Before prescribing hormonal contraception, a health worker will usually ask a woman a series of questions to find out whether she has any medical problems, what her general state of health is, when last she had an HIV test and to make sure she isn’t already pregnant. It’s a good idea to also check her blood pressure.
When someone goes to the vending machine, though, they send a “please call me” message to a mobile number (083-323-1023) which is linked to a call centre operated by the youth and health organisation loveLife.
A counsellor from there calls the person back to ask what products they need from the machine and issues a PIN the user punches into the machine, said Linsey Schluter, communications manager at TB HIV Care, an NPO partner of the health department’s project.
Counsellors are allowed to give PINs for emergency contraception, condoms and pregnancy and HIV self-tests as these products don’t need a prescription. If someone asks for monthly contraceptives “they will be referred to their nearest clinic” where a health worker will check whether the pills can be prescribed.
Rise of the machine
That’s because getting prescription medicine such as hormonal contraception from a self-help machine is not yet approved in South Africa.
The South African Pharmacy Council (SAPC), which oversees the conduct of pharmacists, has strict rules about how medicines are dispensed. For example, they specify when something like a vending machine is set up for people to get their medication:
- a pharmacist must authorise the prescription;
- the package must get a sticker that gives the address of the machine and the details of the pharmacy that operates it; and
- there must be a place where medicines can be securely stored in case the user doesn’t want the selected product, for example if the wrong packet popped out.
- the unit must “be connected via computer with a secure live video and audio link” so a pharmacist can answer a user’s questions. Without this, the unit “may not be operated”.
The council has not yet received an application for contraceptives to be available through automated machines, said SAPC head Vincent Twala.
Since the rules came into effect in 2016, there have been only four applications (of which three were approved). That’s why “the implementation is done in phases”, said Thembi Zulu, acting director for women’s health at the health department, and the machines will, for now, dispense only non-pharmaceutical products such as condoms, lubricants, sanitary pads and HIV-testing kits.
“We will receive proper guidance from the regulatory body [the SAPC],” she said.
Success with self-help systems
Vending machines for sexual health products have proven successful in other countries and can help to ease the pressure on staff budgets without compromising on service delivery or allow health workers to attend to more difficult cases.
Results of a one-year pilot project in Moldova in Eastern Europe presented at the International Aids Conference in Munich in July showed setting up self-help machines from which people could get free HIV self-tests freed up 4,000 hours of social workers’ time. This allowed counsellors to spend more time with groups of people with a higher chance of getting HIV than the general population, such as sex workers or those who use drugs, to understand why they struggle to use HIV treatment or prevention services instead of having only about seven minutes to connect with a client.
PINs and pills: are vending machines the answer to contraceptive stockouts at clinics?
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Why did high-ranking government officials huddle around a bright pink vending machine at the Mthatha Ultra City on the N2 in the Eastern Cape on an autumn Wednesday morning in April? It wasn’t to get crisps and Cokes.
Instead, they unveiled South Africa’s first vending machine from where one can get items such as condoms, lubricants, sanitary pads and HIV-test kits — and in future birth control pills — for free.
Four months since that launch, seven more dispensers have been added — one in the Eastern Cape and six in KwaZulu-Natal — with five more planned to be placed in other provinces before the end of March next year, said health department spokesperson Foster Mohale.
The department said the machines are part of their plan to help young people take charge of their sexual health and prevent teen pregnancies, which have steadily been climbing over the past five years. In 2022, about one in every seven births in South African hospitals were to moms younger than 20 and over the past three years, just more than 11,500 girls between 10 and 14 gave birth.
Last week, though, the Stop Stockouts Project and Ritshidze, an NPO that monitors service delivery at South African clinics, reported planning problems, small budgets and poor record-keeping systems are part of the reason contraceptives have been the items most often out of stock at clinics since 2015.
Senior lecturer of pharmacology at the University of KwaZulu-Natal and member of the national committee that advises the government on what medicines to buy for state facilities, Andy Gray, warned offering hormonal contraception at self-help machines may run into regulatory hurdles.
“There are certainly barriers to accessing modern contraceptives that need urgent attention but I have concerns about the [vending machine plan].”
Punching in a PIN for birth control pills
Gray’s concerns are linked to hormonal birth control drugs being labelled as at least schedule 3 medicines. This means they have to be prescribed by a qualified health worker such as a doctor or a nurse at a government clinic. Pharmacists are also allowed to give someone the so-called morning-after pill (which is a schedule 2 medicine) when emergency contraception is needed (for example, if you had unprotected sex without using contraception or your normal method of birth control failed, like when a condom tore or you missed pills earlier in the month).
Contraceptive pills contain drugs that mimic the hormones released during pregnancy. This either stops an egg from being released during a woman’s monthly menstrual cycle (ovulation) or causes changes in the uterus and cervix so that a sperm can’t join with an egg.
Though vending machines may be a way for teenage girls to get “non-judgmental, adolescent-friendly service, especially outside normal clinic hours”, Gray said letting someone get birth control pills without seeing a health worker face-to-face could open a door to “inappropriate prescription”.
Before prescribing hormonal contraception, a health worker will usually ask a woman a series of questions to find out whether she has any medical problems, what her general state of health is, when last she had an HIV test and to make sure she isn’t already pregnant. It’s a good idea to also check her blood pressure.
When someone goes to the vending machine, though, they send a “please call me” message to a mobile number (083-323-1023) which is linked to a call centre operated by the youth and health organisation loveLife.
A counsellor from there calls the person back to ask what products they need from the machine and issues a PIN the user punches into the machine, said Linsey Schluter, communications manager at TB HIV Care, an NPO partner of the health department’s project.
Counsellors are allowed to give PINs for emergency contraception, condoms and pregnancy and HIV self-tests as these products don’t need a prescription. If someone asks for monthly contraceptives “they will be referred to their nearest clinic” where a health worker will check whether the pills can be prescribed.
Rise of the machine
That’s because getting prescription medicine such as hormonal contraception from a self-help machine is not yet approved in South Africa.
The South African Pharmacy Council (SAPC), which oversees the conduct of pharmacists, has strict rules about how medicines are dispensed. For example, they specify when something like a vending machine is set up for people to get their medication:
The council has not yet received an application for contraceptives to be available through automated machines, said SAPC head Vincent Twala.
Since the rules came into effect in 2016, there have been only four applications (of which three were approved). That’s why “the implementation is done in phases”, said Thembi Zulu, acting director for women’s health at the health department, and the machines will, for now, dispense only non-pharmaceutical products such as condoms, lubricants, sanitary pads and HIV-testing kits.
“We will receive proper guidance from the regulatory body [the SAPC],” she said.
Success with self-help systems
Vending machines for sexual health products have proven successful in other countries and can help to ease the pressure on staff budgets without compromising on service delivery or allow health workers to attend to more difficult cases.
Results of a one-year pilot project in Moldova in Eastern Europe presented at the International Aids Conference in Munich in July showed setting up self-help machines from which people could get free HIV self-tests freed up 4,000 hours of social workers’ time. This allowed counsellors to spend more time with groups of people with a higher chance of getting HIV than the general population, such as sex workers or those who use drugs, to understand why they struggle to use HIV treatment or prevention services instead of having only about seven minutes to connect with a client.
Schluter said it looks like the health department’s vending machines are popular and three will soon be moved to locations where they will fill a bigger need. For example, the second machine in Mthatha, which is at Zimbane village, will be moved to Lusikisiki, and in KwaZulu-Natal two of the machines will move to community centres young people visit often.
“In all three cases, it’s about need and greater accessibility,” she said.
But a self-help system such as this can’t work without a good support network in place, such as uninterrupted power and a stable internet connection and being regularly restocked.
In Kenya, connectivity issues and stockouts of smart vending machines in Nairobi, from which people could get contraceptives, condoms and sanitary pads, resulted in payment delays and hamstrung the service. For this reason, the South African health department’s machines are fitted with a backup power supply that can last for up to six hours in case of a power failure and are restocked each week, said Schluter.
Could an automated system such as this be part of the solution to making it easier for teen girls and young women to make the best decisions about their sexual health? Linda-Gail Bekker, head of the Desmond Tutu Health Foundation in Cape Town, said: “Offering young women sexual health services outside clinics will give them more choice and privacy, but getting their views is as important.
“It’s really valuable to get feedback and buy-in before going to scale.”
Update – 2 September 2024, 3pm: An explanation has been added to clarify that emergency hormonal contraception is a schedule 2 substance.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
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