Impact of the COVID-19 pandemic on the quality of medical products in Zimbabwe: a qualitative study based on key informant interviews with health system stakeholders
Tatenda T Yemeke, Farouk A Umaru, Rashida A Ferrand, Sachiko Ozawa
BMJ Open, doi:10.1136/bmjopen-2022-068923
Objective To explore the impact of the Coronavirus disease 2019 (COVID-19) pandemic on the quality of medical products in Zimbabwe, including market risks for substandard and falsified products and impacts on quality assurance activities. Design Qualitative study based on in-depth key informant interviews. Setting Health system stakeholders across the medical product supply chain in Zimbabwe. Participants 36 key informants were interviewed between April and June 2021. Results We found that the COVID-19 pandemic disrupted quality assurance and regulatory activities of medical products in Zimbabwe, resulted in observations of poorquality personal protective equipment (PPE) and other COVID-19-related products and led to increased risks to quality. Risks to quality due to COVID-19-related disruptions included increased layers of agents in the supply chain and an influx of non-traditional suppliers. COVID-19-related movement restrictions reduced access to health facilities and thus may have increased the usage of the informal market where smuggled and unregistered medical products are sold with less oversight by the regulator. Most reports of poor-quality medical products were for PPE, such as masks and infrared thermometers, used for the COVID-19 response. Besides these reports, many participants stated that the quality of essential medicines in the formal sector, not related to COVID-19, had largely been maintained during the pandemic due to the regulator's stringent quality assurance process. Incentives for suppliers to maintain quality to retain large donor-funded contracts, and the need for local wholesalers and distributors to comply with quality-related aspects of distribution agreements with global manufacturers of brand-name medical products, mitigated threats to quality. Conclusions The COVID-19 pandemic presented opportunities and market risks for circulation of substandard and falsified medical products in Zimbabwe. There is a need for policymakers to invest in measures to safeguard the quality of medical products during emergencies and to build resiliency against future supply chain shocks.
Competing interests None declared. Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details. Patient consent for publication Not applicable.
Ethics approval The study received ethical approval from the research ethics review boards at the University of North Carolina at Chapel Hill (IRB # 20-3065) and from the Medical Research Council of Zimbabwe (MRCZ/A/2596). Additional permission to interview key informants affiliated with the Ministry of Health and Child Care (MOHCC) was granted by the National Institute of Health Research within the MOHCC. Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental file. Study interview guide and codebook are available as article supplementary files. De-identified qualitative memos summarizing participant interviews are available upon reasonable request. Requests should be directed to the corresponding author. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of..
References
Amimo, Lambert, Magit, A review of prospective pathways and impacts of COVID-19 on the accessibility, safety, quality, and Affordability of essential medicines and vaccines for universal health coverage in Africa, Global Health,
doi:10.1186/s12992-021-00666-8Bank, World Bank Country and Lending Groups
Borse, Cha, Chase, Responding to the surge of substandard and falsified health products triggered by the Covid-19 pandemic
Braun, Clarke, What can "thematic analysis" offer health and wellbeing researchers, Int J Qual Stud Health Well-Being,
doi:10.3402/qhw.v9.26152Evans, Higgins, Laing, Poor-quality Antimalarials further health inequities in Uganda, Health Policy Plan,
doi:10.1093/heapol/czz012Jackson, Higgins, Laing, Impact of substandard and falsified Antimalarials in Zambia: application of the SAFARI model, BMC Public Health,
doi:10.1186/s12889-020-08852-wKaddu, 'amore, Clark, Strengthening Regulatory Systems To Improve Medical Product Quality in Low-and MiddleIncome Countries
Maguire, Delahunt, Doing a thematic analysis: A practical, stepby-step guide
Marks, Thomas, Bakhet, Medical equipment donation in low-resource settings: a review of the literature and guidelines for surgery and anaesthesia in low-income and middle-income countries, BMJ Glob Health,
doi:10.1136/bmjgh-2019-001785Namey, Guest, Mckenna, Evaluating bang for the buck: A cost-effectiveness comparison between individual interviews and focus groups based on thematic saturation levels, Am J Eval,
doi:10.1177/1098214016630406Newton, Bond, 53 signatories from 20 countries. COVID-19 and risks to the supply and quality of tests, drugs, and vaccines, Lancet Glob Health,
doi:10.1016/S2214-109X(20)30136-4Novakowski, Garcia-Gonzalez, Wrigglesworth, A Pharmacovigilance system for treatment access and medical donation programs: the Max foundation experience,
doi:10.1186/s12992-018-0391-4Ozawa, Evans, Bessias, Prevalence and estimated economic burden of substandard and falsified medicines in Low-and middle-income countries: A systematic review and meta-analysis, JAMA Netw Open,
doi:10.1001/jamanetworkopen.2018.1662Ozawa, Haynie, Bessias, Modeling the economic impact of substandard and falsified Antimalarials in the Democratic Republic of the Congo, Am J Trop Med Hyg,
doi:10.4269/ajtmh.18-0334Ozawa, Higgins, Nwokike, Modeling the health and economic impact of substandard and falsified medicines: A on June 16, 2023 by guest, Am J Trop Med Hyg,
doi:10.4269/ajtmh.21-1133Pecchia, Health technology assessment of medical devices in low and middle income countries: study design and preliminary
Pecchia, Piaggio, Maccaro, The inadequacy of regulatory Frameworks in time of crisis and in low-resource settings: personal protective equipment and COVID-19, Health Technol,
doi:10.1007/s12553-020-00429-2Pisani, Nistor, Hasnida, Identifying market risk for substandard and falsified medicines: an analytic framework based on qualitative research in China, Indonesia, Turkey and Romania, Wellcome Open Res,
doi:10.12688/wellcomeopenres.15236.1Sithole, Mahlangu, Salek, Evaluation of the regulatory review process in Zimbabwe: challenges and opportunities, Ther Innov Regul Sci,
doi:10.1007/s43441-020-00242-zSithole, Salek, Mahlangu, Comparison of the registration process of the medicines control authority of Zimbabwe with Australia, Expert Rev Clin Pharmacol,
doi:10.1080/17512433.2022.1987883Tesfaye, Abrha, Sinnollareddy, How do we combat bogus medicines in the age of the COVID-19 pandemic, Am J Trop Med Hyg,
doi:10.4269/ajtmh.20-0903{ 'indexed': {'date-parts': [[2023, 6, 9]], 'date-time': '2023-06-09T04:31:21Z', 'timestamp': 1686285081173},
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'abstract': '<jats:sec><jats:title>Objective</jats:title><jats:p>To explore the impact of the Coronavirus '
'disease 2019 (COVID-19) pandemic on the quality of medical products in Zimbabwe, including '
'market risks for substandard and falsified products and impacts on quality assurance '
'activities.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Qualitative '
'study based on in-depth key informant '
'interviews.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>Health '
'system stakeholders across the medical product supply chain in '
'Zimbabwe.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>36 key '
'informants were interviewed between April and June '
'2021.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We found that the '
'COVID-19 pandemic disrupted quality assurance and regulatory activities of medical products '
'in Zimbabwe, resulted in observations of poor-quality personal protective equipment (PPE) and '
'other COVID-19-related products and led to increased risks to quality. Risks to quality due '
'to COVID-19-related disruptions included increased layers of agents in the supply chain and '
'an influx of non-traditional suppliers. COVID-19-related movement restrictions reduced access '
'to health facilities and thus may have increased the usage of the informal market where '
'smuggled and unregistered medical products are sold with less oversight by the regulator. '
'Most reports of poor-quality medical products were for PPE, such as masks and infrared '
'thermometers, used for the COVID-19 response. Besides these reports, many participants stated '
'that the quality of essential medicines in the formal sector, not related to COVID-19, had '
'largely been maintained during the pandemic due to the regulator’s stringent quality '
'assurance process. Incentives for suppliers to maintain quality to retain large donor-funded '
'contracts, and the need for local wholesalers and distributors to comply with quality-related '
'aspects of distribution agreements with global manufacturers of brand-name medical products, '
'mitigated threats to '
'quality.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>The '
'COVID-19 pandemic presented opportunities and market risks for circulation of substandard and '
'falsified medical products in Zimbabwe. There is a need for policymakers to invest in '
'measures to safeguard the quality of medical products during emergencies and to build '
'resiliency against future supply chain shocks.</jats:p></jats:sec>',
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'published-online': {'date-parts': [[2023, 6, 8]]},
'reference': [ { 'key': '2023060810252180000_13.6.e068923.1',
'first-page': '157',
'article-title': 'WHO declares COVID-19 a pandemic',
'volume': '91',
'author': 'Cucinotta',
'year': '2020',
'journal-title': 'Acta Biomed'},
{ 'key': '2023060810252180000_13.6.e068923.2',
'unstructured': 'United Nations office on drugs and crime . COVID-19-related trafficking '
'of medical products as a threat to public health. United Nations, 2020.'},
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'doi-asserted-by': 'crossref',
'first-page': 'e754',
'DOI': '10.1016/S2214-109X(20)30136-4',
'article-title': 'COVID-19 and risks to the supply and quality of tests, drugs, and '
'vaccines',
'volume': '8',
'author': 'Newton',
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'journal-title': 'Lancet Glob Health'},
{ 'key': '2023060810252180000_13.6.e068923.4',
'unstructured': 'Borse NN , Cha J , Chase CG , et al . Responding to the surge of '
'substandard and falsified health products triggered by the Covid-19 '
'pandemic. Rockville, MD: United States Pharmacopeia (USP), 2021.'},
{ 'key': '2023060810252180000_13.6.e068923.5',
'unstructured': 'Medicine Quality Research Group . Medical Product Quality Report – '
'COVID-19 Issues. University of Oxford, 2021.'},
{ 'key': '2023060810252180000_13.6.e068923.6',
'unstructured': 'World Health Organization . Definitions of Substandard and Falsified '
'(SF) Medical Products. Geneva, Switzerland: World Health Organization, '
'2022. Available: '
'https://www.who.int/teams/regulation-prequalification/incidents-and-SF/background/definitions'},
{ 'key': '2023060810252180000_13.6.e068923.7',
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'socioeconomic impact of substandard and falsified medical products. '
'Geneva: Switzerland World Health Organization, 2017.'},
{ 'key': '2023060810252180000_13.6.e068923.8',
'doi-asserted-by': 'crossref',
'unstructured': 'Beargie SM , Higgins CR , Evans DR , et al . The economic impact of '
'substandard and falsified Antimalarial medications in Nigeria. PLOS ONE '
'2019;14:e0217910. doi:10.1371/journal.pone.0217910',
'DOI': '10.1371/journal.pone.0217910'},
{ 'key': '2023060810252180000_13.6.e068923.9',
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'DOI': '10.4269/ajtmh.21-1133',
'article-title': 'Modeling the health and economic impact of substandard and falsified '
'medicines: A review of existing models and approaches',
'volume': '107',
'author': 'Ozawa',
'year': '2022',
'journal-title': 'Am J Trop Med Hyg'},
{ 'key': '2023060810252180000_13.6.e068923.10',
'doi-asserted-by': 'crossref',
'unstructured': 'Jackson KD , Higgins CR , Laing SK , et al . Impact of substandard and '
'falsified Antimalarials in Zambia: application of the SAFARI model. BMC '
'Public Health 2020;20:1083. doi:10.1186/s12889-020-08852-w',
'DOI': '10.1186/s12889-020-08852-w'},
{ 'key': '2023060810252180000_13.6.e068923.11',
'doi-asserted-by': 'crossref',
'first-page': '1149',
'DOI': '10.4269/ajtmh.18-0334',
'article-title': 'Modeling the economic impact of substandard and falsified Antimalarials '
'in the Democratic Republic of the Congo',
'volume': '100',
'author': 'Ozawa',
'year': '2019',
'journal-title': 'Am J Trop Med Hyg'},
{ 'issue': 'Supplement_3',
'key': '2023060810252180000_13.6.e068923.12',
'doi-asserted-by': 'crossref',
'first-page': 'iii36',
'DOI': '10.1093/heapol/czz012',
'article-title': 'Poor-quality Antimalarials further health inequities in Uganda',
'volume': '34',
'author': 'Evans',
'year': '2019',
'journal-title': 'Health Policy Plan'},
{ 'key': '2023060810252180000_13.6.e068923.13',
'doi-asserted-by': 'crossref',
'unstructured': 'World Health Organization . Health in 2015: from Mdgs, millennium '
'development goals to Sdgs, sustainable development goals. 2015. '
'doi:10.52439/KPEH5007',
'DOI': '10.52439/KPEH5007'},
{ 'key': '2023060810252180000_13.6.e068923.14',
'unstructured': 'World Health Organization . Universal health coverage (UHC). 2019. '
'Available: '
'https://www.who.int/en/news-room/fact-sheets/detail/universal-health-coverage-(uhc)'},
{ 'key': '2023060810252180000_13.6.e068923.15',
'unstructured': 'World Health Organization . Sustainable development goals (Sdgs): goal '
'3. target 38. Geneva, Switzerland: WHO, 2019. Available: '
'http://iris.wpro.who.int/handle/10665.1/12880'},
{ 'key': '2023060810252180000_13.6.e068923.16',
'doi-asserted-by': 'crossref',
'unstructured': 'Ozawa S , Higgins CR , Yemeke TT , et al . Importance of medicine '
'quality in achieving universal health coverage. PLOS ONE '
'2020;15:e0232966. doi:10.1371/journal.pone.0232966',
'DOI': '10.1371/journal.pone.0232966'},
{ 'key': '2023060810252180000_13.6.e068923.17',
'unstructured': 'World Health Organization . Full List of WHO Medical Product Alerts. '
'Geneva, Switzerland: World Health Organization, 2021. Available: '
'https://www.who.int/teams/regulation-prequalification/incidents-and-SF/full-list-of-who-medical-product-alerts'},
{ 'key': '2023060810252180000_13.6.e068923.18',
'doi-asserted-by': 'crossref',
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'substandard and falsified medicines: an analytic framework based on '
'qualitative research in China, Indonesia, Turkey and Romania. Wellcome '
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'doi-asserted-by': 'crossref',
'unstructured': 'Ozawa S , Evans DR , Bessias S , et al . Prevalence and estimated '
'economic burden of substandard and falsified medicines in Low- and '
'middle-income countries: A systematic review and meta-analysis. JAMA '
'Netw Open 2018;1:e181662. doi:10.1001/jamanetworkopen.2018.1662',
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'doi-asserted-by': 'crossref',
'unstructured': 'Twesigye G , Hafner T , Guzman J . Making the investment case for '
'national regulatory authorities. J of Pharm Policy and Pract 2021;14. '
'doi:10.1186/s40545-021-00299-7',
'DOI': '10.1186/s40545-021-00299-7'},
{ 'key': '2023060810252180000_13.6.e068923.21',
'doi-asserted-by': 'crossref',
'unstructured': 'Preston C , Valdez ML , Bond K . Strengthening medical product '
'regulation in Low- and middle-income countries. PLOS Med '
'2012;9:e1001327. doi:10.1371/journal.pmed.1001327',
'DOI': '10.1371/journal.pmed.1001327'},
{ 'key': '2023060810252180000_13.6.e068923.22',
'unstructured': 'Kaddu G , D’Amore E , Clark APN . Strengthening Regulatory Systems To '
'Improve Medical Product Quality in Low- and MiddleIncome Countries. '
'Rockville, Maryland: U.S. Pharmacopeial Convention, 2018.'},
{ 'key': '2023060810252180000_13.6.e068923.23',
'unstructured': 'World Health Organization . Zimbabwe Medicines Quality Lab Gets WHO '
'Approva. Geneva, Switzerland: World Health Organization, 2014. '
'Available: https://www.who.int/medicines/news/zwe_med_quality_lab/en/'},
{ 'key': '2023060810252180000_13.6.e068923.24',
'unstructured': 'Bank W . World Bank Country and Lending Groups. Washington, D.C: The '
'World Bank, 2022. Available: '
'https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups'},
{ 'key': '2023060810252180000_13.6.e068923.25',
'doi-asserted-by': 'crossref',
'first-page': '109',
'DOI': '10.1080/17512433.2022.1987883',
'article-title': 'Comparison of the registration process of the medicines control '
'authority of Zimbabwe with Australia, Canada, Singapore, and '
'Switzerland: Benchmarking best practices',
'volume': '15',
'author': 'Sithole',
'year': '2022',
'journal-title': 'Expert Rev Clin Pharmacol'},
{ 'key': '2023060810252180000_13.6.e068923.26',
'doi-asserted-by': 'crossref',
'first-page': '474',
'DOI': '10.1007/s43441-020-00242-z',
'article-title': 'Evaluation of the regulatory review process in Zimbabwe: challenges and '
'opportunities',
'volume': '55',
'author': 'Sithole',
'year': '2021',
'journal-title': 'Ther Innov Regul Sci'},
{ 'key': '2023060810252180000_13.6.e068923.27',
'unstructured': 'Zimbabwe . Rcore Trainings: medicines control authority of Zimbabwe. '
'2021. Available: https://www.mcaz.co.zw/rcore-trainings/'},
{ 'key': '2023060810252180000_13.6.e068923.28',
'doi-asserted-by': 'crossref',
'unstructured': 'Makoni M . COVID-19 worsens Zimbabwe’s health crisis. Lancet '
'2020;396:.:S0140-6736(20)31751-7. doi:10.1016/S0140-6736(20)31751-7',
'DOI': '10.1016/S0140-6736(20)31751-7'},
{ 'key': '2023060810252180000_13.6.e068923.29',
'doi-asserted-by': 'crossref',
'first-page': '425',
'DOI': '10.1177/1098214016630406',
'article-title': 'Evaluating bang for the buck: A cost-effectiveness comparison between '
'individual interviews and focus groups based on thematic saturation '
'levels',
'volume': '37',
'author': 'Namey',
'year': '2016',
'journal-title': 'Am J Eval'},
{ 'key': '2023060810252180000_13.6.e068923.30',
'unstructured': 'Maguire M , Delahunt B . Doing a thematic analysis: A practical, '
'step-by-step guide. 2017;9.'},
{ 'key': '2023060810252180000_13.6.e068923.31',
'doi-asserted-by': 'crossref',
'first-page': '77',
'DOI': '10.1191/1478088706qp063oa',
'article-title': 'Using thematic analysis in psychology',
'volume': '3',
'author': 'Braun',
'year': '2006',
'journal-title': 'Qualitative Research in Psychology'},
{ 'key': '2023060810252180000_13.6.e068923.32',
'doi-asserted-by': 'crossref',
'unstructured': 'Braun V , Clarke V . What can "thematic analysis" offer health and '
'wellbeing researchers. Int J Qual Stud Health Well-Being 2014;9:26152. '
'doi:10.3402/qhw.v9.26152',
'DOI': '10.3402/qhw.v9.26152'},
{ 'key': '2023060810252180000_13.6.e068923.33',
'doi-asserted-by': 'crossref',
'first-page': '1609406917733847',
'DOI': '10.1177/1609406917733847',
'article-title': 'Thematic analysis:striving to meet the trustworthiness criteria',
'volume': '16',
'author': 'Nowell',
'year': '2017',
'journal-title': 'Int J Qual Methods'},
{ 'key': '2023060810252180000_13.6.e068923.34',
'unstructured': 'Medicines control authority of Zimbabwe . Import & export Harare. '
'Zimbabwe: Medicines Control Authority of Zimbabwe, 2021. Available: '
'https://www.mcaz.co.zw/licensing-and-enforcement/import-export/'},
{ 'key': '2023060810252180000_13.6.e068923.35',
'doi-asserted-by': 'crossref',
'unstructured': 'Shiferie F , Kassa E . The scourge of substandard and falsified medical '
'products gets worse with COVID-19 pandemic. Pan Afr Med J 2020;37:344. '
'doi:10.11604/pamj.2020.37.344.26322',
'DOI': '10.11604/pamj.2020.37.344.26322'},
{ 'key': '2023060810252180000_13.6.e068923.36',
'doi-asserted-by': 'crossref',
'first-page': '1360',
'DOI': '10.4269/ajtmh.20-0903',
'article-title': 'How do we combat bogus medicines in the age of the COVID-19 pandemic',
'volume': '103',
'author': 'Tesfaye',
'year': '2020',
'journal-title': 'Am J Trop Med Hyg'},
{ 'key': '2023060810252180000_13.6.e068923.37',
'doi-asserted-by': 'crossref',
'unstructured': 'Amimo F , Lambert B , Magit A , et al . A review of prospective pathways '
'and impacts of COVID-19 on the accessibility, safety, quality, and '
'Affordability of essential medicines and vaccines for universal health '
'coverage in Africa. Global Health 2021;17:42. '
'doi:10.1186/s12992-021-00666-8',
'DOI': '10.1186/s12992-021-00666-8'},
{ 'key': '2023060810252180000_13.6.e068923.38',
'unstructured': 'Infectious Diseases Data Observatory . Medicine quality monitoring '
'globe: infectious diseases data Observatory. 2022. Available: '
'https://www.iddo.org/mqmglobe/'},
{ 'key': '2023060810252180000_13.6.e068923.39',
'doi-asserted-by': 'crossref',
'first-page': 'e754',
'DOI': '10.1016/S2214-109X(20)30136-4',
'article-title': 'COVID-19 and risks to the supply and quality of tests, drugs, and '
'vaccines',
'volume': '8',
'author': 'Newton',
'year': '2020',
'journal-title': 'Lancet Glob Health'},
{ 'key': '2023060810252180000_13.6.e068923.40',
'doi-asserted-by': 'crossref',
'first-page': '1375',
'DOI': '10.1007/s12553-020-00429-2',
'article-title': 'The inadequacy of regulatory Frameworks in time of crisis and in '
'low-resource settings: personal protective equipment and COVID-19',
'volume': '10',
'author': 'Pecchia',
'year': '2020',
'journal-title': 'Health Technol'},
{ 'key': '2023060810252180000_13.6.e068923.41',
'doi-asserted-by': 'crossref',
'unstructured': 'Pecchia L . Health technology assessment of medical devices in low and '
'middle income countries: study design and preliminary. 2018:225–8. '
'doi:10.1007/978-981-10-5122-7',
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