Jun 27, 2022
The Right Way to Do It: Avoiding Discontinuation Through Supply Chain Strengthening
By: Marilyn Noguera
Before human rights were enshrined in family planning, another set of rights were critical to keeping commodity security a priority for countries. Referred to as “the Six Rights,” these still crucial rights summarize the purpose of a supply chain as delivering the right product, in the right quantity, to the right place, at the right time, in the right condition, for the right price. Sustaining these six “rights” is a cornerstone to ensuring effective and sustainable family planning programs and plays a critical role in reducing contraceptive discontinuation — when an individual, for whatever reason, discontinues the use of modern family planning. In this blog, we look at these “rights” and consider how addressing them with state-of-the-art supply chain advances can help ensure family planning users are satisfied and able to continue with their preferred method for as long as they want.
Supply chains exist to get products to customers. Family planning supply chains start with sourcing all the raw materials and active pharmaceutical ingredients needed to produce contraceptive products to manufacturers, and end with finished contraceptive formulations and devices in the hands of customers (or their service provider) when and where they need them. COVID-19 has shone a spotlight on supply chains, highlighting their importance, complexity, and dependencies. Cargo availability, labor shortages, cost of freight, and manufacturing constraints are some of the upstream examples of what can cause problems for everyone who wants a given product (Figure 1). Those challenges are mostly outside of our control. But there are other supply chain issues that don’t get the limelight, that are closer to home, and that we can do something about.
In family planning, breakdowns in the supply chain account for up to one-third of unmet need and are also among the most cited reasons for not using contraception and/or discontinuing use. A well-functioning supply chain is important for users to feel satisfied and continue using their chosen method. Conversely, without a well-functioning supply chain, clients are more likely to be dissatisfied and discontinue use of modern methods. All six “rights” are important for effective supply chain operations and well-stocked programs, and while interrelated, below we attempt to tease out how they play a critical role in reducing contraception discontinuation.
Effective Supply Chains. A key element to effective supply chain management is having the right products on hand to respond to clients’ needs. For this to happen, program and supply chain managers from the health facility through to the program level need to understand client demand and quantify how much of each product will be needed (right quantity), the cost of those products (right price), and when the products need to be delivered and on hand (right time). If quantifying the demand for products is done incorrectly, there can be shortages and overages in the supply chain. Imbalances lead to wasted resources and ineffective service delivery. For example, when products are out of stock at a facility, clients are not able to get the methods they want and may take another method as a substitute. However, the information system will show what methods the clients took but not necessarily what method they wanted, and this error can get perpetuated in registers, reordering processes, etc. This kind of information may not be tracked by an automated system unless someone knows how to reflect the true demand in the system when ordering, so that next time, clients can receive the method they have chosen to be right for them (right product). Having staff members that are aware of unmet need and substitutions and that can adjust order quantities to reflect true demand for contraceptive methods will help align what is on the shelves with what clients want. In Uganda, for example, research found that when women were not able to obtain the method they wanted to use through their usual providers, some turned to more expensive private providers or pharmacies, incurring higher out-of-pocket costs; these women also reported experiencing factors that contribute to discontinuation, including increased stress, unintended pregnancies, or domestic conflicts.
“To ensure women living at the last mile have access to contraceptives, program managers need to ensure that costs — both out-of-pocket as well as opportunity costs — are not a barrier to uptake and continued use of the method they choose.”
Well-Stocked Programs. Family planning program managers need to understand their clients’ preferences and anticipate how preferences might shift due to new products entering the market, cultural influences, and personal reasons. Recent introductions of new ways to provide family planning are creating opportunities to better align client needs with contraceptive products (right product). The emergence of self-care, for example, is helping some clients find a less medicalized version of family planning programming, especially during the COVID-19 pandemic, by providing medicine, services, and information to women who may not have access to health facilities or providers.
A priority issue for supply chain managers is getting products to the last mile — ensuring that those people who don’t have easy access to facilities and providers can have access to quality contraceptive products (right condition) — often through alternative providers, such as community health workers, community-based distributors, and other outlets (right place). To ensure women living at the last mile have access to contraceptives, program managers need to ensure that costs — both out-of-pocket as well as opportunity costs — are not a barrier to uptake and continued use of the method they choose. For programs to grow, service providers must also understand the people with unmet need for family planning and coordinate with supply chain managers to ensure the right commodities are in the right place as women start using family planning. Supply chains begin and end with clients, and when they lose that focus, they fail to be effective and fail their clients. In the case of family planning supply chains, failing to reach the right customer may result in discontinuation.
Supply Chain Coordination. A lack of large-scale supply chain coordination can hinder timely solutions to solve issues, such as stockouts at one facility and oversupply at another. End-to-end visibility of the supply chain can help track products across the supply chain so they can get to the right place, at the right time. The Global Family Planning Visibility Analytics Network (VAN) is designed to help address imbalances in resources and supply among countries so that donors can mobilize resources and help prevent stockouts and clients are not forced to change to a different method. Within countries, research finds that the more tiers between products arriving in the country and reaching clients, the longer it takes for commodities and supplies to move through the logistics system, and with more stops in different warehouses, the greater the chances of damage, theft, expiries, and stockouts — all of which contribute to discontinuation. At the same time, a more streamlined supply chain results in greater availability and can often reduce costs — factors that can contribute to more effective supply chains that support contraceptive continuation.
Supply chains are complex systems. A well-functioning supply chain can help ensure that the right products, in the right condition, reach the right clients, at the right time, and at the right place. Without a functioning supply chain, there’s no product to respond to contraceptive users’ needs. Supply chain failure is an important reason for contraceptive discontinuation that can be addressed through strategic investments in supply chain coordination and family planning programs.
Marilyn Noguera is a senior technical advisor with Palladium, specializing in procurement, logistics, and supply chain management. She has been working on strengthening family planning and other global health supply chains throughout Africa and Latin America since 1998.
