This study is the first conducted in Mauritania to describe the national causes of medicinal stock-outs at the central and peripheral levels. We explored the views and perspectives of health care and other professionals involved in regulating, supplying, and distributing medicines. Our findings provide in-depth insight into the causes of stock-outs at three levels of the public health system (operational, regional and central). They will inform policy-makers and donors in Mauritania about the necessary corrective measures.

The causes of stockouts are multifactorial and interconnected. Based on thematic analysis, we grouped these causes into five categories: insufficient human resource capacity (number of staff, training, retention); communication and coordination problems among stakeholders; logistical constraints, i.e., at the level of transport and storage infrastructure; financial constraints; and inadequate forecasting of needs coupled to complex procurement procedures.

Qualitative studies of the national causes of MSOs of this type are essential if we devise solutions that are more likely to be found locally (37). However, MSOs are a recurring problem in many countries, especially those in sub-Saharan Africa (SSA), despite increased investment in the purchase of medicines and the introduction of measures to encourage the local production of generic medicines on the continent (37, 38, 39). Mauritania does not manufacture medicines and is consequently 100% dependent on imported health products. For most African countries, pharmaceutical imports represent up to 70-90% of medicines consumed, which proves their high level of dependence and predisposes their populations to drug shortages (40). However, Mauritania’s regulatory system still needs to mature, and the country seems to need more time to invest in local production. The stock-out problem could be addressed by acting at other levels of the pharmaceutical and health system.

First, this study highlights the insufficient human resource capacity at health facilities and CAMEC. This finding is in line with the results of the health system mapping conducted in 2020, which showed that only 65.7% of the positions at health centres and posts were filled by state-qualified nurses, and only 49% were filled by medical social nurses, who are generally responsible for managing drug depots (41). The mapping also highlighted the uneven distribution of health care staff, with approximately 1/3 of health human resources located in the capital, to the detriment of the regions, and the lack of training for pharmacists and pharmacy technicians (the few pharmacists have been trained abroad and remain too few to meet the country’s needs). These human resource issues are a real challenge for Mauritania’s health care systems and most sub-Saharan African countries (42, 43, 44) and hamper the availability of medicines (45, 46). Indeed, other authors have shown a link between poor availability of medicines and low staffing levels or poor qualifications (45, 46, 47) and argued that available, well-trained human resources are a driving force behind supply chain performance and the prevention of stock-outs of essential medicines (45, 48, 49, 50), at least when the causes of stock-outs are located in a country. While the challenges related to staff availability and retention are well known in Mauritania, most participants within the five districts supported by the AI-PASS project surprisingly perceived and insisted on the need for training in pharmaceutical management. The AI-PASS project deploys considerable resources to offer several training courses on medicine management. It has established local mentoring by technical assistants in each of the five health districts to strengthen the day-to-day capabilities of health staff. The lesson learned here is that training alone is not sufficient if trained staff are not part of a well-oiled and not-overloaded team with adequate communication and connection to peers at other health system levels.

Indeed, problems of communication and coordination among stakeholders, as well as transparency on the distribution and supply of medicines, have been highlighted by most participants as significant causes of stockouts. More broadly, these findings raise the question of interprofessional collaboration (51, 52), essential for ensuring quality care for the population, including an efficient medicine supply and distribution system. Such problems are recurrent in SSA, probably due to a weak culture of written communication, a lack of adequate means of communication, and sometimes rigid hierarchical links that are not conducive to good communication and coordination. In the case of pharmaceutical stock management, the lack of communication and coordination results in inaccurate estimates of stocks and needs and inadequate orders and stock planning (46).

Third, our findings show that the logistic weakness of the distribution chain is a significant contributor to MSOs in Mauritania. Most participants indicated that CAMEC’s available infrastructure needs to be improved to cover a territory as vast as Mauritania. It does not enable it to make essential medicines available to the last mile. Moreover, CAMEC supplies medicines only up to the regional level, which prevents or remediates shortages and MSOs in peripheral health facilities. Other studies conducted in Africa similarly indicated that weakness in the pharmaceutical distribution chain is at least partly caused by insufficient, uncoordinated, underfunded and non-standardised logistics and poor storage and distribution practices and appears to be one of the main causes of MSOs (53, 54, 55, 56).

Fourth, in Mauritania, MSOs result from insufficient and inadequate infrastructure and financial resources at the level of both health facilities and CAMEC. Such problems are recurrent in many African countries (38, 46). In Mauritania, insufficient storage areas and inadequate storage conditions at the peripheral, regional and central levels hamper ordering sufficient quantities of medicines. In addition, financial constraints at both health facilities and CAMEC mean that these institutions need more working capital to order medicines regularly and in line with actual needs. In many SSA countries, these challenges are present and exacerbated by low public investment in the pharmaceutical sector and health insurance coverage (57, 58).

Finally, the poor performance of medicine procurement procedures, the lack of willingness or commitment to join regional initiatives for group purchasing, and the inadequate estimates of actual needs found in our study have also been documented as causes of stockouts in other African contexts.

Overall, this study shows that the in-country causes of MSOs are diverse and interconnected. Moreover, it raises questions about the performance of the model of a public purchasing centre, such as CAMEC, and of a central pharmaceutical management and distribution system, which is certainly justified but needs substantial improvement. Unfortunately, the private sector needs to be better regulated, and it tends to serve its interests. Moreover, once these public models have been established, they become so powerful that they are difficult to control or even reform, which can be problematic (38, 54, 56). Long-term needs include transformative changes to go beyond traditional rigid schemes and build a flexible and well-regulated system that can fulfil its public health role by delivering medicines when and where needed.

However, when examining the specific problems of MSOs in Mauritania, practical solutions must be found urgently. CAMEC must define a clearer vision and an accountability mechanism to fulfil its health care mandate. Similarly, the development of a National Drug Supply and Distribution Strategy for Mauritania remains a priority, as does the allocation of substantial resources for its implementation.

At the same time, increasing focus should be placed on strengthening the various pillars of the health care system (59, 60), which needs high-quality initial and in-service training (e.g., through integrated supervision) and production by schools and faculties of sufficient numbers of health care personnel, including pharmacy technicians and pharmacists, to meet the country’s coverage needs. In addition, we need to ensure the equitable distribution of medicines throughout the country by implementing more rigorous, decentralised management and incentives to improve their retention. Substantial investment in infrastructure (construction, renovation, and equipment) will also be essential to ensure that medicines are stored adequately at health facilities or CAMEC. Effective coordination and pooling of the MoH’s efforts with its technical and financial partners can help to implement these solutions.

Establishing transit depots at the moughataa level could be a short-term alternative for bringing medicines closer to health facilities until the technical conditions are met for creating sales depots within the moughataa, as in most neighbouring countries (61). The need for sales depots at the moughtataa level is more acute in regions other than Nouakchott, given its proximity to the central CAMEC. Capacity-building for the management teams running the moughataas’ activities could make a lasting contribution to this objective. Investments are also needed to gradually switch from the current passive mode of transport to an active mode so that medicines can be transported to health facilities or, at the very least, to the health centres that head up the moughataas. Additionally, the digitisation of a management and communication system and the development of a logistics information system capable of providing complete data from all levels of the supply chain (central, regional, Moughataa, and health facilities) should help to rationalise the supply chain and facilitate efficient and transparent communication between all actors (61, 62).

In most SSA countries, most patients pay for their medicines out of pocket, while less than 20% (17.8%) of the population is covered by at least one social protection benefit (63). In this sense, the recent creation of the National Solidarity and Health Fund “Caisse nationale de solidarité et sante (CNASS)” in Mauritania, which aims to cover more than 70% of the population in the informal sector, is a source of hope (64). An agreement between the CNASS and CAMEC has been signed to help improve the supply of medicines to member health facilities. In addition, the CNASS should help guarantee more stable resources for health facilities, thus preventing their decapitalisation. These non-exhaustive courses of action could be implemented as part of the ongoing supply chain review to improve the last-mile medicine distribution (61). Finally, new studies are needed to assess the availability and prices of medicines, the causes of shortages of program medicines, and, later, the impact of current reforms and the CNASS on the availability of medicines in health facilities.