The old saying goes “no product, no program”. The Reproductive Health Supplies Coalition was established over a decade and a half ago for that very purpose: to ensure access to a range of affordable, quality assured supplies.
But the phrase “no product, no program” rests on certain fundamental assumptions — not the least of which is the capacity of programs to deliver services. In many ways, COVID is calling that assumption into question. So I am concerned that in today’s environment, our famous “mantra” may be leading us down some dark alleys and perhaps even diverting attention from efforts that could make a difference in effectively sustaining access to FP services and the supplies women can use.
We in the Coalition are in a privileged position to balance this product/program dynamic, in part because our 500+ member organizations span the breadth of the RH community; in part because of platforms such as the Global FP VAN, (the VAN) which provide insight into product flows but also the relative risk of supply chain disruptions; and in part because analyses of consumption data, such as the Commodity Gap Analysis (CGA), provide a nuanced sense of how products are being used and who is using them — whether they are going to be repeat users, first time users, and so on. So we sit at the nexus of a host of diverse perspectives, all of which provide as it were, a more balanced sense of today’s reality.
One of the big challenges we face in trying to make sense of COVID-19 is how to balance the global supply chain challenges with country realities on the ground. At the global level, we’ve all read about the problems afloat. We’re aware of difficulties manufacturers are facing as they try to access the API they need for production of key supplies; we’ve heard of them shutting down or cutting back production; we’re increasingly hearing about the transportation barriers, both air and sea, which means that product, even if it is available, can’t reach the countries that need it. We are reading of barriers at national points of entry — offloading, customs clearances, and even product prioritization. And then, last but not least, we are hearing about distribution challenges at country level — which themselves are attributable to a host of factors, commercial, operational, etc.
Now, many of us in the supplies community recognize that these realities, as painful as they may be for certain actors, cannot — in themselves — be blamed for all, or even many, of the changes taking place in the service delivery space. Service delivery programs on the ground may very well be contracting, but I would argue that it’s not because of COVID-triggered supply shortages or stockouts.
And so within the supply chain community, our focus has been less on today’s challenges than on what happens next. Will today’s actions — or inaction — determine our ability to rebound in four, six, or 12 months’ time? If countries wait to place orders, where will they be when new demand reaches its peak? And if manufacturers can’t benefit from sustained revenue streams, will they even be around to fill orders when the peak occurs?
These are the concerns of those whose fingers are on the pulse of global supply chains and the health of the global market. They are driving many of the calls for continued investment by government and the donor community, and for sustained engagement by countries in supply chain decision making. But at the end of the day, these are not the concerns that drive day to day service delivery decisions or even the policies that govern program actions in the short term.
And that is why it is so critical that we look at the supplies environment, not just from the global perspective, but from the perspective of those on the ground — because not all countries find themselves in the same situation with regards to supplies or, even more importantly, in the same situation with regards to making use of the supplies they actually have.
There is a perception among many in our community that before the COVID-19 crisis, things were working pretty well. Some have even argued that if COVID-19 has shown us anything, it is how well the global market and supply chain systems had been functioning. Well, perhaps that’s been the case for some — but certainly not for all. Our recent analysis of the 2030 Ecosystem for RH supplies, for example, pointed out many of the challenges facing the global supplies market: from declining profit margins; to a shrinking manufacturing base; to declines in donor funding. We also know that the last two years have seen major supply constraints especially of implants and injectables.
So while COVID may be affecting all countries, each country is confronting the virus from varying positions of strength or weakness. In today’s world, every country is striking a balance between on the one hand, the supplies they have in stock, and on the other, the services now in place to deliver those supplies. So we are seeing before us, an ever-increasing fluidity in the relationship between product and program — and so the messaging and guidance we provide to our partners at country level must reflect that.
Let’s face it, many of these short-term solutions to ensuring continued access to contraception run counter to recent trends in method use.
I mentioned earlier the unique insights that tools such as the CGA are providing, with regard to anticipated increases in method use, by new or continuing users, and product distribution across the public and private sectors. The VAN is also offering us better visibility into shipment patterns and forecasts, and in so doing making it possible to anticipate the risks associated product delivery. Together, these two tools offer us — and by extension country planners –the insight necessary to develop smart, short term strategies for ensuring that women who wish to contracept can still do so, despite the changing face of the service delivery environment. They provide us with the evidence needed to design strategies that, for example, may entail greater use of self-care methods as an alternative option for those seeking LARCs or any other supplies that might be in short supply — or that are simply no longer being offered at health care facilities. In that sense, these tools provide us with the necessary information to build on recommendations recently circulated by the Royal College of Obstetricians and Gynecologists that advance ongoing provision of effective contraception, but that envisions the use of “bridging methods” in the short term.
Data from the CGA can also help us understand better some of the supply ramifications of new self-care strategies: increasing advanced provision (for example providing women with six or 12 pill cycles to reduce their need for another visit), greater local procurement, where feasible, and even innovative financing to quickly scale-up pill manufacturing/distribution.
Let’s face it, many of these short-term solutions to ensuring continued access to contraception run counter to recent trends in method use. As we saw in both the CGA and the CHAI/RHSC Family Planning Market Report, it’s been injectables and implants that have been driving recent growth in contraceptive use, while use of “self-care” methods (especially pills & condoms) has been low and stagnating. What that means is that the future that we’ve been planning for, and procuring for, may not be the future we experience in the coming months or year.
But it’s also important to note that while the continued scale up of implants may be undermined if COVID-19 leads to severe disruptions in service provision, there is a silver lining to be found in our recent success. The recent scale-up of implant growth means that many women are already protected and therefore removed from the pool of those requiring re-supply.
We are entering a new world — hopefully a comparatively short-lived new world — but one that entails a much more symbiotic relationship between what we’ve traditionally understood as “product” and “program”
Finally, the likely growth in private sector engagement associated with increased use of short acting methods, also promises new challenges. There are clearly equity concerns, especially if we see women who once accessed services from the public sector, increasingly finding themselves having to pay out of pocket. Equally concerning is the sustainability of the private sector itself. Will distributors or commercial actors invest scarce resources in contraceptives if there are no guarantees they will be bought, or if there are doubts as to whether these changes will be sustained as life returns to normal in the coming years?
We are entering a new world — hopefully a comparatively short-lived new world — but one that entails a much more symbiotic relationship between what we’ve traditionally understood as “product” and “program”. As my colleagues in the supply chain space are quick to remind us all, today’s funding and supply chain decisions at the global level will absolutely determine how effectively we address the RH health needs of women and girls in the future. But in the short term, product alone will not sustain the success of programs forged in an era before social distancing. That will be the job of those with feet on the ground.
(First presented at a webinar “Maintaining momentum in family planning: How can social and behavior change programs adapt to the new reality of COVID-19?”hosted by USAID and FP2020 on 23 April 2020.)