The purpose of this study was to examine SCM inefficiencies in rural PHC facilities in South Africa, focusing on how these challenges affect clinic operations, patient care, service delivery and health outcomes from the perspective of OMs and PHC supervisors.

The study objectives were:

This section outlines the central gaps motivating the study and establishes how systemic inefficiencies translate into managerial adaptation. It also links directly to the propositions that guide subsequent analysis. Despite decades of investment in strengthening South Africa’s PHC system, operational bottlenecks in the management of the supply chain (procurement process of medical supplies, equipment and stationery) remain prevalent, particularly in rural facilities or clinics (Matlala et al. 2021; Rispel et al. 2020). These clinics serve as an entry into the health system, the first point of contact for millions of patients, yet are often burdened by unreliable, disjointed and uncoordinated supply chains; fragmented procurement processes and chronic resource shortages (Mukeredzi et al. 2023). Operational managers, who are tasked with overseeing SCM (medical supplies, equipment and other supplies) at the clinic level, report minimal involvement in procurement decision-making and supplier selection, relying instead on bureaucratic hospital-based supply chain processes that are not suited for the dynamic needs of rural clinics (Pienaar et al. 2024). The continued use of manual inventory systems and the lack of direct access to suppliers hinder efficient stock management, leading to stock-outs of essential medical and other supplies and, as a result, delaying effective and needed patient care (Tshabalala et al. 2022).

Moreover, existing health system reforms, including the ICRM programme, have not sufficiently addressed the operational realities of rural clinics (Mhlungu et al. 2024; Pillay et al. 2023). Clinics are expected to meet increasingly complex service delivery demands without corresponding improvements in their supply chain infrastructure or managerial autonomy (Mbunge et al. 2022). These structural inefficiencies worsen staff workload, disrupt service delivery, and negatively impact health outcomes, particularly in maternal and child health, chronic care and emergency services (Gumede et al. 2019; Mahlaba et al. 2021). While prior research has documented supply chain challenges in the broader public health sector, empirical evidence specifically focusing on the operational impacts of SCM inefficiencies at the rural PHC clinic level, through the lens of OMs, remains scarce (Ouma et al. 2024). Hence, its actual evidence-based impact on the provision of services at PHC (the core and provider of primary health care services) is unknown.

Without evidence-based interventions to improve SCM systems and empower OMs, South Africa’s rural PHC clinics will continue to face avoidable service disruptions and compromised patient outcomes.

In addition, despite the increasing recognition of healthcare and SCM as vital for ensuring equitable access to essential medical commodities in LMICs, critical gaps remain in our conceptual understanding of how frontline managers respond to systemic procurement and logistics vulnerabilities (Dubey, Gunasekaran & Childe 2022; Yadav 2024). While SCM research often emphasises infrastructure or technical inefficiencies, there is insufficient attention to how such inefficiencies alter the roles and decision-making of OMs during routine service delivery (Setiawati, Simatupang & Okdinawati 2024). Thus, this study seeks to address the gap in understanding how centralised procurement systems, manual inventory processes and fragmented logistics in rural South Africa reshape managerial expectations and resilience at the clinic level.

Furthermore, by focusing on the managerial and institutional dynamics of SCM, rather than only infrastructural deficiencies, this study aims to expand theoretical frameworks and inform policy reforms in decentralising procurement and enhancing system responsiveness. Generating empirical insights from frontline managers is essential for informing policies and operational reforms aimed at optimising healthcare delivery in resource-constrained PHC settings.

This section synthesises existing research on healthcare SCM, resilience and institutional theory, highlighting both structural and managerial gaps in LMIC contexts. It provides the conceptual foundation for the propositions introduced earlier.

This study is underpinned by three interrelated theoretical perspectives that help explain supply chain challenges and managerial responses in rural South African healthcare settings.

Building on the theoretical framework outlined above, the methodology was designed to examine how SCM inefficiencies manifest in rural PHC clinics and how OMs respond to these challenges. The research design, data collection and analytical approach were selected to ensure that both structural constraints and managerial adaptations could be captured in sufficient depth.

The study drew on the SCOR model to frame the analysis of SCM processes. The SCOR model also guided the way SCM processes were examined. It offered a clear structure for looking at how clinics plan, source, deliver and return essential items. This structure was used to organise the themes on procurement, inventory management and distribution, and to link specific barriers to particular points in the supply chain. Insights from dynamic capabilities and institutional theory then helped to interpret how managers responded to these constraints in their daily work.

Dynamic capabilities theory guided attention to how OMs adjusted routines, combined resources and improvised solutions when procurement, particularly the inventory systems (NSI requisitions), failed. Institutional theory, in turn, helped to frame these adaptations within the constraints of formal rules, hierarchies and bureaucratic procedures that shape clinic-level decision-making. Insights from both dynamic capabilities and institutional theory informed the interpretation of managerial practices and systemic influences. The integration of these three theories ensured that the methodology is both empirically grounded and theoretically aligned.

This study adopted a qualitative, exploratory research design to investigate SCM inefficiencies in the management of medical supplies and equipment in rural PHC clinics. A qualitative approach was deemed appropriate to capture the in-depth experiences and perspectives of OMs responsible for supply chain oversight at the clinic level (Creswell & Poth 2018). Given the unavailability of clinic-level operational data in South Africa’s rural health sector, an exploratory design was particularly suitable for generating empirical insights and uncovering underlying operational barriers (Mukeredzi et al. 2023).

The research was conducted in rural PHC clinics located within the uMkhanyakude Health District of KwaZulu-Natal, South Africa. This district, recognised for its geographical isolation and resource constraints, encompasses 56 PHC clinics and five community healthcare centres within five sub-districts that serve dispersed and impoverished rural populations. Clinics are managed by OMs responsible for overseeing medical supplies, equipment and operational services within the constraints of centralised SCM structures.

The study population consisted of OMs overseeing the day-to-day operations of PHC clinics, specifically responsible for medical supplies and equipment management and PHC supervisors who are responsible for managing OMs.

Purposive sampling was utilised to identify participants with specific operational responsibilities managing clinics and in SCM (Etikan, Musa & Alkassim 2016). This included managing all SCM activities and value chain at PHC level. Selection criteria included:

A total of 19 participants (17 OMs and two PHC supervisors) were purposively selected across various clinics within the district, ensuring representation of diverse clinic sizes, locations and operational challenges. Sampling continued until thematic saturation was achieved.

Data were collected through semi-structured, in-depth interviews. An interview guide, developed from literature and pilot-tested prior to implementation, focused on exploring:

Interviews were conducted in English, audio-recorded with participant consent, and supplemented with field notes. Each interview lasted approximately 45–60 min and was conducted either on-site or virtually depending on participant preference and logistical feasibility.

Interviews were transcribed verbatim and analysed using thematic analysis, following Braun and Clarke’s six-phase framework (Braun & Clarke 2019). Transcripts were iteratively coded using a combination of deductive codes informed by literature and inductive codes emerging from the data. NVivo software (version 12) facilitated data management and coding processes. Themes were derived focusing on:

Patterns of improvisation and workarounds were read through a dynamic capabilities’ lens, while the persistence of rigid SCM processes, mainly procurement and reporting structures, was interpreted using institutional theory.

The trustworthiness of the findings was ensured through reflexivity, audit trails and member checking with a subset of participants to validate emerging themes (Nowell et al. 2017).

The study adhered to the four criteria of trustworthiness (credibility, dependability, confirmability and transferability) as outlined by Lincoln and Guba (1985). The strategies that were implemented to ensure rigour included prolonged engagement with participants, triangulation of data sources (interviews and field notes), reflexive journaling by the researcher, peer debriefing sessions with supervisory experts, and lastly, thick description to enhance contextual understanding.

Ethical clearance was granted by the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (Ref: HSS/2107/017D) prior to commencement with data collection. Permission to conduct the study was obtained from the KwaZulu-Natal Department of Health. Written informed consent was secured from all participants prior to data collection. Participants’ confidentiality and anonymity were rigorously maintained throughout the study.

One of the most prevalent challenges identified was the persistence of bureaucratic, centralised procurement systems that restrict clinic autonomy. Recent studies have shown that local procurement changes can help alleviate these limitations by making government agencies more responsive and reducing bureaucratic red tape. For example, the Global Health Supply Chain Program – Procurement and Supply Management (GHSC-PSM 2023) found that subnational procurement best practices facilitate faster access to essential supplies through simplified contracting and primary supplier arrangements. Direct health facility financing greatly improved the timeliness of sourcing medicines and consumables, according to research from Tanzania (Ruhago et al. 2023), proving the value of giving facilities greater financial and operational autonomy. The procurement process remains heavily centralised at sub-district and hospital levels, resulting in delays and inefficiencies. These delays are further shaped by the complex legislative framework governing government-funded procurement, such as the Public Finance Management Act and Preferential Procurement Policy Framework Act (which often impose multiple compliance requirements that limit flexibility and reduce the feasibility of timely clinic-level decision-making).

Clinics lack direct engagement with suppliers, limiting their ability to respond flexibly to urgent needs. Studies in the South African context indicate that stock visibility system (SVS) and the national surveillance centre (NSC) have improved transparency and supplier accountability, yet their effectiveness is contingent upon empowering frontline staff to act on the data generated (Falco, Meyer & Putter 2023; Global Health Supply Chain – Technical Assistance [GHSC-TA] 2019). These findings highlight that without complementary decentralisation of authority, visibility tools alone cannot resolve procurement bottlenecks. These systemic weaknesses are consistent with reports from other LMIC contexts, where rigid bureaucratic ordering systems constrain service responsiveness (Pienaar et al. 2024; Rispel et al. 2020).

The persistence of procurement delays and weak inventory systems in South African rural clinics is consistent with evidence from other LMIC contexts. In Ghana, for instance, inefficiencies in procurement procedures and limited facility-level autonomy have been shown to compromise the availability of essential medicines in remote districts (Boateng, Darko & Mensah 2021). Similarly, in Nepal, rural PHC centres have struggled with chronic interruptions in supply as a result of fragmented procurement and infrastructural barriers, particularly during health emergencies (Bhandari, Paudel & Adhikari 2020). These comparative insights highlight that systemic weaknesses are not isolated to South Africa but reflect broader structural constraints facing LMIC health systems.

Recent scholarship highlights that digital transformation, including the use of big data analytics, can provide predictive insights that improve forecasting accuracy and optimise procurement cycles in health supply chains (Al Nuaimi & Awofeso 2025; Talwar, Kaur & Gupta 2021). For rural PHC facilities, such innovations could help anticipate demand spikes and prevent recurring stock-outs, although their success remains dependent on infrastructural readiness and managerial capacity (Tortorella, Fogliatto & MacCarthy 2023). This suggests that SCM systemic inefficiencies should not only be addressed through decentralisation but also through gradual adoption of analytical and digital tools that strengthen resilience against volatility.

Inadequate stock tracking and reliance on manual inventory controls further compound procurement inefficiencies. Similar challenges have been reported across LMICs, where manual inventory systems are strongly associated with errors, delays and weak accountability. In South Africa, Mbonane, Sibanda and Matlala (2023) found that while healthcare professionals recognised the value of SVS for stock monitoring, adoption was hindered by inadequate training and lack of managerial support. Comparative assessments of digital health logistics management systems, demonstrated by studies in Ethiopia’s Amhara Region, revealed significant differences between physical and electronic inventory records, with inventory accuracy rates around 70% and variations in data completeness and timeliness. These findings highlight the inadequate efficacy of digital tools in the absence of strong infrastructure, ongoing training and data verification protocols (Mekonen, Cho & Fenta 2025).

The absence of standardised digital systems exposes facilities to stock mismanagement, human error and reduced accountability. National assessments validate this disparity, indicating that despite the implementation of SVS in over 3,000 PHC clinics and 300 hospitals, significant differences in digital adoption and connectivity persist (Falco et al. 2023). These findings indicate that digitisation is not merely a technology issue but also an equity issue, as rural institutions frequently lack the infrastructure to effectively benefit from these systems.

Prior literature recognises digitisation as key to improving inventory accuracy and visibility across health systems (Mbunge et al. 2022; WHO 2021). However, the technological divide in rural PHC settings persists, leaving frontline managers to improvise with fragmented paper-based systems.

Maintenance delays also contribute significantly to operational disruptions, as repairs are often dependent on hospital-based teams that frequently lack the resources to reach remote clinics. The continuity of service in rural clinics is directly dependent on the quality of infrastructure. West et al. (2021) indicated that inadequate maintenance and limited space in Mpumalanga rural clinics affected nurses’ capacity to deliver consistent care. In-depth evaluations of the ICRM programme initially established to enhance PHC quality indicate ongoing implementation problems, particularly in rural and detached clinics. Onoya et al. (2025) stated in their fast evaluation that several facilities continue to fall short of the ICRM requirements as a result of infrastructure deficiencies, restricted management capabilities and supply chain disruptions. These infrastructural deficiencies mirror broader findings that weak maintenance systems undermine PHC resilience and sustainability in rural regions (Pillay et al. 2023).

The findings also illustrated how SCM inefficiencies cascade into operational strain, staff burnout and patient service disruptions. Operational managers are forced to divert their time away from strategic functions to perform routine procurement and stock management. This diversion of managerial capacity aligns with broader evidence on workforce strain in South Africa. From a dynamic capabilities perspective, these managers constantly stretch their roles and redesign small processes to ensure service continuity. However, institutional theory reminds us that these efforts take place within rigid SCM systems (particularly procurement) and reporting systems that restrict genuine system improvement, leaving OMs to absorb the strain rather than changing the underlying rules.

Khan et al. (2024a) and Khan et al. (2024b) note that the cumulative burden of administrative tasks and resource shortages contributes to high levels of burnout and role dissatisfaction among health professionals. Such role misalignment undermines not only managerial effectiveness but also system resilience in the long term. This role misalignment undermines their intended leadership contributions and exacerbates inefficiencies, echoing similar evidence from other sub-Saharan African PHC settings (Mahlaba et al. 2021; Mukeredzi et al. 2023). Beyond workforce strain, inequities are reinforced when rural patients experience avoidable delays or are forced to incur out-of-pocket costs because of service interruptions. Evidence shows that health system resilience is closely linked to equitable distribution of supplies, with fragile systems often amplifying disparities between rural and urban populations (Ergun et al. 2023). This means that supply chain inefficiencies are not only technical failures, but also drivers of inequality that compromise the sustainability of universal health coverage goals (WHO 2021).

Frequent stock-outs and delays in infrastructure repairs contribute to service interruptions, diminished patient trust and increased reliance on informal workarounds. Patient experiences in South Africa validate the correlation between supply reliability and trust in healthcare services. A recent investigation of rural hospitals revealed that the scarcity of medications, inadequate infrastructure and recurrent service interruptions undermined patients’ trust in the healthcare system (Chitha et al. 2024). West et al. (2021) also noted that patients perceive frequent shortages as signs of systemic neglect, adversely affecting health-seeking behaviour.

While such adaptive practices help sustain day-to-day service delivery, they reflect deeper systemic dysfunctions and fragile governance structures (Naidoo et al. 2023). In line with other African studies, the personal sacrifices of PHC managers, including financial outlays, highlight the resilience of frontline staff while also revealing unsustainable coping mechanisms that perpetuate inequities in health systems (Matlala et al. 2021).

The proposed solutions emphasise decentralisation, digitisation and training as critical reform areas. Decentralised procurement, including the allocation of petty cash or emergency micro-budgets, would enhance flexibility and responsiveness to urgent supply needs. Results from a study in Tanzania indicate that direct financing of health facilities enhances local responsibility and increases the availability of essential supplies by allowing clinics to purchase what they require promptly and in real time (Ruhago et al. 2023). Similarly, United States Agency for International Development (USAID)’s global supply chain assessments indicate that subnational procurement methods can improve efficiency while maintaining oversight through framework contracts and performance monitoring (GHSC-PSM 2023). Such measures resonate with growing evidence that localised financial autonomy can strengthen accountability and timeliness in PHC service delivery (Ouma et al. 2024).

The study also highlights the urgent need for structured training in SCM and financial oversight for OMs. Limited exposure to management training (particularly customised DOH health SCM) undermines their ability to implement efficient and accountable processes. Empowering frontline managers with skills in procurement governance, budgeting and digital systems is therefore essential to sustainable reform (Mukeredzi et al. 2023). However, training alone is unlikely to address these challenges without clearer administrative structures in rural clinics, as weak organisational arrangements continue to limit the practical application of new skills. In addition to managerial training, strengthening system resilience may require embedding predictive analytics and integrated data systems that enable real-time monitoring and proactive decision-making (Talwar et al. 2021; Yadav 2024). Comparative reviews also suggest that aligning SCM strategies with sustainability principles such as green procurement practices and efficient waste management can reduce costs and environmental impacts while improving the availability of essential supplies (Rezali, Chen & Wong 2021). These broader innovations demonstrate that reforms should combine financial autonomy, digital tools and sustainability-oriented practices to ensure long-term equity and resilience.

Digitisation of procurement and inventory systems emerges as another key strategy. The implementation of such systems has commenced in South Africa. Falco et al. (2023) demonstrate that the NSC has improved the monitoring of pharmaceutical supply at the national level, but Mbonane et al. (2023) demonstrate that the efficacy of SVS is significantly contingent upon sufficient user training and managerial support. The findings indicate that digital tools require accompanying capacity-building programmes and robust infrastructure to be effective at the clinic level.

While challenges such as poor connectivity and lack of hardware were identified, broader health system evidence affirms that even low-cost digital tools can improve efficiency, accuracy and transparency (Mbunge et al. 2022; WHO 2021). Addressing infrastructural deficits, therefore, represents both a technological and equity imperative for rural PHC.

While these theoretical insights extend SCM scholarship, they also carry practical implications. Barriers in procurement, inventory management and distribution undermine both rural healthcare delivery and the resilience of supply chains more broadly. The application of dynamic capabilities theory, institutional theory and the SCOR model illustrates how OMs adapt within these systemic constraints reconfiguring scarce resources (Boada et al. 2024; Dubey et al. 2023), while simultaneously constrained by entrenched bureaucratic rules (Langabeer 2022). The SCOR model, typically applied in manufacturing and logistics, also proves valuable for diagnosing inefficiencies in rural healthcare procurement and delivery (Setiawati et al. 2024). Together, these perspectives provide pathways for translating theoretical insights into targeted operational improvements.

The findings carry important implications for policy, practice and scholarship. For policymakers, addressing inefficiencies in rural PHC SCM requires reforms that decentralise procurement, strengthen digital inventory management, and enhance accountability mechanisms. Evidence from other LMICs shows that decentralised procurement improves timeliness, responsiveness and transparency (Ouma et al. 2024; Ruhago et al. 2023). For South Africa, this suggests that devolving certain procurement responsibilities could reduce bottlenecks and allow greater responsiveness to local demand.

For practice, the results highlight the value of investing in digital systems such as the NSC and SVS. Studies show these tools improve transparency and oversight, although their effectiveness depends on adequate infrastructure, managerial training and user engagement (Falco et al. 2023; Mbonane et al. 2023). Building local capacity to manage such systems is therefore essential for sustaining improvements in procurement and distribution.

For scholarship, the study extends SCM research in LMIC health systems by demonstrating the relevance of dynamic capabilities, institutional theory, and the SCOR model in diagnosing last-mile delivery challenges. It shows how OMs navigate resource scarcity, bureaucratic routines and infrastructural gaps, thereby reframing SCM as a field that is not only technical but also institutional and managerial (Dubey et al. 2023; El Baz et al. 2023; Langabeer 2022).

Finally, the equity implications are significant. Supply chain management inefficiencies disproportionately affect rural patients, reinforcing barriers to access and perpetuating health inequities (Chitha et al. 2024). Strengthening the rural PHC healthcare SCM is therefore central to advancing universal health coverage and achieving more equitable health outcomes in South Africa.

In light of these implications, the following recommendations are proposed to guide policy and practice and also strengthen the rural PHC healthcare SCM in South Africa:

This study contributes to SCM scholarship by extending the application of dynamic capabilities, institutional theory and the SCOR model to rural healthcare contexts. It demonstrates, in line with dynamic capabilities theory, how OMs reconfigure scarce resources to sustain service delivery. Drawing on institutional theory, this study examines how bureaucratic routines and hierarchical controls limit meaningful system change. In contrast, the SCOR model helps identify these issues within specific SCM processes, particularly in procurement and distribution. These insights advance theory by shifting attention from technical processes to the governance and adaptive practices shaping last-mile delivery.

Practically, the study highlights the importance of decentralising procurement, digitising inventory systems, and investing in strengthening managerial capacity through DOH-customised SCM training. Such reforms can strengthen transparency, accountability and responsiveness, thereby improving the resilience of rural PHC SCM.

By linking theoretical frameworks with operational realities, the study offers a balanced contribution to both scholarship and practice, while emphasising equity implications for rural patients who face the greatest barriers to healthcare access.

This study was limited to a specific rural setting in one district and comprised a small qualitative sample of 19 participants. Although this is adequate for topic saturation in qualitative studies, this may constrain the generalisability of findings to other districts or clinic types (clinics situated in townships or metropolitan regions). The dependence on interview data introduces the potential for perception bias, and the lack of triangulation with objective supply chain records, such as SVS or NSC reports, limits the validation of the frequency and severity of the alleged inefficiencies. This study exclusively examined the viewpoints of OMs and their line managers (PHC supervisors), excluding patients, suppliers and senior administrators, whose perspectives would have contributed to a more comprehensive understanding of systemic challenges. Consequently, these constraints emphasise the necessity for further research using mixed approaches, larger samples and multi-stakeholder viewpoints to enhance the evidence base.

Another limitation is that, although the study focused solely on healthcare SCM in rural South Africa, many of the barriers identified such as bureaucratic procurement, transport delays and reliance on manual inventory processes are common across other rural supply chains in LMICs. This again limits the generalisability of findings solely to healthcare and suggests that comparative, cross-sectoral research is required. Future studies could therefore investigate how similar SCM inefficiencies affect agriculture, education or the distribution of essential goods in rural areas, thereby building a more comprehensive evidence base for strengthening community-level resilience.

Future research should evaluate decentralised procurement models, implementation outcomes of digital systems and governance reforms across rural and peri-urban settings. Ultimately, resilient healthcare SCM at the clinic level is not merely a technical fix, but a prerequisite for sustaining equitable healthcare access in rural South Africa and beyond.