From penicillin to a blood thinner: what medicine shortages really cost | Prof Colleen Aldous

A supplier can no longer deliver three strengths of rivaroxaban, a blood thinner used to prevent clots and strokes. The health department is hunting for stock and has issued interim guidance. But the tender price hides the real bill. Switching treatment can mean new blood tests, extra clinic trips and higher transport costs. Europe’s penicillin squeeze points to a similar risk. Cheap buying can push reliable makers out. So what should South Africa measure before the next contract fails?.By Prof Colleen Aldous.South Africa's medicine shortages demand attention long before a shelf is empty. A 23 October national circular says the supplier contracted to provide three strengths of rivaroxaban can no longer meet its obligations. Rivaroxaban is an anticoagulant used to treat or prevent blood clots and, in selected patients with atrial fibrillation, reduce the risk of stroke. The Department of Health (DoH) has issued interim clinical guidance and is exploring alternative sources of supply.The circular does not say that every facility has run out, nor how many patients have missed a dose. It does show how a threatened supply interruption can trigger a search for stock and new clinical guidance. If patients need to change treatment, that can also mean counselling and, for some, blood tests that their usual medicine did not require. A tender's quoted price tells us little about the full cost of maintaining continuous treatment when the contracted supply falters.A problem shared across bordersMedicine shortages are international. The American Society of Health-System Pharmacists recorded 225 active shortages in the United States at the end of September 2026 and 87 new shortages in the first nine months of the year. Chemotherapy medicines remain among the products affected. Even a large, wealthy buyer cannot assume that an alternative manufacturer has spare capacity ready for immediate delivery.Those American figures cannot be compared directly with a South African count because the two systems define and record shortages differently. They also do not establish an international shortage of rivaroxaban. The broader lesson is that manufacturing interruptions, concentrated supply and sudden changes in demand can affect any country. The WHO identifies shortages and stock-outs of essential medicines, particularly for non-communicable diseases, as a barrier to access across health systems.The pressure on penicillin manufacture offers another view of the problem. A Reuters report on Sandoz's Kundl plant in Austria describes Europe's last fully integrated site making penicillin from its early production stages through to finished antibiotics. Sandoz says low-priced imported ingredients and purchasing practices focused on price threaten the plant's viability. In its 2025 results, the company reported that falling prices for key penicillin ingredients had already affected its generics business. The plant has not closed. This is a warning about the economic sustainability of capacity, rather than evidence of a current penicillin shortage caused by Kundl.Sandoz has sought an EU investigation into allegedly unfairly priced Chinese amoxicillin ingredients. That allegation remains to be tested through the trade process, a low price alone does not prove dumping. The public-health concern can be assessed separately. If buyers rely increasingly on a small number of upstream producers, how quickly could another qualified plant increase output after a disruption? Reuters reported that China's share of EU imports of penicillins and their derivatives rose from 44% in 2019 to 86% in 2025. That is a share of imports in a defined trade category, not a measure of all penicillin consumed in Europe or of South Africa's suppliers..Read more:.Local drugmakers sound alarm: Import policies gutting SA medicine manufacturing base .South Africa then faces a series of decisions. National tenders determine which suppliers provide medicines. Regulators assess products and may permit exceptional imports when justified. Provinces order and distribute the medicines, while facilities must have the right strength in stock when a patient arrives. A global shock may start a problem. Contract design, forecasting and response time determine how much of it reaches the patient. Equally, a local contract failure should not automatically be blamed on a global shortage.In October 2026, the Western Cape government described manufacturing and regulatory challenges, supplier constraints, import and customs delays, and delays in product testing or release. It said it had raised stock-outs nationally in June and sought an intervention with timelines in September. These are different bottlenecks requiring different remedies. More local manufacturing could help with some vulnerabilities, but it cannot by itself fix late orders, a poorly structured tender or a failure to move available stock between facilities.What rivaroxaban revealsAccording to the department's circular, Cipla Medpro said it could no longer fulfil its contract for rivaroxaban 10mg, 15mg and 20mg tablets. Officials were exploring quotations from registered manufacturers outside the contract. Cipla also said it would discontinue its 2.5mg tablets because supply was no longer commercially viable, although it expected its existing stock to meet average public-sector demand until the end of that tender period. An expectation based on average use still needs monitoring if demand changes.Finding a replacement is more complicated than asking another supplier to send tablets. The department's Contract Management Unit notes that manufacturers outside national contracts may be able to provide only limited quantities because they do not routinely produce at public-sector volumes. The rivaroxaban circular says the department is also exploring section 21 import authorisation if a suitable international source can be identified. These routes require procurement and regulatory work before stock can reach facilities, the circular does not quantify the costs or lead times.Clinical substitution carries costs of its own. The rivaroxaban circular separates recommendations for people treated after deep vein thrombosis or pulmonary embolism from those receiving stroke prevention for atrial fibrillation. It identifies apixaban as an option in certain circumstances and warfarin for selected patients with severe kidney impairment. A change to warfarin requires regular international normalised ratio (INR) blood tests and dose adjustment. The department explicitly asks facilities to make that monitoring available. The patient also needs to know when the old treatment ends and the new one begins, a decision that belongs with the treating clinician.For a person who lives far from a testing service, additional appointments would have a price. If a replacement were available only at a hospital pharmacy, transport would incur additional costs. Such burdens could fall on households and frontline services even if the purchase price of alternative medicine looked favourable. We cannot calculate a national patient cost from the circular, because it contains no facility-level numbers. We can identify what should be measured: switching, additional tests, repeat visits, interrupted dispensing and any emergency procurement premium.Buy reliability as well as tabletsThe national DoH maintains a monthly hot list for contracted essential medicines at risk of shortage. It records supply pressures, causes and proposed remedial action. This is a useful start. A stronger procurement review would examine how many products depend on a single supplier, whether backup suppliers can produce the necessary volumes, how early a contractor must signal failure, and what it costs to activate an alternative. A backup printed on a procurement plan has little value if it cannot deliver before patients run out.Contracts should be assessed against total cost over the period of care, including delivery reliability and the cost of failure. The Kundl penicillin case illustrates the longer-term industrial question. A low purchase price may cease to be a bargain if it drives a qualified manufacturer out of the market. This is a risk to test, not a reason to accept any manufacturer's requested price or protective tariff. Public support for production or spare capacity should buy verifiable quality, volumes and continuity. Procurement assumptions should be published and delivery measured. Where alternative suppliers require approval or a different pack size, the lead time should be known before an emergency. Forecasts should reflect actual use across provinces, and stock visibility should reach the facility rather than stop at a central depot.There is also a question of accountability. For the rivaroxaban disruption, the public should be told which strengths and facilities are affected, when alternative stock is expected, and whether patients who need a change of treatment can obtain the required clinical review and monitoring. An aggregate report would protect patient privacy. It would allow Parliament and the public to assess the response without confusing a supply warning with proof that patients went untreated..Read more:.Genetics and personalised medicine: How functional genomics guides cancer treatment.The October holiday-dispensing notice already asks facilities to consider local stock before issuing more than a month's supply of treatment for some chronic conditions. That may preserve stock across more patients, while requiring additional journeys from those least able to afford them. A reliable medicine system must account for these shifted costs.The rivaroxaban warning offers an opportunity to test whether South Africa can act before a national contract problem becomes a patient crisis. The Sandoz story asks whether procurement systems preserve enough qualified production to respond when the next disruption occurs. These are different risks, and both require evidence about supplier resilience, timely information, safe substitution and delivery to the last clinic..Sign up for your early morning brew of the BizNews Insider to keep you up to speed with the content that matters. The newsletter will land in your inbox every morning on weekdays. Register here.Support South Africa's bastion of independent journalism, offering balanced insights on investments, business, and the political economy, by joining BizNews Premium. Register here.If you prefer WhatsApp for updates, sign up to the BizNews channel here.

From penicillin to a blood thinner: what medicine shortages really cost | Prof Colleen Aldous

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