According to WHO, in 2018 two billion people had no access to basic medicines, causing a cascade of preventable misery and suffering which disproportionately affect Low- and Middle- Income Countries (LMICs). This research explores why stockout and expiration
of medicines occur in Uganda, a Low-income country.

An embedded multiple-case study was conducted in Uganda focussing on two lifesaving Reproductive Health (RH) commodities – oxytocin injection and misoprostol tablets in the public sector (case 1) and the private sector (case 2) supply chains. Within each case,
the study distinguished high-level (hospitals and HCIV) from low-level (HCIII) health facilities. Data were picked from documents, archival records, and thirty-nine in-depth interviews were conducted. Data were managed using NVivo (12 plus) software.

The study found that performance of health supply chains is shaped by stockout and stock expiration, which are more common in public health supply chains and low-level HFs. The key antecedents of performance of health supply chains are; strategies (including
shared goals, contribution of resources, and shared benefits); structures (including coordinating institutions, SC relationships, coordinating committees and government guidelines); systems, namely information systems (including Information Technology
and information sharing), and performance measurement system (including KPIs and joint performance monitoring); and processes (including demand forecast and supply plan, procurement, warehousing and inventory management, order processing, last mile
distribution, and redistribution of excess stock).

The most impacting antecedents are shared benefits, SC relationships, government guidelines, Information Technology, warehousing and inventory management, and order processing.

The study contributes to theory by proposing and testing a comprehensive framework for improving performance of health supply chains in LMICs. Secondly, the study contributes to practice through providing guidance for effective interventions in health supply chains of LMICs. The recommendations of the study allow to fine tune interventions based on the specific supply chain – public versus private and high-level versus low-level.

Thirdly, the study contributes policy recommendations for improving performance of health SCs in Uganda including review of mandate of the National Medical Stores; leveraging private sector, financial tracking; and aligning departmental strategic plans and
KPIs.