In developing countries, where budgets for medicines are often tight, the supply cycle needs to be well-managed to prevent all types of wastage, including pilferage, misuse and expiry. This wastage reduces the quantity of medicines available to patients and therefore the quality of health care they receive.
At least US$550 000 worth of antiretrovirals and 10 million antimalarial doses recently expired in Uganda’s National Medical Stores (NMS).
The Ugandan pharmaceutical supply system comprises three non-profit wholesalers (one government medical store and two private non-profit ventures) and several private for-profit wholesale pharmacies that supply medicines in bulk to retail units (private retail pharmacies, hospital pharmacies and drug shops). Drug shops are the smallest retail medicine outlets, are supervised by non-pharmacist health-care professionals, and are limited to handling small amounts of over-the-counter medicines.
The expiry of medicines highlights a problem with the supply chain, which includes medicine selection, quantification, procurement, storage, distribution and use.4–6 We need to find out the factors contributing to expiry at each stage of the supply cycle in order to design pragmatic strategies to reduce the problem. The main aim of this study was to find out whether medicine expiry extends beyond public medicine outlets to the private for-profit sector, to assess the factors that contribute to or cause expiry and find out which medicines are particularly prone to expiry in the supply chain in Uganda.
Expiry of medicines in supply facilities was common among medicines for vertical health programmes (with percentage of outlets reporting expiry) including vitamin A capsules, antiretroviral medicines, antituberculosis agents, chloroquine, sulfadoxine/pyrimethamine and nystatin tablets, though expiry of medicines such as anticancer agents, tetracycline eye ointment and mebendazole was also common. Note that the number of respondents varied because not all medicines are stocked by all units. Surprisingly, all these top-expiring medicines are either essential (with a high turnover because they are used by the majority of the population) or vital (without them, the patient would die).
A possible explanation for the expiry of anticancer drugs is slow turnover because they treat rare diseases and are expensive. Similarly, tetracycline eye ointment and mebendazole have plenty of better substitutes, which may explain their slow turnover. We corroborated some of these findings with the respondents’ perceived features of medicines that commonly expire in their stores. Poor management of a change in treatment policy was implicated in the expiry of huge stocks of chloroquine, sulfadoxine/pyrimethamine and isoniazid.
On probing for contributing factors in the supply chain, the main ones included neglect of stock monitoring, lack of knowledge of basic expiry prevention tools, nonparticipation of clinicians in medicine quantification in hospitals, profit- and incentive-biased quantification, third party procurement by vertical programmes and overstocking. A few less common contributing factors were also reported.