Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption

Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

Lessons learnt from daily oral PrEP delivery to inform national planning for PrEP ring introduction for women in low-income and middle-income countries: a qualitative inquiry of international stakeholders

INTRODUCTION

Some African countries plan to introduce and scale-up new long-acting pre-exposure prophylaxis methods (LA-PrEP), like the monthly dapivirine vaginal ring (PrEP ring) and injectable cabotegravir. National costed implementation plans, roadmaps for successful product implementation, are often overlooked. International stakeholders engaged in oral PrEP planning, introduction and scale-up are an information resource of lessons learned to advise LA-PrEP planning. We consulted such international stakeholders and synthesised oral PrEP lessons to inform the development of a costed rollout plan template for LA-PrEP.

METHODS

From selected global health organisations (five international nongovernmental, four donor, four university/research and two multilateral), we interviewed 27 representatives based in America, Europe, Asia and Africa about strategic content and approaches for LA-PrEP policy, programming and implementation. We conducted a thematic analysis of the interview data for implementation considerations.

RESULTS

From the consultations, we identified six implementation themes for LA-PrEP introduction and scale-up: (1) ethically increasing choice and avoiding coercion; (2) de-stigmatising PrEP by focusing on preference rather than risk-based eligibility; (3) integrating LA-PrEP into services that are more woman-oriented, couple-oriented and family-oriented, and providing private spaces for LA-PrEP delivery; (4) de-medicalising delivery of relatively safe products (eg, PrEP ring); (5) constructing multilevel, nuanced communication strategies to address measured and perceived product efficacy and effectiveness; and (6) devising product-agnostic, modular approaches to service delivery. Despite the widespread emphasis on integration, few stakeholders offered empirical examples of successful integration approaches and frameworks.

CONCLUSIONS

Lessons learnt from stakeholder participants suggest standardised and modular processes can improve efficiencies in LA-PrEP planning and implementation. Tiered communication strategies addressing product efficacy and effectiveness will improve clients' and providers' efficacy in making informed decisions. Integration is important for LA-PrEP delivery, but data on empirical integration approaches and frameworks is minimal: further research in this discipline is needed.

Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

The impact of local supply of popular contraceptives on women's use of family planning: findings from performance-monitoring-for-action in seven sub-Saharan African countries

Contraceptive use has substantial implications for women's reproductive health, motivating research on the most effective approaches to minimize inequalities in access. When women prefer to limit or delay fertility but are not using contraception, this potentially reflects demand for contraception that is not being satisfied. Current literature emphasizes a nuanced integration of supply and demand factors to better understand this gap. In this research, we examine the interconnectedness of supply and demand factors both conceptually and methodologically by augmenting existing measures of local supply with a demand-side factor-community-level preferences for contraceptive methods. Using novel data from Performance Monitoring for Action (PMA) in seven sub-Saharan African countries, we test whether the available supply of locally preferred methods at nearby service delivery points (SDP) explains variation in women's uptake of contraception beyond the more typical measure of contraceptive stockouts. Findings from logistic regression analyses (N = 32,282) suggest that demand and supply can be understood as tightly interconnected factors which are directly affected by local social preferences. The odds of women using modern contraception increase significantly when locally preferred methods are available, and this is true even after controlling for the availability of methods in general. The new measure tested in this research centers women and their specific desires in a manner consistent with the promotion of contraceptives as an important human right.

Contracting retail pharmacies as a source of essential medicines for public sector clients in low- and middle-income countries: a scoping review of key considerations, challenges, and opportunities

BACKGROUND

Insurances in high-income countries (HIC) often contract with private community pharmacies to dispense medicines to outpatients. In contrast, dispensing of medicines in low- and middle-income countries (LMICs) often lacks such contractual arrangements. Furthermore, many LMICs lack sufficient investment in supply chains and financial and human resources to guarantee stock levels and services at public medicine-dispensing institutions. Countries striving to achieve universal health coverage (UHC) can, in principle, incorporate retail pharmacies into their supply chains to expand access to essential medicines (EMs). The objectives of this paper are (a) to identify and analyze key considerations, opportunities and challenges for public payers when contracting out the supply and dispensing of medicines to retail pharmacies and (b) to provide examples of strategies and policies to address these challenges.

METHODS

A targeted literature strategy was used to conduct this scoping review. We created an analytical framework of key dimensions: (1) governance (including medicine and pharmacy regulation); (2) contracting (3) reimbursement; (4) medicine affordability (5) equitable access; and (6) quality of care (including 'patient-centered' pharmaceutical care). Using this framework, we selected a mix of three HIC and four LMIC case studies and analyzed the opportunities and challenges encountered when contracting retail pharmacies.

RESULTS

From this analysis, we identified a set of opportunities and challenges that should be considered by public payers considering public-private contracting: (1) balancing business viability with medicine affordability; (2) incentivizing equitable access to medicines; (3) ensuring quality of care and delivery of services; (4) ensuring product quality; (5) task-sharing from primary care providers to pharmacies and (6) securing human resources and related capacity constraints to ensure sustainability of the contract.

CONCLUSION

Public-private partnerships offer opportunities to improve access to EMs. Nonetheless, managing these agreements is complex and is influenced by a variety of factors. For effective contractual partnerships, a systems approach is needed in which business, industry and regulatory contexts are considered in tandem with the health system. Special attention should be devoted to rapidly changing health contexts and systems, such as changes in patient preferences and market developments brought about by the COVID-19 pandemic.

Choice of a family planning outlet in urban areas: The role of distance and quality of services in Kenya and Uganda

Introduction

Quality of care and physical access to health facilities affect facility choice for family planning (FP). These factors may disproportionately impact young contraceptive users. Understanding which components of service quality drive facility choice among contraceptive users of all ages can inform strategies to strengthen FP programming for all potential users of FP.

Methods

This study uses data from Population Services International's Consumer's Market for Family Planning (CM4FP) project, to examine drivers of facility choice among female FP users. The data collected from female contraceptive users, the outlet where they obtained their contraceptive method, and the complete set of alternative outlets in select urban areas of Kenya and Uganda were used. We use a mixed logit model, with inverse probability weights to correct for selection into categories of nonuse and missing facility data. We consider results separately for youth (18–24) and women aged 25–49 in both countries.

Results

We find that in both countries and across age groups, users were willing to travel further to public outlets and to outlets offering more methods. Other outlet attributes, including signage, pharmacy, stockouts, and provider training, were important to women in certain age groups or country.

Discussion

These results shed light on what components of service quality drive outlet choice among young and older users and can inform strategies to strengthen FP programming for all potential users of FP in urban settings.

Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study

BACKGROUND

The prevalence of modern contraception use is higher in Kenya than in most countries in Sub-Saharan Africa. The uptake has however slowed down in recent years, which, among other factors, has been attributed to challenges in the supply chain and increasing stockouts of family planning commodities. Research on the frequency of contraceptive stockouts and its consequences for women in Kenya is still limited and mainly based on facility audits.

METHODS

This study employs a set of methods that includes mystery clients, focus group discussions, key informant interviews, and journey mapping workshops. Using this multi-method approach, we aim to quantify the frequency of method denial resulting from contraceptive stockout and describe the impact of stockouts on the lived experiences of women seeking contraception in Western Kenya.

RESULTS

Contraceptives were found to be out of stock in 19% of visits made to health facilities by mystery clients, with all contraceptive methods stocked out in 9% of visits. Women experienced stockouts as a sizeable barrier to accessing their preferred method of contraception and a reason for taking up non-preferred methods, which has dire consequences for heath, autonomy, and the ability to prevent unintended pregnancy. Reasons for contraceptive stockouts are many and complex, and often linked to challenges in the supply chain - including inefficient planning, procurement, and distribution of family planning commodities.

CONCLUSIONS

Contraceptive stockouts are frequent and negatively impact patients, providers, and communities. Based on the findings of this study, the authors identify areas where funding and sustained action have the potential to ameliorate the frequency and severity of contraceptive stockouts, including more regular deliveries, in-person data collection, and use of data for forecasting, and point to areas where further research is needed.

Trends in contraceptive method mix among adolescents and youth aged 15-24 in low- and middle-income countries

Background

Method mix - the percent distribution of contraceptive use by method among contraceptive users - reflects both client choice of method and method availability. In a country where clients have access to a wide range of methods at an affordable price, method mix is a strong proxy for method choice. In contrast, where access is limited by numerous factors - method availability, cost, or provider attitudes - method mix may not capture method choice well. Given that method mix can be measured reliably from population-based surveys, it is useful in exploring method choice. While the method mix for all women of reproductive age (15-49 years) has been described previously, the method mix for adolescents and young women aged 15-24 remains unexplored despite this population's high risk for unintended pregnancy.

Objectives

This study investigates the contraceptive method mix for women aged 15-24 in low- and middle-income countries (LMICs) with national survey data and describes how the method mix differs by age group, geographic region, and marital status for women.

Methods

Using data from the Demographic and Health (DHS) Surveys, the contraceptive method mix among women aged 15-24 across 64 LMICs is analyzed by age, marital status, and region, with measures of skew and average deviation. Three case studies are presented in which the trend over time in the method mix is examined.

Results

There are large variations in method mixes across regions, which reflect their differences in various supply and demand constraints. However, there is consistently high usage of short-acting methods among both age groups, 15-19 and 20-24, compared to the full population of all women of reproductive age. Male condoms overwhelmingly predominate as the method used by women 15-24 in all regions.

Conclusion

The marked differences found by marital status, region, and age show the need for programs to be tailored to local circumstances. Additionally, the large unmet need for contraception signals the ongoing urgency for strengthened programmatic efforts, and for a wider offering of methods to enlarge the choices available to young women. Unmarried women in particular deserve attention, as well as young married women who wish to postpone a pregnancy.

Understanding factors associated with continuation of use of injectable contraceptives in Karnataka and Maharashtra, India: a cross-sectional household study

The Government of India has worked to expand access to injectable contraceptives through the introduction of a three-monthly injectable contraceptive MPA under the ‘Antara’ program in 2017. However, the uptake of injectable contraceptives has remained low, and few studies have investigated the experiences of public health facility injectable clients in India. We examined factors associated with continuing, discontinuing, and switching methods among injectable users obtaining services from public health facilities in the Indian states of Karnataka and Maharashtra. The study team recruited respondents (N=1009) that had received their first injectable dose from in public sector facilities between February – May 2019 and conducted a follow-up visit at their residence in December 2020. We used multivariate logistic regression to study the association of the demographic characteristics, service quality, satisfaction with services, follow-up visits, and decision-making on injectable continuation and switching to other family planning methods. Injectable usage rates declined significantly, with 44% of clients receiving a second dose and only 16% receiving a third dose. Over half of women (54%) cited problems related to periods as the reason for discontinuing injectable use after the first dose. Respondents were more likely to continue their method at third dose if they were older (25-35 years) (OR:1.68, p<0.05) and had received a reminder for a follow-up dose (OR: 2.41, p Our results also highlight the importance of addressing side-effects experience by women, which may be better managed by community-based follow-up visits and high-quality counselling services.

DMPA-SC stock: Cross-site trends by facility type

Objectives

To measure trends in the supply of DMPA-SC in public and private health facilities and compare with other prominent modern methods.

Study design

We used repeated cross-sectional data from service-delivery-point surveys in six settings: Burkina Faso, Democratic Republic of Congo (Kinshasa and Kongo Central), Nigeria (Kano and Lagos), and Uganda, each with 3-5 rounds of data collected between 2016 and 2020. We analyzed trends in DMPA-SC availability using percent of service delivery points offering the method and percent experiencing stockouts; trends were compared with those for DMPA-IM, IUD, implants, and other short-acting methods, by facility type.

Results

All settings showed increased offering of DMPA-SC over time for both private and public facilities. Larger proportions of public facilities provided DMPA-SC compared to private facilities (66%–97% vs 16%–50% by 2019–2020). DMPA-SC was provided by fewer facilities than DMPA-IM (90%–100% public, 34%–69% private by 2019–2020), but comparable to implants (83%–100% public, 15%–52% private by 2019–2020) and IUDs (55%–91% public, 0%–44% private by 2019–2020). Trends of DMPA-SC stock varied by setting, with more consistent stock available in private facilities in the DRC and in public facilities in Burkina Faso and Nigeria. Uganda showed decreasing stock in public facilities but increasing stock in private facilities.

Conclusion

DMPA-SC availability has been increasing since its introduction in sub-Saharan Africa, yet significant gaps in stock exist. Countries should consider alternative distribution models to address these issues.

Implications

Our findings may help inform countries about the need to monitor DMPA-SC availability and to consider solutions that ensure contraceptive options are available to women who need them and disruptions to contraceptive use are minimized.