Antiretroviral medicine stock-outs

Export Indicator

Percentage of treatment sites that had a stock-out of one or more required antiretroviral medicines during a defined period
What it measures
This indicator measures the effectiveness of the procurement and supply management system in making medicines available. The consequences of stock-out—the scale of treatment interruption and risk for drug resistance—depend on the number of people whose treatment product stock-out will disrupt.
Rationale
As countries scale up antiretroviral therapy services, ensuring that antiretroviral medicines are there for the people who need them is important. Antiretroviral therapy is a long-term treatment strategy for people living with HIV, and interruptions may lead to treatment failure and HIV drug resistance. Efficient supply management is needed to ensure an uninterrupted supply of antiretroviral medicines.
Numerator
Number of health facilities dispensing antiretroviral medicines that experienced a stock-out of one or more required antiretroviral medicines during a defined period
Denominator

Total number of health facilities dispensing antiretroviral medicines during the same period

Calculation

Numerator/denominator

Method of measurement
This information is collected centrally at the level at which health facilities submit their inventory control reports or requisition forms for antiretroviral medicines.
 
This indicator requires:
  • Stock inventory control reports from health facilities, also indicating the stock of each item.
  •  Requisition forms submitted by facilities during a defined period (such as previous order period, previous quarter and past year) for antiretroviral medicines.
  • A list of the medicines that each facility is expected to dispense if these are not already included in the inventory control reports or requisition forms.
 
These work if the national logistics management information system is operational. If not, health facility surveys such as the service provision assessment or the service availability mapping may be used provided they include questions on antiretroviral medicine stock-outs.
 
If there is one logistics management information system with details on the availability of antiretroviral medicine at the health-facility level, information should be extracted to construct the indicator. Alternatively, the information may be collected through a survey or site visits.
 
If only a few health facilities dispense antiretroviral medicines, they should all be included in the survey or site visits. If a large number dispense antiretroviral medicines, selecting a representative sample may be necessary. The full list should be available at the national level.
 
In sampling, it is important to ensure that the sample includes facilities at different levels, such as central, district and peripheral. In countries dispensing antiretroviral medicines at pharmacies or other delivery points that are not health facilities, stock-outs should also be monitored at these venues; feasibility will depend on the coverage of the logistics management information system.
 
The HIV drug resistance early warning indicator on antiretroviral medicine stock-out monitors the percentage of months in the reporting year without stock-outs. This can be measured at the facility level and aggregated for the national estimate.
Measurement frequency

Annually

Disaggregation

Type of site: for example, general clinic, maternal and child site or TB site

Additional information requested
Comment on whether information is based on national data or survey data from a sample of facilities. Provide comments that would help interpret data: for example, if only public or private sector data are included and whether they may be an overestimate or underestimate.
Strengths and weaknesses
This indicator captures a crucial component of the antiretroviral therapy programme: whether there is an uninterrupted supply of antiretroviral medicines at the health-facility level.
 
It does not provide information on why stock-out problems occur, which antiretroviral medicines are or were out of stock, how long the stock-out lasted or the quality of antiretroviral medicine storage, delivery and distribution.
 
If stock-outs exist, assess whether the problem lies in the national distribution system or whether the problem is a financial flow or a global antiretroviral medicine shortage. Find out whether the cause is supply projections, the distribution system or another issue. Use this as an opportunity to see whether the logistics management information system is functioning.
 
In some situations, simply monitoring stock-outs could be misleading because a facility may keep reserve stock but maintain a policy of not issuing it. Such facilities would not be counted as having experienced a stock-out using this indicator definition, even though people would not receive a required medicine for treatment. In settings in which reserve stock is not issued, collecting information on a functional stock-out is preferable: that is, the inability to access or use a required antiretroviral medicine.
Further information
Harmonized monitoring and evaluation indicators for procurement and supply management systems. Early-warning indicators to prevent stock-outs and overstocking of antiretroviral, antituberculosis and antimalaria medicines. Geneva: World Health Organization; 2011 (http://www.who.int/hiv/pub/amds/monitoring_evaluation/en).