South Africa: Stockouts are a Barrier to Women's Sexual and Reproductive Health Rights

5 September 2022

Johannesburg — The Stop Stockout Project (SSP) has drawn attention to challenges in accessing contraceptives at public health clinics across South Africa in its latest survey.

"Difficulties in accessing contraceptives violates or limit women's sexual and reproductive health rights, including their right to life, health, privacy, education, equality, freedom and security and of their dignity," said Candice Sehoma, Access Campaign Advocacy Officer for Doctors Without Borders or Médecins Sans Frontières (MSF).

The Stop Stockout Project conducted a survey to collect data on contraceptive availability across the country. The data was collected between April and June 2022, by Ritshidze, a community-led monitoring project. During this period Ritshidze clinic monitors surveyed 15 750 patients in 402 health facilities across seven provinces which are Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo, Mpumalanga and North West. The data collected reflects the reports made to community monitors by both public healthcare users and public healthcare providers. Reports were then referred to the SSP hotline for resolution.

Ritshidze is a project being implemented by organizations representing people living with HIV—including the Treatment Action Campaign (TAC), the National Association of People Living with HIV (NAPWA), Positive Action Campaign, Positive Women's Network (PWN) and the South African Network of Religious Leaders Living with and affected by HIV/Aids (SANERELA+)—in alliance with Health Global Access Project (Health GAP), the Foundation for AIDS Research (amfAR), and Georgetown University's O'Neill Institute for National and Global Health Law.

The organisation works towards improving the quality of HIV and TB services provided in the public health sector through a community-led clinic monitoring system which is being rolled out in hundreds of primary healthcare facilities across the country.

The impact falls squarely on women and girls

This report titled Access to Contraceptives in South African Public Health Clinics between April and June 2022 found that since SSP began surveying the issue of medicine stockouts in 2013, overall medicine stock-outs situation in South Africa has broadly improved significantly of those reported and contraceptives now represent the biggest share of stockouts in the public healthcare system. While 6.9% of patients reported a stockout when at a clinic, 40% of these were stockouts of a contraceptive. Within the contraceptives category, 76.3% of stockouts reported were injectables.

"Women and girls are bearing the burden of the unavailability of contraceptives in South Africa, despite a clear constitutional right to access to healthcare services, including reproductive healthcare services. Inability to access contraceptives when needed can lead to unwanted pregnancies, which in turn can directly impact their physical and mental health, financial security, and ability to continue education or working," said  Baone Twala, SECTION27 legal researcher.

This is despite Section 27 of the South African constitution that provides that everyone has the right to have access to health care services, including reproductive health care services and no one may be refused emergency medical treatment. Twala says failure to prioritise access to contraceptives for all who wish to access them is a failure by the government to prioritise the lives of women and girls across the country.

"This report shines a light to the many health systems affecting contraceptive supplies and shortages. As a nurse myself, I can sense and speak about the absence of support of the front-line health workers who are more than aware of the contraceptive needs of their communities. The health system is under-resourced and under-staffed, nurses and other front line health care workers are often overloaded, working without supervision or support at a ground level; this includes lack of capacity building and training on the provision of other method of contraception like the longer lasting reversible modern methods such as implants and intrauterine devices. Not knowing how to provide a method also plays a part in stock orders, low demand from the clients can also be the result for the low promotion or the request of these methods," said Lucy O'Connell, a nurse and advisor at the Southern Africa Medical Unit of Doctors without Borders.

In a country where gender-based violence is so profound and widespread, often women's rights to choose and be fully in control of their bodies are infringe. GBV is broad but it can be broadly defined as harmful acts directed at an individual based on their gender. It is rooted in gender inequality, the abuse of power and harmful norms. It can include sexual, physical, mental and economic harm, threats of violence, coercion and manipulation.

"With endemic violence against women in South Africa, failure to meet our reproductive health needs is another stressor as women without access to contraception are forced into a position of negotiating condom use, or risk an unplanned pregnancy. For some of the most vulnerable women in our country, this lack of access can be catastrophic," said Indira Govender of the Rural Doctors Association of South Africa (RUDASA).

Amnesty International's March 2022 report found that the Covid-19 lockdowns contributed to "soaring rates" of sexual and gender-based violence across Africa.

This is evident that the Covid-19 pandemic which left many economies crippled has also added negatively to the many already broken health systems. According to the World Health Organisation,the exceptional measures governments and health authorities used during the Covid-19 pandemic, such as lockdowns, quarantine or reorganizing health services, directly affected the full realization of sexual and reproductive health and rights.

Frequent stockout means that many have to switch from their preferred method of contraception to available ones.

"If patients are not switched carefully, we may increase their risk of pregnancy. Some patients are using particular methods without their partners knowing, and changing methods may create interpersonal problems. Alternatives such as condoms and abstinence may be difficult to negotiate with partners, and are less effective methods. The first year on a contraceptive method carries the highest risk, therefore switching methods subjects patients to exposure to risks just as a new user would be. We already have an unmet need for contraception for various reasons, and stockouts worsen the situation," said Mala Panday, Obstetrician Gynaecologist, Family Planning Services Department at the King Dinizulu Hospital Complex in Durban, KwaZulu-Natal.

Panday noted that switching also means that patients need longer counselling on alternate methods, which takes time and increases waiting times.

O'Connell said that capacity training would help the situation as healthcare providers would be updated on the latest guidelines which ensures safety and efficacy of the different methods of contraceptives expanding into the demedicalisation of self managed methods such as the self injectable and vaginal ring methods which would begin to ensure that women have an assured autonomy of their bodies regarding contraception.

Key recommendations

Considering the widespread misogyny and gender-based violence in the country, the report highlights that the country cannot afford a de-prioritisation of women's sexual reproductive health issues and makes a number of recommendations to the government. The report recommends that the government should urgently create a plan to address contraceptive stockouts in primary healthcare facilities, including shortening the time for resolution of stockouts where they occur; Provide guidelines for how primary healthcare facilities should manage stockouts, should they occur; Monitor implementation of the National Integrated Sexual and Reproductive Health Rights (SRHR) policy, including providing access to long-term removable contraceptives such as intrauterine devices (IUDs), and ensuring that stock meets need; and ensure that women and girls are able to access their preferred contraceptive.

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