Drug Shortages in Africa
DDBA 8560 - Seminar in Healthcare Managerial Decision Making
Drug Shortages in Africa
As Africa is a large continent, with countries which have diverse methods of dealing with drug
supply, this section focuses primarily on the situation in two countries, Malawi and Uganda.
In Malawi essential drugs are provided free of charge to patients at all public health facilities in
order to ensure equitable access to health care. The country thereby spends about 30% of the
national health budget on drugs (Lufesi et al, 2007).
However, not all of the essential drugs provided are always in stock. A difference between the
information recorded on the Stock Cards at the health centres and that recorded in the Patient
Records may contribute to the overall poor drug supply situation. In order to ensure equitable
access to life saving drugs, logistics in general should be put in order before specific disease
management programmes are initiated (Lufesi et al, 2007).
Numerous complaints by Malawian patients and local newspaper articles reflect the shortage of
drugs used to combat life-threatening diseases. 5The state-controlled supply system requires each
health centre to report the stock situation to the District Pharmacy each month. The health
centres do not have a pharmacist or pharmacy technician on the staff. The District Pharmacy,
which also does not have trained pharmacy staff, compares the reported stock situation with a
stock size guideline and sends an order to the Regional Medical Store. After a certain time lag,
the health centre receives the drugs (Lufesi et al, 2007). Unfortunately, by the time the drugs are
received, the demand situation may have completely changed, meaning that this method is
The time taken between ordering and receiving the drugs, lack of appropriate skills for health
workers managing drugs and lack of supervision may also have contributed to the shortage of
drugs in the health centres (Lufesi et al, 2007). Drugs take between 8 to 105 days from the time
of ordering to the time the drugs are actually received by the health centre. None of the health
workers managing drugs are trained in basic drug management skills and that they are rarely
supervised by the district pharmacist (Lufesi et al, 2007).
There are also gross discrepancies between the Stock Cards filled in at the health centres and the
Patient Records. The most likely explanation is that drugs are de facto dispensed to patients but
not recorded as such, which constitutes lack of compliance with procedures. 5The procedures
themselves may be out of touch with real life challenges in a busy outpatient clinic. In any case,
this kind of malpractice makes it difficult to deal with allegations of theft which, according to
newspaper reports (Banda, 2006; Nyirongo, 2005) and studies in other countries (Ferrinho et al,
2004; Geest, 1987) cannot be excluded to take place.
It is possible to envisage ways to improve the system: training the personnel in 5bookkeeping
combined with supportive supervision, a type of intervention proven to be 5effective in
Zimbabwe (Quick et al, 2005) decentralization of the drug budget to the District, which 5might
allow the Districts to buy drugs from other sources when the government medical 5store fails to
supply, as was found to be the case in Uganda (Jitta et al, 2003) and a small co-payment 5from
patients that can be used to replenish the supplies at health centre level. As the Bamako initiative
has proved, this increases the availability of drugs (Uzochukwu and Onwujekwe, 2005).
The main reason for the observed shortage of drugs at health centre level was insufficient
deliveries from the Regional Medical Store. On the one hand the public sector may be procuring
insufficient drugs to 5meet the country's needs, on the other hand there may be a leakage of drugs
from the 5public sector into the private sector, such as has been described in other countries
(Foster, 1991, Hogerzeil, 1986).
In Uganda, similar to the case in Malawi, a review of drug management and procurement has
revealed that although there was fairly regular supply of drugs, there were frequent drug stock-
outs in many health units. 5In addition, large quantities of expired drugs and medical supplies are
found in most district level facilities. This is attributed to poor quantification practices and to
donors ordering large quantities of drugs without proper co-ordination with the recipient
departments (Muyingo et al, 2000). Expired medicines stock is clearly a waste of resources
which cannot be afforded in a resource-constrained nation (Foster, 1991). The Ministry of Health
of Uganda introduced the ‘Pull’ system of drug supply in the year 2003 in an effort to overcome
the problems of drug availability and expiries. This system requires the health units to determine
the types and quantities of medicines and medical supplies they need (Uganda Malaria Control
Programme, 2005; Uganda Ministry of Health, 2004).
Other factors that the key informants felt were affecting the availability of drugs were the low
levels of staffing and lack of training in the system of procurement (Tumwine et al, 2010). Lack
of transport was also identified as a hindrance to drug availability. Finally, Lack of funds to
purchase drugs also affected their availability, to the extent that health facilities end up
purchasing less drugs than they need (Tumwine et al, 2010).
Abrupt changes of policies may also cause expiry of drugs. For example, the changes in anti
malarial policy whereby the first line drugs were changed from chloroquine and Fansidar to
artemether-lumefantrine, despite the already large supplies of the former, led to expiry of the
drugs in stock (Tumwine et al, 2010). Lack of transport affects availability because health
facilities tried to buy quantities of drugs that could be delivered using the available transport.
This might be less than what is required. When a hospital is far from its main supplier, this
implies that frequent trips cannot be made easily with the available transport. Lack of transport
has also been cited as a contributing factor to non-availability of drugs in Southern Sudan (Snow,
Due to the temptations of corruption, it is not surprising that many governments have regulations
that require physicians as well as nurses and pharmacists to practice only within the public
sector. It is also clear that there are risks associated with dual (public and private) practice by
health care professionals. Misappropriation of scarce public resources (e.g., use of facilities and
drugs), diversion of patients away from public services, (Nyazema, 2003) reduced quality of
care, and increased waiting times in the public sector are some of the more obvious possible
Abdullah, S. N., Ismail, K. N. I. K., & Nachum, L. (2016). Does having women on boards create
value? The impact of societal perceptions and corporate governance in emerging markets.
Strategic Management Journal, 37(3), 466-476.
Aguilera, R. V., Filatotchev, I., Gospel, H., & Jackson, G. (2008). An organizational approach to
comparative corporate governance: Costs, contingencies, and complementarities. Organization
science, 19(3), 475-492.
Bhagat, S., & Black, B. (2001). The non-correlation between board independence and long- term
firm performance. J. CorP. l., 27, 231.
Boivie, S., Bednar, M., Aguilera R. & Andrus, J. (2016). Are boards designed to fail? The
implausibility of effective board monitoring. The Academy of Management Annals, 10(1), 319-
Chen, G., Crossland, C., & Huang, S. (2016). Female board representation and corporate
acquisition intensity. Strategic Management Journal, 37(2), 303-313.
Dalton, D. R., Daily, C. M., Ellstrand, A. E., & Johnson, J. L. (1998). Board composition,
leadership structure, and financial performance: Meta-analytic reviews and research agenda.
Strategic Management Journal, 19: 269-290.
Dang, R., Nguyen, D. K., & Vo, L. C. (2014). Does the glass ceiling exist? A longitudinal study
of women's progress on french corporate boards. Journal of Applied Business Research, 30(3),
Fich, E. M., & Shivdasani, A. (2006). Are busy boards effective monitors? Journal of Finance,
Fiss, P. C., & Zajac, E. J. 2006. The symbolic management of strategic change: Sensegiving via
framing and decoupling. Academy of Management Journal, 49: 1173–1193.
Gabaldon, P., Anca, C., Mateos de Cabo, R., & Gimeno, R. (2016). Searching for women on
boards: An analysis from the supply and demand perspective. Corporate Governance: An
International Review, 24(3), 371-85.
Hermalin, Benjamin E., and and Michael S. Weisbach. (2003). “Boards of Directors as an
Endogenously Determined Institution: A Survey of the Economic Literature,” Economic Policy
Review, 9 (1), 7–26.
Homan, A. C., Van Knippenberg, D., Van Kleef, G. A., & De Dreu, C. K. (2007). Bridging
faultlines by valuing diversity: diversity beliefs, information elaboration, and performance in
diverse work groups. Journal of applied psychology, 92(5), 1189.
Ingram, A. E., Lewis, M. W., Barton, S., & Gartner, W. B. (2016). Paradoxes and innovation in
family firms: The role of paradoxical thinking. Entrepreneurship Theory and Practice, 40(1),
Joseph, J., Ocasio, W., & McDonnell, M. H. (2014). The structural elaboration of board
independence: Executive power, institutional logics, and the adoption of CEO-only board
structures in US corporate governance. Academy of Management Journal, 57(6), 1834- 1858.
Kaczmarek, S., Kimino, S., & Pye, A. (2012). Board task‐related faultlines and firm
performance: A decade of evidence. Corporate Governance: An International Review, 20(4),
Karra, N., Tracey, P., & Phillips, N. (2006). Altruism and agency in the family firm: Exploring
the role of family, kinship, and ethnicity. Entrepreneurship: Theory and Practice, 30(6), 861–877.
Khanna, P., Jones, C. D., & Boivie, S. (2014). Director human capital, information processing
demands, and board effectiveness. Journal of Management, 40(2), 557-585.
Kirsch, A. (2017). The gender composition of corporate boards: A review and research agenda.
The Leadership Quarterly. https://doi.org/10.1016/j.leaqua.2017.06.001
Leblanc, R. (2005). Assessing board leadership. Corporate Governance: An International
Review, 13(5), 654-666.
Matsa, D. A., & Miller, A. R. (2013). A female style in corporate leadership? Evidence from
quotas. American Economic Journal: Applied Economics, 5(3), 136-69.