1. Stock Outs in SA A country wide survey Response to a national crisis Presenter: Amir Shroufi Bella Hwang, Amir Shroufi, Tom Ellman, Gilles Van Cutsem, Monique Lines, Mwenya Mubanga, Andrew Mews

2. Contents History of the survey Why a national stockout survey Methods Results The media response What now

3. Why ARV & TB stockouts so important Increased risk of drug resistance Increased risk of sickness Eventually illness over time leading to death Patient distress and increased expenses Increased risk loss to follow up

4. MSF responds to depot crisis - Mthatha October 2012, staff strike, Subsequent service disruption Called in by civil society Supplies not received in warehouse Items not issued to medical facilities Drugs not dispensed to patients MSF & TAC support December 2012

5. The situation in Mthatha - January 2013 Worked with TAC in depot Notification & resolution stockouts Wanted info for wider advocacy Systematically called all clinics Depot serves > 100,000 on ARVs 24% had to send patients away > 700 resistance, 20-80 deaths “I am afraid to die, every time they tell me there is no treatment I think of dying,”

6. Media interest Provincial denial National acceptance MSF is “distorting the facts”..report is a…“a clear mischievous attempt to mislead the world” “Shut it down, bring in the army” “ we know exactly what’s short, but we have no way of knowing what’s happening at facilities” A provocative report

7. Why do a national survey? Reports from other provinces No good national info – No transparency Officially ‘not a problem’ – No accountability We knew it was feasible We knew it was affordable Clear national importance Eastern Cape Depot – December 2012

8. Methods Sept - Oct 2013 (8 weeks) 2.5 trained survey assistants 11 Questions 5 follow-up attempts ART/TB Sister or Pharmacist 371 person hours to complete Total Cost: $3,180 USD

9. Results Of 3827 facilities, 61% contactable, of which 91% participated

10. Results - geographic distribution

11. Impact on ART patients Sent home w/no drugs OR Referred elsewhere w/no drugs Shortened supply given Borrowed supply Change dose/regimen given 20%

12. Media & Advocacy strategy August 2013: NDOH informed & engaged October 2013: survey complete Released 26 November 2013 (AIDS Day) Factual and objective report Patient and professional testimony Acted as a civil society coalition Called for acknowledgement & actions

14. Mobilization of activists

15. The government response “Government denies shortage of TB, HIV/Aids treatments” eNCA “We do not believe the results of this survey”

16. The following 7 months Government re-engaged with us Consulted on plans to re-engineer supply chain Hundreds of facility level stokouts resolved Stop stockouts has grown as a watchdog The issue has continued to energize activists

17. Stop Stockouts Project-Ongoing Stock out Reporting SMS, Please Call Me, Web and Mobile Stock out verification Lay cadre & pharmacist managed Stock out Resolution NDOH informed, action fed back Reporter informed & cases mapped

18. Conclusions Telephone survey allowed for rapid and cheap assessment of stock outs Cheap yet high impact on a national level Stock outs in SA more widespread than suspected Assessment can lead to action Local action gave us legitimacy nationally