Community pharmacists experienced increased medicine shortages during the disruptive situations. Patients were perceived to suffer poor health outcomes and negative emotions. Participants felt that dealing with prolonged medicine shortages experienced during the disruptions was time-consuming and caused patients to lose trust in them, impairing the pharmacist-patient relationship. The perceived financial impact on patients was out-of-pocket costs, whereas pharmacies lost sales. Mitigation strategies were medicine substitution, contacting stakeholders and stock management. These findings were not dissimilar to those experienced during normal working conditions.

This is the first qualitative study to explore medicine shortages in South African community pharmacies. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used in this study, to ensure credibility. Trustworthiness is displayed through the transparency and consistency of the research steps followed [23, 24]. Recall bias may be a limitation and this study cannot be generalised, as the sample was small and limited to one city. Interviews with pharmacists who suffered property loss due to disruptive situations were omitted from this study.

Participants had similar explanations for the term “medicine shortages”, unlike the findings of Bogaert et al., who interviewed various stakeholders [20]. Opposing views on the dynamics of medicine shortages in recent years may be attributed to recall bias. The “ripple effect” described is congruent with the “vicious cycle” described by Tan et al. [16]. The perceived reasons for medicine shortages included pandemics, natural disasters and civil unrest. This builds on the previously reported causes under normal conditions [1, 18]. The COVID-19 pandemic was believed to impact the supply chain. The panic buying of medicines aligns with studies in Pakistan and India [7, 17]. This study highlights that civil unrest and flooding were perceived to exacerbate and prolong supply chain issues. However, the impact of electricity disruptions, which may be attributed to adaptations, was not discussed.

Medicine shortages may result in poor financial, emotional and health outcomes for patients. Patients were perceived to pay out-of-pocket costs, in line with prior studies [1, 4, 5]. Pharmacists felt that dealing with medicine shortages was time-consuming. When alternative medicines were unavailable, patients would go to other pharmacies. Comparable outcomes occurred in Belgium and Pakistan, where pharmacists reported an increased workload and a loss of income [6, 7]. The mitigation strategies of contacting other pharmacies via group messaging applications mirror previous findings [8, 12, 15]. In addition to medicine substitution mentioned in previous research, this study highlights dispensing different dosage forms or splitting fixed-dose combinations into individual medicines [15,16,17]. Bulk stock was perceived to restrict cash flow, similar to the findings of Tan et al. [16].

As reported in previous studies, communication, collaboration and policy changes were suggested [1, 5, 7, 8, 14,15,16]. Several countries have regulations for mandatory reporting and national medicine shortage websites [25]. The South African public sector has a dedicated website, entitled the “Stop Stockouts Project” and the National Drug Policy of 1996 advocates keeping adequate essential medicines [8]. However, there is still a need for a national database and policies in the private sector. More uniformity between the public and private sectors in South Africa is anticipated, as the country shifts to universal health coverage with the National Health Insurance (NHI) [26].

Further national qualitative research on medicine shortages should include a patient perspective; and a quantitative evaluation of which products were most affected.