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PINs and pills — are vending machines the answer to contraceptive stockouts at clinics?

PINs and pills — are vending machines the answer to contraceptive stockouts at clinics?
Sipokazi Fokazi
By Sipokazi Fokazi
4 Sep 2024
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Government clinics running out of contraceptive medicines, which the latest Stop Stockouts and Ritshidze report says are linked to planning problems, small budgets and poor record systems, and frosty attitudes from nurses when young girls ask for birth control are not helping to bring down South Africa’s high teen pregnancy numbers. Could a vending machine from which to get your monthly pills be the answer?

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 autumny Wednesday morning in April?

It wasn’t to get crisps and Cokes.

Instead, they unveiled South Africa’s first vending machine from where someone can get things like condoms, lubricants, sanitary pads and HIV-test kits – and in future, also 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 too before the end of March next year, says Foster Mohale, the Health Department’s spokesperson.

The department says the machines are part of its 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 years old gave birth. 

Last week, though, the Stop Stockouts Project and Ritshidze, a nonprofit organisation that monitors service delivery at South African clinics, reported that planning problems, small budgets and poor record-keeping systems are part of the reason that contraceptives have been the medicines most often out of stock at clinics – since 2015.

But, warns Andy Gray, a senior lecturer in 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, 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 do have some 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 (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 some 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. 

Although vending machines may be a way for teenage girls to get “non-judgemental, adolescent-friendly service, especially outside of normal clinic hours”, Gray says 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 that 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 then calls the person back to ask what products they need from the machine and issues a PIN that the user punches into the machine, explains Linsey Schluter, the communications manager at TB HIV Care, a nonprofit partner of the Health Department’s project. 

Counsellors are allowed to give PINs for emergency contraception, condoms and pregnancy and HIV self-tests since these products don’t need a prescription.

But, says Schluter, 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 like hormonal contraception from a self-help machine is not approved in South Africa yet. 

The South African Pharmacy Council (SAPC), which oversees the conduct of pharmacists, has strict rules about how medicines are dispensed. 

For example, they specify that 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 instance if the wrong packet popped out.

The rules also say that the unit must “be connected via computer with a secure live video and audio link” so that a pharmacist can answer a user’s questions. Without this, the unit “may not be operated”.

The council has not received an application for contraceptives to be available through automated machines yet, says SAPC chief Vincent Tlala. Moreover, 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”, says 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 be receiving proper guidance from the regulatory body [the SAPC],” she says. 

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.  

For example, results of a one-year pilot project in Moldova in Eastern Europe presented at the International Aids Conference in Munich in July showed that 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 says 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 now at Zimbane Village, will be moved to Lusikisiki, and in KwaZulu-Natal two of the machines will move to community centres that young people visit often.    

“In all three cases, it’s about need and greater accessibility,” she says.

But a self-help system like this can’t work without a good support network in place, such as uninterrupted power and a stable internet connection, and being regularly restocked. For example, in Kenya, connectivity issues and stockouts of smart vending machines in Nairobi, from where 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 back-up power supply that can last for up to six hours in case of a power failure and are restocked each week, explains Schluter.

Could an automated system like 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? 

Says Linda-Gail Bekker, head of the Desmond Tutu Health Foundation in Cape Town: “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.” DM

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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