
care
facilities
77%
of
clinics,
70%
of
community
health
centers,
and
98%
of
hospitals
did
not
have
EDL
tracer
medications
available
in
the
pharmacy
or
medication
storage
room
(HST
et
al.
2012).
Patients
utilizing
the
public
PHC
system
report
that
they
are
frequently
sent
home
from
health
facilities
without
medication
or
told
to
return
at
a
later
date.
Some
patients
who
are
reliant
on
lifesaving
medications
resort
to
paying
out
of
pocket
for
essential
medicines
at
private
pharmacies.
For
chronic
patients
living
in
poverty,
availability
is
directly
related
to
affordability,
as
out
of
pocket
expenses
for
repeated
attempts
to
obtain
medication
can
be
devastating
for
the
entire
household.
Furthermore,
a
lack
of
medication
and
supplies
is
demoralizing
for
health
workers
who
are
unable
to
provide
necessary
services.
Stock
outs
cause
relationships
between
patients
and
providers
to
become
strained,
particularly
because
patients
consider
access
to
medication
as
an
indicator
of
the
overall
state
of
the
public
health
system
(Steyn
et
al.
2009,
Goudge
et
al.
2009,
Levitt
et
al.
2011,
MSF
et
al.
2013).

12. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
10
Acceptability
Studies
indicate
that
anticipated
disrespect
and
ineffective
care
from
providers
counteracts
health-­‐
seeking
behavior
amongst
patients
accessing
public
services
in
South
Africa.
Long
wait
times,
unsanitary
facilities,
and
a
lack
of
privacy
and
confidentiality
were
also
reported
amongst
patients
expressing
dissatisfaction
with
public
health
services.
Productive
patient-­‐provider
relations
are
lacking
in
South
Africa
largely
due
to
overburdened
health
care
professionals
resulting
from
human
resource
constraints.
However,
it
should
be
noted
that
differences
between
sociocultural
norms
amongst
providers
and
patients
also
have
a
large
role
to
play
in
the
acceptability
of
services
and
the
belief
in
the
efficacy
of
treatment
regimes
amongst
patients.
A
lack
of
communication
and
understanding
can
also
negatively
shape
the
patient-­‐provider
interaction.
Without
clear
information
patients
feel
that
they
are
unable
to
advocate
for
themselves
and
often
feel
disempowered.
Such
feelings,
when
combined
with
medicine
and
supply
shortages
can
potentially
ruin
the
trust
and
relationship
between
provider
and
patients
(Schneider
et
al.
2006,
Goudge
et
al.
2009,
Harris
et
al.
2011,
MSF
et
al.
2013).
Pharmaceutical
Supply
Chain
Management
in
South
Africa
The
public
sector
drug
regulatory
system
in
South
Africa
is
founded
upon
the
National
Drug
Policy
of
1996
(NDP).
The
NDP
outlines
objectives
to
improve
the
availability
and
accessibility
of
essential
medicines,
quality
assurance
measures,
and
rational
use
of
medicines.
Initially,
the
primary
goals
of
the
NDP
were
to
establish
an
Essential
Drugs
Programme
(EDP)
and
to
develop
an
Essential
Drugs
List
(EDL)
and
Standard
Treatment
Guidelines
(STGs).
Compiled
and
reviewed
regularly
by
experts
on
the
EDL
committee,
these
documents
serve
as
the
foundation
of
essential
medicines
access
at
primary
care
and
hospital
level
facilities.
The
process
of
procurement
and
distribution
of
medicines
begins
at
the
hospital
level,
where
the
Pharmacy
and
Therapeutics
Committee
(PTC)
at
each
hospital
submits
orders
and
expected
drug
needs
to
the
NDoH.
Hospital
demands
form
the
basis
of
the
medicine
quantities
requested
in
the
tender
process.
The
NDoH
then
manages
a
competitive
tender
process
with
pharmaceutical
suppliers.
Once
tenders
are
awarded,
suppliers
distribute
medicines
to
each
of
the
nine
provincial
government
warehouse
depots.
The
various
provincial
DoH
offices
manage
tenders
with
private
logistics
companies
to
run
the
pharmaceutical
depots.
In
most
provinces,
medicines
will
also
be
distributed
to
smaller
district-­‐level
depots
and
hospitals,
from
which
small
rural
PHC
clinics
will
then
request
stock.
These

13. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
11
steps
can
be
visualized
within
the
pharmaceutical
management
framework
proposed
by
Management
Sciences
for
Health
(MSH)
(Figure
1)
(Essack
et
al.
2011).
Figure
1:
Pharmaceutical
Management
Framework
(Source:
MSH)
Various
problems
at
every
level
of
the
supply
chain
compound
medicine
access
issues
for
patients
at
the
rural
PHC
level.
While
selection
is
based
on
the
South
African
EDL
and
STGs,
government
tenders
are
often
issued
for
several
hundred
other
medicines
that
are
not
associated
with
the
EDL
(Gray
&
Suleman
2000).
It
is
not
clear
whether
this
inefficiency
is
due
to
oversight
or
a
need
to
evaluate
the
tender
process.
In
a
review
of
tenders
for
antibiotics
from
2007
to
2011
it
was
discovered
that
hospital
PTC
requests
for
antibiotics
have
seen
little
change,
despite
expected
increases
(Essack
et
al.
2011).
Recently,
there
have
been
instances
in
which
pharmaceutical
suppliers
have
been
unable
to
deliver
on
tenders
that
have
been
offered
to
them.
In
early
2013,
several
thousand
clinics
reported
shortages
of
the
newly
introduced
fixed
dose
combination
(FDC)
ARVs
because
the
sole
supplier
could
not
produce
enough
of
the
FDC
pills
according
to
the
scheduled
contract.
In
2012,
the
Limpopo
provincial
pharmaceutical
depot
was
placed
under
administration
and
the
private
logistics
company
contract
was
cancelled
when
it
was
discovered
that
millions
of
Rand
in
expired
medication
were
destroyed
because
they
were
not
distributed
to
facilities.
Also
in
2012,
staff
at
a
district
pharmaceutical
depot
in
the
Eastern
Cape
staged
a
month
long
strike
followed
by
DoH
suspensions
for
75%
of
the
staff.
A
mere
10
working
staff
members
remained
to
provide
services
to
300
medical
facilities
that
provide
ARVs
to
over
100,000
patients.
Three
months
following
the
strike
over
53%
of
facilities
served
by
the
depot
reported
experiencing
TB
and
ARV
stock
outs
(MSF
et
al.
2013).
At
the
distribution
level,
communication
issues
between
the
provincial
and
district
depots
and
facilities
have
resulted
in
drugs
not
ordered
on
time
or
not
ordered
at
all.
These
delays
are
particularly
difficult
for
remote
PHC
facilities,
where
supply

14. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
12
deliveries
occur
on
a
monthly
basis.
Despite
the
use
of
human
resources
task
shifting
and
sharing
in
the
public
healthcare
sector,
these
stock
issues
are
made
more
difficult
by
a
lack
of
skilled
health
professionals
such
as
pharmacists.
It
is
clear
that
national
and
provincial
pharmaceutical
supply
chain
management
is
fragmented.
There
are
no
clear,
cohesive,
or
systematic
national
standards
or
procedures
for
stock
monitoring
and
reporting.
Many
medicine
shortages
and
stock-­‐outs
are
underreported,
which
only
exacerbates
access
issues,
puts
patients
at
risk
for
poor
health
outcomes,
and
inadvertently
leads
to
increased
drug
resistance
and
communicable
infections.
Mobile
Technologies
and
Health
Globally,
pervasive
interest
in
information
and
communications
technologies
(ICT)
in
health
and
development
has
grown
considerably.
Enthusiasm
for
mHealth
is
based
upon
the
ability
to
rapidly
collect,
store,
and
collate
information
in
a
short
amount
of
time
from
remote
locations.
The
widespread
use
of
basic
mobile
phones,
and
the
limited
level
of
skill
or
literacy
required
to
use
them,
suggest
that
they
are
convenient
mediums
for
data
collection
or
limited
information
transfer
amongst
diverse
populations
in
low
resource
settings
(Kaplan
2006,
Leon
et
al.
2012).
Furthermore,
the
role
of
mHealth
as
a
means
to
engender
a
transition
from
the
role
of
patients
as
passive
recipients
of
health
care
services
to
active
participants
suggests
an
opportunity
for
empowerment
(Demiris
et
al.
2008).
Despite
broad
based
policy
and
debate
regarding
ICT
for
health
and
development,
many
innovative
uses
of
mHealth
have
been
confined
to
small
pilot
programs
and
studies
conducted
within
the
non-­‐profit
sector.
Due
to
the
small
scale
of
these
studies
and
their
diverse
approaches
to
the
use
of
mHealth,
it
is
difficult
to
generalize
about
the
efficacy,
value,
and
impact
of
scaled
mHealth.
With
the
exception
of
small
mHealth
treatment
adherence
programs
for
HIV
and
TB,
there
is
scant
literature
on
the
use
of
mHealth
to
improve
health
outcomes
for
chronic
communicable
and
non-­‐communicable
diseases
in
low
and
middle-­‐income
countries
(LMIC).
Notwithstanding
the
success
of
several
pilot
projects,
few
studies
have
researched
the
use
of
mobile
technology
to
improve
pharmaceutical
stock
levels
on
a
large
scale.
While
there
are
small
advocacy
projects
run
by
local
and
international
civil
society
organizations
that
encourage
patient
reporting
of
stock
outs,
there
are
no
systems
of
accountability
that
allow
for
bidirectional
communication
between
patients
and
providers
to
manage
pharmaceutical
stock
(Kaplan
2006,
Barringson
et
al.
2010,
Leon
et
al.
2012).

15. INNOVATIONS
IN
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ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
13
There
is
great
potential
for
the
implementation
of
mHealth
technology
in
South
Africa
for
the
following
reasons:
(1)
At
76%
saturation,
mobile
phone
use
in
South
Africa
is
prevalent
in
both
rural
and
urban
settings.
(2)
In
comparison
to
other
LMICs,
the
ICT
industry
is
relatively
well
developed
and
there
are
diverse
mobile
network
providers.
(3)
Lastly,
there
is
an
enabling
policy
environment
for
implementing
mHealth
(Leon
et
al.
2012).
In
2012
the
National
Department
of
Health
released
the
eHealth
Strategy
for
South
Africa.
This
document
provides
a
review
of
policies
and
a
strategic
approach
for
the
use
of
electronic
health
informatics
in
South
Africa’s
public
healthcare
system.
Within
this
report,
a
situational
analysis
of
South
Africa’s
capacity
for
eHealth
is
provided.
The
report
also
defines
the
ways
in
which
eHealth
interventions
can
contribute
to
the
strategic
objectives
of
the
NDoH.
Suggested
interventions
include
a
drug
supply
and
logistics
support
system,
an
electronic
medical
records
(EMR)
and
pharmacy
system
interface,
an
SMS
patient
reminder
system
for
appointments
and
medicines,
and
a
communication
mechanism
for
community
health
workers
(CHWs).
In
a
review
of
mHealth
in
South
Africa,
Leon
et
al.
is
critical
of
inherent
health
system
challenges
that
create
barriers
to
successful
implementation
of
mHealth
interventions.
These
challenges
include
the
need
for
leadership
and
stewardship,
the
current
culture
of
healthcare
service
delivery,
requisite
systems
of
sustainable
funding,
and
the
ability
to
integrate
mHealth
interventions
with
existing
health
information
systems
(HIS)
(Figure
2).
Figure
2:
Health
systems
framework
for
making
decisions
about
mHealth
(Source:
Leon
et
al.)

16. INNOVATIONS
IN
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TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
14
In
the
context
of
mHealth
for
community-­‐based
health
services,
Leon
et
al.
has
the
following
points
to
make
about
each
health
system
dimension:
• Stewardship
–
The
majority
of
mHealth
interventions
conducted
in
South
Africa
have
been
initiated
by
non-­‐governmental
organizations
(NGOs).
Accordingly,
they
were
conducted
on
a
small
scale
and
did
not
involve
the
larger
public
health
system,
nor
did
they
require
policy
support
from
the
government.
Although
the
NDoH
has
released
an
eHealth
strategy,
there
remains
a
lack
of
high-­‐level
political
and
financial
support
from
the
government
for
implementation
of
mHealth.
Stewardship
also
requires
a
commitment
to
establishing
public-­‐
private
partnerships,
securing
funding,
and
the
identification
of
best
practices
for
mHealth
interventions.
• Organizational
–
Although
the
goal
of
mHealth
is
to
improve
the
efficiency
of
health
systems,
the
introduction
of
mHealth
interventions
present
new
management
challenges.
Poor
health
outcomes
in
South
Africa
are
largely
attributed
to
organizational
weaknesses,
such
as
a
lack
of
management
and
accountability
resulting
in
inadequate
service
delivery.
Furthermore,
healthcare
professionals
at
the
district
and
provincial
levels
have
demonstrated
difficulties
utilizing
existing
health
information
for
management
(HIM).
• Technological
–
Implementing
new
large-­‐scale
mHealth
programs
require
user-­‐friendly
platforms
for
diverse
stakeholder
populations.
Stakeholders
at
all
levels
must
also
believe
in
the
usefulness
of
the
technology
and
the
data
it
produces.
It
is
important
that
a
new
intervention
have
the
ability
to
seamlessly
integrate
into
existing
HIS.
This
is
a
difficult
obstacle
to
overcome
in
South
Africa,
where
patient
management
systems
are
different
for
each
provincial
DoH
(Figure
3).
Figure
3:
Patient
Management
Systems
by
Province
(Source:
NDoH)

17. INNOVATIONS
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ESSENTIAL
MEDICINES:
FOCUS
ON
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15
• Financial
–
As
noted
previously,
most
mHealth
interventions
in
South
Africa
have
been
small-­‐
scale
pilot
projects
initiated
by
NGOs
with
independent
funders.
Establishing
long-­‐term
funding
for
large
scale
mHealth
will
be
problematic
in
a
system
that
already
exhibits
inadequate
stewardship.
Pharmaceutical
Supply
Chain
Management
mHealth
Innovations
in
Sub
Saharan
Africa
SMS
for
Life
‘SMS
for
Life’
is
a
pilot
study
that
was
conducted
in
Tanzania
for
21
weeks
in
2009
and
2010.
The
mHealth
intervention
focused
on
improving
stock
of
anti-­‐malarial
medication
at
the
health
facility
level
utilizing
SMS
messages
and
electronic
mapping.
Stock
counts
were
conducted
at
each
facility
on
a
weekly
basis
and
then
reported
via
SMS
messages.
District
management
teams
were
able
to
view
stock
levels
through
a
web-­‐based
reporting
tool
that
assimilated
data
from
SMS
messages
at
each
facility
(Figure
4).
Figure
4:
Schematic
of
SMS
system
in
'SMS
for
Life'
pilot
(Source:
Barrington
et
al.)
Weekly
stock
visibility
allowed
district
medical
officers
to
redistribute
anti-­‐malarial
medications
between
facilities,
thereby
reducing
the
risk
of
stock
outs.
The
‘SMS
for
Life’
pilot
involved
129
health
facilities
in
three
districts.
At
the
beginning
of
the
program
78%
of
facilities
experienced
stock
outs
of
one
or
more
anti-­‐malarial
medication,
and
at
the
end
of
week
21
only
26%
of
facilities
reported
stock
outs.
Stock
reporting
via
SMS
remained
high
at
over
93%
for
the
duration
of
the
pilot,
though
this
was
likely
due
to

18. INNOVATIONS
IN
ACCESS
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ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
16
mobile
credit
incentives.
‘SMS
for
Life’
was
a
public-­‐private
partnership
between
the
Ministry
of
Health
and
Social
Welfare’s
National
Malaria
Control
Programme,
the
Roll
Back
Malaria
Partnership,
Novartis
Pharma
AG,
Vodafone,
and
IBM.
Barrington
et
al.
credit
government
commitment,
adequate
mobile
telephone
coverage,
the
use
of
personal
phones,
airtime
credit
incentives,
effective
training
sessions,
and
adequate
health
facility
storerooms
as
project
implementation
success
factors
(2010).
The
‘SMS
for
Life’
model
has
expanded
to
include
other
medicines
and
is
currently
being
piloted
in
other
SSA
countries.
KEMSA
In
2001
the
Kenyan
government
decided
to
create
a
parastatal
agency
to
procure,
store,
manage,
and
distribute
medical
supplies
to
public
health
facilities
using
private
sector
logistics
and
management
techniques
(Aronovich
&
Kinzett
2001).
This
agency
is
known
as
the
Kenyan
Medical
Supplies
Agency
(KEMSA),
and
in
2013
it
became
a
state
corporation
under
the
KEMSA
Act
of
2013.
A
decentralization
of
health
services
funding
and
operations
to
the
county
level
was
one
of
the
rationalizations
in
establishing
KEMSA.
Under
the
new
system
KEMSA
is
responsible
for
procuring
supplies
with
its
own
funds,
ordering
from
KEMSA
is
then
completed
by
counties
according
to
their
needs.
County
governments
pay
KEMSA
for
the
supplies
and
are
accountable
for
the
cost
of
distribution.
KEMSA
replenishes
stock
through
profits
from
sales
to
counties.
KEMSA
start
up
costs
were
sponsored
by
the
World
Bank’s
Health
Sector
Support
Project.
Also
in
2013,
KEMSA
announced
the
launch
of
KEMSA
E-­‐Mobile,
a
partnership
between
the
Center
for
Disease
Control
Foundation,
mHealth
Kenya,
Safaricom,
Fintech,
Dazzle,
and
SafeMark.
KEMSA
E-­‐Mobile
is
a
series
of
applications
and
platforms
that
allow
public
health
facilities
and
Kenyan
Citizens
to
interact
with
KEMSA’s
logistic
management
information
system.
At
the
health
facility
level,
consumption
can
be
reported
and
supplies
can
be
ordered
via
mobile
phone,
this
facility
level
information
is
then
made
available
to
county
health
management
teams.
For
Kenyan
Citizens,
KEMSA’s
E-­‐Mobile
program
provides
a
level
of
transparency
and
integrity,
allowing
them
to
anonymously
report
suspicious
or
inappropriate
supply
issues
at
health
facilities
and
to
inquire
about
drug
availability
at
their
closest
facility
via
mobile
phone.
A
comprehensive
review
of
KEMSA’s
E-­‐Mobile
initiative
has
not
been
released
due
to
the
recent
introduction
of
the
program.
iDART
by
Cell
Life
Intelligent
dispensing
for
antiretroviral
treatment
(iDART)
is
a
software
program
developed
by
Cell
Life
in
collaboration
with
the
Desmond
Tutu
HIV
Foundation,
Cape
Peninsula
University
of
Technology,
and
the
University
of
Cape
Town
to
improve
the
dispensing
of
ARVs
and
treatment
adherence
within
the
public

19. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
17
health
care
sector
in
South
Africa.
The
system
is
intended
to
allow
pharmacists
to
readily
and
accurately
dispense
ARVs,
manage
EDL
stock
levels,
and
generate
reports
for
a
growing
number
of
HIV
patients.
iDART
requires
either
direct
dispensing
of
ARVs
or
pre-­‐packaged
remote
dispensing
with
unique
barcodes
that,
when
scanned,
collect
patient
information.
The
iDART
system
is
compatible
with
DoH
monitoring
and
evaluation
mechanisms,
thereby
allowing
for
improved
reporting
for
the
government
and
international
donors.
In
2010
the
Canadian
International
Development
Agency,
in
collaboration
with
Maternal
Adolescent
and
Child
Health
(MatCH)
at
the
University
of
the
Witwatersrand,
designed
a
randomized
controlled
trial
to
evaluate
the
introduction
of
an
SMS
component
to
iDART
to
reduce
treatment
interruption
and
increase
adherence
amongst
new
ART
patients.
Four
sites
were
chosen
for
the
RCT,
which
was
completed
in
late
2013.
To
date
results
of
this
study
have
not
been
published.
Limitations
This
analysis
was
limited
by
relatively
scant
literature
on
the
role
of
mHealth
to
improve
supply
chain
management
of
essential
medicines
in
low
resource
settings.
Furthermore,
the
existing
literature
generally
features
small
scale
mHealth
interventions
initiated
by
NGOs
with
fixed
funding
and
project
time
scales.
There
were
difficulties
finding
comprehensive
information
on
the
process
of
pharmaceutical
supply
chain
management
in
South
Africa
because
national
LIMS
are
fragmented
by
the
decentralization
of
public
healthcare
services
to
the
provincial
level
and
the
privatization
of
pharmaceutical
distribution.
Lastly,
very
few
studies
have
investigated
patient
perspectives
on
access
to
medicines
and
healthcare
in
South
Africa,
or
the
potential
to
integrate
bi-­‐directional
mHealth
communication
systems
with
patients
to
improve
supply
chain
management
and
access.
Conclusions
and
Recommendations
Despite
spending
more
money
on
healthcare
than
other
LMICs,
South
Africa
has
unacceptably
poor
health
outcomes.
Additionally,
South
Africa
is
also
home
to
the
largest
populations
of
individuals
affected
by
HIV
and
TB
-­‐
considerable
constituents
of
the
quadruple
disease
burden,
of
which
the
other
three
are
NCD,
poor
maternal
and
child
health,
and
violence.
Human,
financial,
and
physical
resources
remain
inequitably
distributed
within
the
South
African
health
system
in
spite
of
the
gains
that
have
been
made
in
the
public
healthcare
sector
following
democratic
transition
in
1994.
Rural
and
impoverished
populations
within
South
Africa
consequently
bear
the
brunt
of
these
inequities.

20. INNOVATIONS
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ESSENTIAL
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ON
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18
With
over
2.1
million
individuals
initiating
treatment,
South
Africa
operates
the
largest
ARV
program
in
the
world.
However,
tracking
treatment
compliance
and
loss
to
follow
up
remains
an
obstacle.
South
Africa
is
also
the
epitome
of
a
country
in
transition
and
chronic
NCD
is
on
the
rise.
The
disease
burden
in
South
Africa
necessitates
a
regular
and
reliable
supply
of
essential
drugs
for
chronic
illnesses.
Impoverished
patients
are
constrained
to
utilizing
PHC
clinics
with
few
resources.
In
reviews
of
the
South
African
PHC
system
patients
report
poor
service
delivery
and
regular
shortages
of
medications.
Patients
are
often
told
to
return
to
facilities
at
a
later
date
to
collect
out
of
stock
medications.
Patients
within
the
public
healthcare
sector
generally
choose
facilities
based
on
distance
in
order
to
reduce
the
economic
impact
of
transport
costs,
however,
repeated
attempts
to
obtain
medication
can
result
in
catastrophic
costs
for
the
entire
household.
Inadequate
access
to
medicines
may
lead
to
treatment
non
adherence,
potential
development
of
resistant
strains
of
TB,
HIV
reinfection,
and
poor
health
outcomes
overall
–
though
there
are
no
known
studies
to
confirm
this
relationship.
The
economic
impact
of
these
consequences
are
also
unknown.
Pharmaceutical
supply
chain
management
within
South
Africa
is
controlled
at
the
provincial
level,
with
NDoH
heading
the
tender
process
for
obtaining
supplies
and
medicines.
The
quasi-­‐provincial
implementation
of
drug
delivery
and
public
health
services
creates
a
difficult
environment
with
which
to
streamline
HIM
and
data
collection
for
improved
decision-­‐making.
Multiple
advocacy
organizations
have
documented
essential
drug
stock
outs
resulting
from
the
inefficiencies
of
supply
chain
management
in
the
public
sector.
MHealth
has
the
potential
to
empower
South
African
patients
by
connecting
them
with
necessary
information,
such
as
facility-­‐based
drug
availability.
Additionally,
bidirectional
communication
transforms
the
traditional
patient
role
from
passive
recipient
to
active
participant
in
the
health
care
system.
Initiating
large-­‐scale
participatory
mHealth
in
South
Africa
to
improve
the
pharmaceutical
supply
chain
will
require
leadership
and
stewardship
at
all
levels.
Previous
mHealth
pilot
projects
have
demonstrated
the
importance
of
public-­‐private
partnerships.
A
scaled
mHealth
innovation
will
require
sustainable
funding,
the
identification
of
stakeholders,
and
the
involvement
of
multilateral
agencies,
civil
society
organizations,
academia,
the
private
ICT
industry,
and
the
South
African
government.
It
would
be
advantageous
for
the
South
African
Government
to
build
on
the
successes
of
existing
pharmaceutical
supply
chain
management
mHealth
programs
in
SSA.

21. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
19
Widespread
mobile
phone
use,
an
advanced
ICT
network,
and
an
enabling
policy
environment
suggest
that
the
potential
to
implement
mHealth
in
South
Africa
to
improve
supply
chain
management
is
great.
However,
it
should
be
noted
that
introducing
mHealth
will
likely
create
additional
management
responsibilities.
In
South
Africa
there
are
skilled
human
resource
shortages
in
the
healthcare
sector
and
an
unfavorable
culture
of
service
delivery.
Until
such
resource
constraints
can
be
ameliorated,
it
is
unlikely
that
introducing
innovative
approaches
will
produce
beneficial
results.

22. INNOVATIONS
IN
ACCESS
TO
ESSENTIAL
MEDICINES:
FOCUS
ON
SOUTH
AFRICA
20
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