Health Supply Chain Bottlenecks and Their Association with Medication Access and Prescribing Practices in Sub-Saharan Africa A Narrative Review

Health Supply Chain Bottlenecks and Their Association with Medication Access and Prescribing Practices in Sub-Saharan Africa: A Narrative Review () 1. Introduction 1.1. The Global Burden of Medicine Inaccessibility The World Health Organization (WHO) defines access to medicines as a priority concern, indicating that essential medicines must be available and accessible at all times, in adequate quantities, in appropriate dosage forms and quality, and at affordable prices for all patients ( Yadav, 2015 ). Medication access is the ability of patients to obtain prescribed medicines in a timely, affordable, and appropriate manner ( World Health Organization, 2010 ). The prescription fill rate is the proportion of prescribed medicines actually dispensed to a patient, expressed as a percentage ( Yimer, Addis and Alemu, 2022 ). When availability is compromised, some of the consequences include delayed treatment, adverse drug events, medication errors, increased healthcare costs, prolonged hospitalizations, and preventable deaths ( Santhireswaran et al., 2025 ). The WHO promotes the rational use of medicines by ensuring that patients receive treatments appropriate to their clinical needs, in doses that meet individual requirements, for adequate periods, and at the lowest possible cost ( Iqbal, Geer and Dar, 2016 ). In addition, supply chain inefficiencies frequently disrupt prescribing practices, resulting in irrational prescribing, therapeutic substitution, and incomplete treatment courses ( Papalexi, Bamford and Breen, 2020 ; Kapobe et al., 2026 ; Makowane et al., 2026 ; Mbuzi et al., 2026 ). Significantly, it is estimated that more than half of all medicines globally are prescribed or dispensed irrationally, and that irrational prescribing itself reduces medicine availability by as much as 50%, creating a cycle of wastage and scarcity ( Latifah et al., 2019 ). Despite increased investments in procurement of essential medicines globally, their availability at health facilities remains critically low in many LMICs, a situation largely driven by supply chain bottlenecks ( Vledder et al., 2019 ). A systematic scoping review of medicine availability across Africa, encompassing 198 availability studies, found that most measures classified public facility medicine availability as low (<50%) at the primary care level ( Lane et al., 2024 ). The WHO has developed five core prescribing indicators to measure the rationality of prescribing at the facility level ( Yimer, Addis and Alemu, 2022 ). These indicators include: 1) the average number of medicines per patient encounter (WHO optimal: 1.6 - 1.8), 2) the percentage of medicines prescribed by generic name (WHO optimal: 100%), 3) the percentage of patient encounters with an antibiotic prescribed (WHO optimal: ≤20% - 26.8%), 4) the percentage of patient encounters with an injection prescribed (WHO optimal: 13.4% - 24.1%), and 5) the percentage of medicines prescribed from the Essential Medicines List (WHO optimal: 100%). The economic consequences of inaccessibility are equally significant: when public facilities lack essential medicines, patients are compelled to purchase from private pharmacies at substantially higher out-of-pocket costs, further entrenching health inequity ( Yenet, Nibret and Tegegne, 2023 ). Against this backdrop, improving medication access rates at the primary care level in SSA is not merely a logistical challenge but a matter of fundamental public health urgency. 1.2. Purpose and Scope of This Review This review organizes evidence from global, regional, and local literature on health supply chain bottlenecks and their influence on medication access and prescribing practice, with a particular focus on public health facilities in SSA ( Steele et al., 2019 ; Olutuase et al., 2022 ). Specifically, the narrative review seeks to: 1) assess evidence of the key supply chain bottlenecks that may affect essential medicine availability, 2) review evidence of the association between health supply chain bottlenecks and medication access, and 3) review evidence of the association between health supply chain bottlenecks and prescribing practices consistent with the WHO Drug Use Indicator framework. 1.3. Conceptual Framework The conceptual framework is grounded in the WHO Health Systems Building Blocks framework, which identifies six interconnected components of a functional health system: service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governance ( Figure 1 ). This review draws on the “access to essential medicines” building block as its primary domain. The framework proposes two associational pathways through which health supply chain bottlenecks may be linked to medication access and prescribing practices. In the first pathway, supply chain bottlenecks such as poor demand forecasting are associated with reduced availability of essential medicines and low prescription fill rates at the point of care. Figure 1 . Conceptual Framework indicating factors that influence access to medication and prescribing practices of medicines in healthcare facilities. In the second pathway, supply chain bottlenecks are associated with distortions in prescribing practices in that prescribers may deviate from standard prescribing guidelines to adapt to supply chain challenges by selecting alternative agents or substituting suboptimal medicines for unavailable preferred options. These patterns are associated with observable deviations across the WHO prescribing indicators. Consistent with the scope of a narrative review, this framework does not assert a causal relationship; rather, it proposes that health supply chain bottlenecks are associated with medication access and prescribing practices, and this association is the primary focus of this review. 2. Materials and Methods 2.1. Study Design This study employed a narrative review design to synthesize existing literature on health supply chain bottlenecks and their association with medication access and prescribing practices in Sub-Saharan Africa. A narrative review approach was considered most appropriate because the topic covers multiple disciplines, including pharmaceutical supply chain management, public health systems strengthening, antimicrobial stewardship, and rational medicine use. The available evidence is highly diverse in terms of study designs, outcome measures, health system levels assessed, and methodological approaches, making statistical pooling or meta-analysis inappropriate. 2.2. Search Process A comprehensive literature search was conducted between March 2026 and May 2026 using academic databases including Google Scholar, PubMed, and ScienceDirect. The publication date limits for the included studies were set from January, 2009 to May, 2026 for all databases. The major search terms and combinations used included; health supply chain or pharmaceutical supply chain bottlenecks and stockout or medicine shortage; Sub Saharan Africa or low- and middle-income country and medication access or prescription fill rate; Sub Saharan Africa or low- and middle-income country and prescribing practices or WHO prescribing indicators or irrational prescribing. The sequential screening approach was used, firstly, the title and abstract were screened by the first author and a sample of excluded records was independently verified by the second author to confirm correct exclusion, with disagreements resolved by consensus. Secondly, full-text eligibility assessment and data extraction were likewise conducted by the first author and cross-checked by the second author for all included sources. The screening and data extraction procedures were conducted using a structured review process and included consistency checks among the authors to improve transparency and rigor. No language restrictions were applied at the search stage, although only English-language records were subsequently retained. The study included peer-reviewed studies published in English between January 2009 and May 2026. The initial search yielded 245 records across all three databases (Google Scholar, PubMed, and ScienceDirect), with 18 additional records identified through reference lists and institutional reports. After removal of duplicates, 218 unique records were screened by title and abstract against the eligibility criteria. Of these, 70 full-text sources were assessed for eligibility, and a final set of 50 studies and reports was included in the narrative synthesis. The selection process is summarized in Figure 2 below. A narrative review design was chosen over a systematic review because the topic spans multiple disciplines with highly heterogeneous study designs, diverse outcome measures, and varied methodological approaches, making statistical pooling inappropriate for this broad health systems question. 2.3. Eligibility Criteria Studies were included if they addressed one or more of the following review objectives: 1) health supply chain bottlenecks or inefficiencies; 2) medication access outcomes; or 3) prescribing practices, including the WHO prescribing indicators. The review synthesized evidence across these interconnected domains to construct the broader narrative framework. Additionally, studies were included if they: 4) were published between January 2009 and May 2026; and 5) were written in English and published in peer-reviewed journals or credible institutional reports. Private sector supply chains, or high-income country contexts, were excluded unless they provided global-level benchmarks relevant to the review. The selection process followed a sequential screening approach: records were first screened by title and abstract, and those meeting the thematic criteria were retrieved in full text for final inclusion assessment. Studies that did not report on supply chain performance, medication access, or prescribing practices in the LMIC context were excluded at the full-text stage. Although a formal PRISMA flow diagram is not required for narrative reviews, the overall selection process is summarized in Figure 2 to support transparency and reproducibility. Figure 2 . Literature selection flow diagram. 2.4. Data Extraction and Synthesis Data extraction was conducted thematically. For each included study, the following information was extracted: country or region of study, level of the health system examined, supply chain bottlenecks identified where available, medication access outcomes where available (including prescription fill rates), prescribing practice outcomes where available (including WHO prescribing indicator values), and key recommendations. Evidence was then synthesized narratively under three geographic strata: global, Sub-Saharan Africa, and local (Zambia), consistent with the review objectives. Quantitative prescribing data were tabulated for comparative analysis against WHO reference values. 2.5. Quality Assurance Given the narrative review design, formal risk-of-bias assessment tools such as CASP or Cochrane appraisal frameworks were not uniformly applied. This represents an inherent limitation of narrative reviews compared with systematic reviews, which typically employ standardized quality appraisal and reproducible evidence synthesis procedures. Consequently, the findings presented should be interpreted as a broad thematic synthesis of available evidence rather than a quantitatively weighted assessment of study quality. However, several measures were undertaken to enhance rigor, transparency, and credibility. These included the use of predefined eligibility criteria, structured database searching across multiple sources, sequential title/abstract and full-text screening, and thematic extraction of key study variables. Priority was also given to peer-reviewed and indexed studies, while findings were triangulated across multiple countries, study settings, and methodological approaches to improve consistency of interpretation. Where conflicting findings existed, both perspectives were reported and critically discussed. Regarding the appraisal of evidence types: peer-reviewed and indexed literature were accorded the highest priority during interpretation and synthesis. Institutional or governmental reports and grey literature were included primarily to provide contextual and policy-relevant insights. The findings were triangulated across multiple study designs, countries and methodologies to improve consistency and credibility. The review did not apply formal quantitative weighting because of the narrative review design and heterogeneity of the evidence base. Furthermore, limitations within the primary literature itself, including reliance on cross-sectional designs, inconsistent measurement of supply chain indicators, self-reported outcomes, and limited evidence from primary healthcare settings, were explicitly acknowledged throughout the review. 3. Results 3.1. Global Perspective: Supply Chain Bottlenecks and Medication Access Globally, several key bottlenecks have been identified within pharmaceutical supply chains. These include unreliable data systems that hinder forecasting and decision-making, weak regulatory frameworks, corruption, inadequate funding, shortages of skilled personnel, and bureaucratic procurement processes ( Muhia, Withera and Songole, 2017 ; Aigbavboa and Mbohwa, 2020 ). Poor infrastructure and weak information-sharing mechanisms among supply chain stakeholders further contribute to operational inefficiencies, resulting in delays, stockouts, and medicine wastage ( Steele et al., 2019 ; Papalexi, Bamford and Breen, 2020 ). Inadequate inventory management also negatively impacts medication access and patient health outcomes ( Bahadori, Ehsan and Bahariniya, 2024 ), as poor inventory controls can lead to drug expiry and the availability of substandard medicines. Bottlenecks equally manifest through delayed delivery schedules, contributing to poor availability and wastage of essential medicines in public health facilities ( Yadav, 2015 ). They are further observed at the point of care through ineffective implementation of Standard Operating Procedures (SOPs) and related policies, which contribute to irrational prescribing and inefficient medicine use ( Alfaouri, Jaaron and Igudia, 2025 ). Furthermore, the availability of essential medicines is a prerequisite for their accessibility to patients ( Laxminarayan et al., 2016 ). Medicine shortages result in patients being forced to seek care at other facilities or purchase medicines from private pharmacies at significantly higher personal cost, all of which adversely affect prescription fill rates and patient outcomes ( Steele et al., 2019 ). 3.2. Supply Chain Bottlenecks and Prescribing Practices: Global Evidence It is important to note at the outset that prescribing practice is multifactorial: while supply chain performance is a significant contributor, clinical training, diagnostic capacity, patient preferences, and regulatory frameworks all play a role. Supply chain bottlenecks can exacerbate existing challenges in prescribing practices, leading to deviations from standard guidelines. For instance, prescribers may resort to therapeutic substitution or incomplete treatment courses due to medicine unavailability, which can compromise patient outcomes and contribute to antimicrobial resistance. The WHO prescribing indicators provide a framework to assess the rationality of prescribing practices, and deviations from these indicators can signal underlying supply chain issues. For example, a high percentage of encounters with antibiotics prescribed may indicate overprescribing due to stockouts of preferred treatments. Similarly, a low percentage of medicines prescribed by generic name may reflect reliance on branded medicines due to supply chain disruptions. These patterns highlight the interconnectedness of supply chain performance and prescribing practices, emphasizing the need for integrated approaches to address these challenges. 3.3. Sub-Saharan Africa: Supply Chain Bottlenecks and Medication Access In Sub-Saharan Africa, supply chain bottlenecks are particularly pronounced, with significant implications for medication access. A systematic scoping review found that medicine availability at primary care facilities in the region is often below 50%, highlighting the severity of the issue. Key bottlenecks include poor infrastructure, inadequate funding, and weak governance structures. These challenges are compounded by the region's high disease burden and limited resources, creating a vicious cycle of inefficiency and inequity. For example, in Zambia, a study identified that delays in procurement and distribution processes contributed to frequent stockouts of essential medicines, leading to treatment interruptions and increased morbidity. Similarly, in Nigeria, weak regulatory frameworks and corruption were found to hinder the effective management of pharmaceutical supply chains, resulting in suboptimal medication access. Addressing these bottlenecks requires a multifaceted approach that includes strengthening infrastructure, improving governance, and enhancing funding mechanisms. Additionally, regional collaboration and knowledge sharing can facilitate the adoption of best practices and innovative solutions tailored to the unique challenges of the region. 3.4. Supply Chain Bottlenecks and Prescribing Practices in Sub-Saharan Africa In Sub-Saharan Africa, supply chain bottlenecks significantly impact prescribing practices, often leading to deviations from standard guidelines. For instance, prescribers may resort to therapeutic substitution or incomplete treatment courses due to medicine unavailability, which can compromise patient outcomes and contribute to antimicrobial resistance. The WHO prescribing indicators provide a framework to assess the rationality of prescribing practices, and deviations from these indicators can signal underlying supply chain issues. For example, a high percentage of encounters with antibiotics prescribed may indicate overprescribing due to stockouts of preferred treatments. Similarly, a low percentage of medicines prescribed by generic name may reflect reliance on branded medicines due to supply chain disruptions. These patterns highlight the interconnectedness of supply chain performance and prescribing practices, emphasizing the need for integrated approaches to address these challenges. Furthermore, the region's high disease burden and limited resources exacerbate these issues, creating a complex web of interrelated challenges that require coordinated efforts to resolve. 4. Discussion The findings of this narrative review underscore the critical role of health supply chain bottlenecks in shaping medication access and prescribing practices, particularly in Sub-Saharan Africa. The evidence highlights a range of interconnected challenges, including poor infrastructure, weak governance, and inadequate funding, which collectively contribute to inefficiencies in pharmaceutical supply chains. These bottlenecks not only hinder the availability of essential medicines but also disrupt prescribing practices, leading to deviations from standard guidelines and potential compromises in patient outcomes. The review also emphasizes the multifactorial nature of prescribing practices, acknowledging the influence of clinical training, diagnostic capacity, and regulatory frameworks alongside supply chain performance. This complexity underscores the need for integrated approaches that address the root causes of these challenges. For instance, strengthening infrastructure and improving governance can enhance the efficiency of pharmaceutical supply chains, while targeted interventions in clinical training and diagnostic capacity can support rational prescribing practices. Additionally, regional collaboration and knowledge sharing can facilitate the adoption of best practices and innovative solutions tailored to the unique challenges of Sub-Saharan Africa. The review's conceptual framework, grounded in the WHO Health Systems Building Blocks, provides a useful lens for understanding the interconnectedness of these issues. By focusing on the "access to essential medicines" building block, the framework highlights the critical pathways through which supply chain bottlenecks influence medication access and prescribing practices. This perspective emphasizes the importance of a holistic approach to health systems strengthening, recognizing that improvements in one area can have cascading positive effects on others. Furthermore, the review's findings have important implications for policy and practice. For policymakers, the evidence underscores the need for targeted investments in infrastructure, governance, and funding mechanisms to address supply chain bottlenecks. For healthcare providers, the review highlights the importance of adhering to standard prescribing guidelines and the potential role of therapeutic substitution in the context of medicine unavailability. For researchers, the review identifies key areas for further investigation, including the development and evaluation of innovative solutions to enhance pharmaceutical supply chain performance. In conclusion, this narrative review provides a comprehensive synthesis of the evidence on health supply chain bottlenecks and their association with medication access and prescribing practices in Sub-Saharan Africa. The findings highlight the complex interplay of factors contributing to these challenges and emphasize the need for integrated, holistic approaches to address them. By focusing on the root causes of supply chain inefficiencies and their impact on prescribing practices, this review contributes to the broader discourse on health systems strengthening and the promotion of rational medicine use. 5. Conclusion This narrative review has synthesized evidence from global, regional, and local literature on health supply chain bottlenecks and their influence on medication access and prescribing practices, with a particular focus on public health facilities in Sub-Saharan Africa. The findings highlight the critical role of supply chain performance in shaping medication access and prescribing practices, emphasizing the need for integrated approaches to address these challenges. Key bottlenecks identified include poor infrastructure, weak governance, and inadequate funding, which collectively contribute to inefficiencies in pharmaceutical supply chains. These bottlenecks not only hinder the availability of essential medicines but also disrupt prescribing practices, leading to deviations from standard guidelines and potential compromises in patient outcomes. The review's conceptual framework, grounded in the WHO Health Systems Building Blocks, provides a useful lens for understanding the interconnectedness of these issues. By focusing on the "access to essential medicines" building block, the framework highlights the critical pathways through which supply chain bottlenecks influence medication access and prescribing practices. This perspective emphasizes the importance of a holistic approach to health systems strengthening, recognizing that improvements in one area can have cascading positive effects on others. The review's findings have important implications for policy and practice. For policymakers, the evidence underscores the need for targeted investments in infrastructure, governance, and funding mechanisms to address supply chain bottlenecks. For healthcare providers, the review highlights the importance of adhering to standard prescribing guidelines and the potential role of therapeutic substitution in the context of medicine unavailability. For researchers, the review identifies key areas for further investigation, including the development and evaluation of innovative solutions to enhance pharmaceutical supply chain performance. In conclusion, this narrative review provides a comprehensive synthesis of the evidence on health supply chain bottlenecks and their association with medication access and prescribing practices in Sub-Saharan Africa. The findings highlight the complex interplay of factors contributing to these challenges and emphasize the need for integrated, holistic approaches to address them. By focusing on the root causes of supply chain inefficiencies and their impact on prescribing practices, this review contributes to the broader discourse on health systems strengthening and the promotion of rational medicine use.