TCI Global Toolkit: Service DeliveryContraceptive Commodity Security
What Is It?
When people are able to choose, obtain, and use affordable, high-quality contraceptives whenever and wherever they want them. Commodity security exists when supportive national policies are in place, logistics management systems are functioning, and the family planning supply chain results in timely and adequate supply of contraceptives to both service providers and clients.
The specific contraceptive commodities consist of:
- Hormonal contraceptives – oral contraceptive pills and injectable contraceptives
- Medical supplies and equipment for permanent methods (female sterilization and vasectomy), such as scalpel blades, antiseptic lotions and anesthetic agents
- Intrauterine devices
- Barrier contraceptives including female and male condoms, diaphragms and caps
- CycleBeads for the Standard Days Method
To ensure family planning commodity security, a proper understanding of the national supply chain, compliance with the national ordering and reporting process and commodity management skills at each level of the Ministry of Health system are needed.
What Are the Benefits?
- Ensures availability of a range of contraceptive choices for clients
- Eliminates missed opportunities in meeting family planning clients’ needs
- Decreases unmet need for family planning by ensuring uninterrupted availability of contraceptive commodities in the facility and minimizing stockouts
- Eliminates contraceptive wastage or losses by ensuring proper selection, procurement, distribution, storage and use of commodities
How to Implement?
Assess national-level commitment
Determining support for commodity procurement at the national level is crucial for your county, city and/or facility-level efforts to improve commodity security. It can be done by looking into some basic indicators, including the following:
- Presence of an active national committee in charge of contraceptives and reproductive health supplies
- Existence of a national government line item for contraceptive procurement
- Availability of a commodity security strategy in which contraceptives and reproductive health supplies are included
- Share of contraceptive supplies financed by the government
For more information and additional indicators and ways to assess national-level commitment, please see the Commodity Security and Logistics section of the MEASURE Evaluation Family Planning and Reproductive Health Indicators Database.
Ensure Robust Data Collection on Commodities
To forecast, plan and monitor the supply chain, you will need high-quality data on the commodities in your country as well as your community. This relies heavily on the information gathered at individual health facilities, at regional warehouses and, in the case of the Informed Push Model, by dedicated logisticians. A centralized electronic system can send real-time information from the county, sub-county and/or facility level to the national level for decision making and national planning (see Step 3).
Advocate at the sub-national level
Your advocacy efforts at the national and county levels should include efforts to improve family planning financing, resource mobilization and supply chain management. To do this, you will collaborate with various partners, including donors, civil society organizations and the government.
In India, the Ministry of Health and Family Welfare (MoHFW) rolled out a dedicated Family Planning Logistic Management Information System (FPLMIS) in 2017 to help improve access to and increase use of modern contraceptive methods, but only for rural areas with plans to eventually use it in urban areas. As a result, The Challenge Initiative for Healthy Cities (TCIHC) met with the state family planning division in December 2018 to make the case for advancing the rollout of the FPLMIS in urban areas, explaining how this would strengthen the supply chain at the urban primary health centers (UPHCs) as well as the last mile via urban ASHAs, a relatively new cadre of frontline health workers in the urban health delivery system. This would mean potential family planning clients would not be turned away without a method from outreach camps or urban health and nutrition days, and no ASHA would have to refuse a method to an eligible family planning client during her household visits due to lack of family planning commodities, specifically oral contraceptive pills (OCP) and condoms. Moreover, this would save time expended by ASHAs, Auxiliary Nurse Midwives (ANMs), pharmacists and medical officers-in-charge in compiling requests for supplies. The state family planning division was convinced by these arguments and approved rolling out the FPLMIS to TCIHC-supported cities. This decision allowed TCIHC to support the creation of unique identification codes for each cadre and a complete database of service delivery points as well as ASHAs, ANMs and other human resources essential to inform supply and demand of commodities for urban areas and facilities. TCIHC supported district teams in coaching ASHAs and ANMs on how to place orders (indenting process) and UPHC staff on inventory management and distribution of supplies.
Improve supply chain management
One way of reducing stockouts is to use the Informed Push Model, implemented by Senegal, to successfully reduce stockouts at the facility level. This model brings the supplies closer to the health facility and streamlines the steps through task sharing supply chain responsibilities from service providers to logistics professionals (Daff et al., 2014). A dedicated logistician brings the commodities on a truck from the regional warehouse to the facilities. The logistician also restocks facilities monthly to maintain a minimum stock level to meet estimated supply needs, eliminating the need for facilities to place and pick up orders. Facilities pay only for the quantities sold.
Key features of the Informed Push Model:
- Proceeds from contraceptive commodity purchases get moved back into the supply chain, helping to keep contraceptive methods in stock and prices low
- Logistics operators design and carry out a regular schedule for supply deliveries
- Logistics operators collect data on product consumption at the time of delivery
- The model alleviates the burden on health facilities
Keys to Strengthening Commodity Security
Another way to reduce stockouts is to introduce a better tracking system. In Kenya, TCI’s predecessor project — the Urban Reproductive Health Initiative, locally referred to as Tupange — introduced an SMS/web-based commodity tracking system to collect consumption data from facilities. The data were then transmitted to a central server using a mobile phone.
Note that a mobile-based reporting system could also be used with the Informed Push Model (in this case, the logistician would be the main person to input the information).
Train health workers on supply management
To build capacity in commodity management, Kenya provided in-depth training from the national curriculum (RHCM training manual). The training covered reproductive health commodities management, forecasting, and quantification of needs.
After the training, the health workers received the following tools and materials:
- Contraceptive data requesting and reporting data (CDRR) tool
- Standard order and report form (SORF)
- Ministry of Health 512 Daily Activity Register (DAR)
- Bin cards
- Stock control cards
- Job aids for quantification of commodity requirements
- Continuous mentorship through on-the-job training and whole-site trainings
- Standard Operating Procedures for Reproductive Health Commodity Management from the Ministry of Health
In Nigeria, TCI strengthens providers’ capacity to complete requisition forms and do quantification/forecasting of stock and strengthen the Contraceptive Logistics Management System to include more on family planning. Specifically, TCI supports trainings of health workers on completing the requisition form and daily consumption record to ensure more accurate record keeping and tracking of contraceptive stocks, which aids in projecting stock needs. In addition, in States such as Taraba, where the Logistics Management Coordination Unit (LMCU) is functional for other commodities. TCI supports strengthening the system by ensuring that every facility submits it forms in a timely manner. This aids in the State requisition review and redistribution of stock from one facility to another. These trainings are done as part of Nigeria’s quality improvement approach.
It is important to provide refresher trainings to ensure regular capacity building and to address any issues as they arise.
Monitor and evaluate your supply chain
Based on data collected by health care providers, commodity managers and/or dedicated logisticians, quantify the needs for contraceptive supplies at the facility level.
Redistribute commodities based on your collected data. Redistribution is the moving of commodities from one place to another to minimize stockouts or excess stocks. The individual in charge of redistribution depends on the model and the context. At the county level in Kenya, this responsibility is taken up by the county pharmacist.
To measure the success of your contraceptive commodity security program, monitor and evaluate to ensure reduced stockouts, improved reporting rates, and timely and correct reporting forms.
What Is the Evidence?
In India, improved indenting of family planning commodities by frontline health workers (i.e., ASHAs) into the family planning logistics management information system (FPLMIS), a digital application tool, has reduced the shortage or stock outs of family planning commodities, specifically condom and oral contraceptive pills (OCPs). TCIHC’s continued efforts at state level to intensify coaching of supply chain workforce at each level, empowering them with the skills to use the digital application and the thrust from Mission Pragati by the government in strengthening doorstep delivery of short acting methods account for a 120% growth in condoms, 82% in Chayya and 70% in OCP between October-December 2020 and January-March 2021 in TCIHC supported cities. For other methods TCIHC-supported cities recorded a 106% growth in injectables and 70% in IUCDs in January-March 2021 compared to October-December 2020.
Evidence from the Urban Reproductive Health Initiative (URHI)
In Kenya, before the Tupange project started, there were frequent stockouts, resulting in missed opportunities and poor procurement, distribution, and supply chain management at both the national and facility level. After Tupange’s contraceptive security intervention:
- The government and donors committed to increasing funding for commodities, from US$5.97 million in 2011 to $6.2 million in 2013 (government) and from $1.32 million in 2011 to $12.9 million in 2013 (donor).
- Health facilities were less likely to report stockouts at endline than at baseline.
- Improved inventory management practices led to minimization of wastage, pilferage, loss and expiries, which in turn led to better commodity availability at the facility level, improved method mix availability and increased family planning uptake.
- Clear recordkeeping practices facilitated inter-facility redistribution in cases of emergency or sudden stock fluctuations–for example, due to increased client numbers at outreaches or in-reaches–thereby minimizing stock imbalances and interruption of activities within facilities.
- Reporting rates improved, from less than 40% at baseline to over 80% at endline, resulting in better data for decision making in the Tupange facilities. In comparison, national reporting rates remained below 40%.
In Senegal, when the Informed Push Model was introduced into health centers in Pikine and Kaolack, the average monthly contraceptive stockout rate fell from 83% for implants and 43% for the Depo Provera injectable in 2010-2011 to 0% for both methods in 2012. Overall this approach reduced contraceptive stockouts to less than 2%. Improved product availability at the facility level led to increased uptake in family planning methods.
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Contraceptive commodities often consist of:
To move forward with implementing any county, city or facility-level interventions to improve commodity security, there needs to be strong support at the national level where commodity procurement typically happens.
The Informed Push Model, implemented by Senegal, is one way to successfully reduce stockouts at the facility level.This model brings the supplies closer to the health facility and streamlines the steps in between by task sharing supply chain responsibilities from service providers to logistics professionals.
What are some challenges typical to ensuring contraceptive commodity security?
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- Explore the Contraceptive Security Indicators 2015 Global Data Dashboard to see whether your country is one of the 45 countries with a contraceptive security policy. This is a good starting place for any discussions around contraceptive security with national stakeholders.
- Consider partnering with the private sector to grow a private-sector market for family planning commodities and reduce the public-sector burden.
- To move forward with implementing any county, city or facility-level interventions to improve commodity security, there needs to be strong support at the national level where commodity procurement typically happens.
- Health workers are the ones who ultimately “sell” the contraceptives. If they are not properly trained and involved in the reporting of commodities, the system can fail.
- Lack of buffer stocks and inadequate storage capacity at facilities can delay distributions in the supply chain. Identify facilities that have spacious storage capacity that can work with other facilities with limited storage space to hold stocks for them. Also consider provision of county buffer stores.
- Devolution – that is, transferring responsibility for the health budget from the national level to counties – can be expected to destabilize commodity security in the short-term. You can address this problem by training county health management teams on advocacy and proper commodity management including forecasting and supply planning.
- Stock imbalances can happen when facilities overstock commodities or the commodities have short expiry dates. Redistribution of commodities to facilities that can consume the products minimizes wastage.
- Low reporting rates affects decision making regarding quantification, distribution and redistribution because consumption data are lacking. Provision of reporting tools and training on their use are expected to improve reporting rates. A dedicated county team should be put in place to follow up on reporting.
- The Tupange Project in Kenya: Multifaceted Approach to Increasing Use of Long-Acting Reversible Contraceptives
- Financing Commodities and Services: Essential for Meeting Family Planning Needs (High Impact Practices Brief)
- What Is Commodity Security? (K4Health Toolkit)
- The SPARHCS Process Guide: A Planning Resource to Improve Reproductive Health Commodity Security