Understanding and addressing contraceptive stockouts to increase family planning access and uptake in Senegal.

BACKGROUND: Senegal's government has pledged to reduce contraceptive stockouts, which have been frequent in public sector health facilities. An innovative distribution system called the Informed Push Model (IPM) addresses supply chain obstacles through direct regional-to-facility delivery of contraceptives and use of private sector logistics operators. Following promising pilot results, Senegal's Ministry of Health and Social Action committed to a three-year (2013-2016) expansion of IPM to all public health facilities nationwide. METHODS: From August 2014-July 2016, IPM's six logisticians made 29,319 visits to restock public sector health facilities. During these regular facility visits, the logisticians conducted a physical inventory to flag contraceptive stockouts (no usable stock of any single method available) and asked facility staff to identify the primary reason for documented stockouts. Our descriptive study examines stockout trends over the course of IPM scale-up. We also describe trends in contraceptive consumption over the three-year period using facility-level data collected by the logisticians. RESULTS: Contraceptive consumption rose by 91% over 35 months in the first three IPM regions, and by 118% in the next five regions (over 26 months). After scale-up to 1,394 health facilities, nationwide consumption rose by 48% over one year. On average, logisticians documented stockouts at fewer than 2% of facility visits. In comparison, two pre-IPM studies in 2011 identified stockouts of selected modern contraceptives at 60-70% of facilities visited, with 84% of clients reporting stockouts in the past year. Six factors (including consumption spikes, IPM-preventable causes, and community outreach) explained most remaining stockouts. CONCLUSIONS: IPM has been highly successful in ensuring full availability of contraceptives across regions and health facilities. The model also has facilitated the flow of essential data on consumption and stockouts from facilities up to district, regional, and central-level managers. These achievements highlight the relevance of professionalizing supply chain management while continuing to mitigate stockouts through enhanced stakeholder communication and improved training, coaching, and supervision of third-party logistics operators. Supply reliability is critical in shaping demand for and regular use of contraception. The government is transitioning the IPM to full management by the National Supply Pharmacy.

Taking stock: protocol for evaluating a family planning supply chain intervention in Senegal.

BACKGROUND: In Senegal, only 12% of women of reproductive age in union (WRAU) were using contraceptives and another 29% had an unmet need for contraceptives in 2010-11. One potential barrier to accessing contraceptives is the lack of stock availability in health facilities where women seek them. Multiple supply chain interventions have been piloted in low- and middle-income countries with the aim of improving contraceptive availability in health facilities. However, there is limited evidence on the effect of these interventions on contraceptive availability in facilities, and in turn on family planning use in the population. This evaluation protocol pertains to a supply chain intervention using performance-based contracting for contraceptive distribution that was introduced throughout Senegal between 2012 and 2015. METHODS: This multi-disciplinary research project will include quantitative, qualitative and economic evaluations. Trained researchers in the different disciplines will implement the studies separately but alongside each other, sharing findings throughout the project to inform each other's data collection. A non-randomised study with stepped-wedge design will be used to estimate the effect of the intervention on contraceptive stock availability in health facilities, and on the modern contraceptive prevalence rate among women in Senegal, compared to the current pull-based distribution model used for other commodities. Secondary data from annual Service Provision Assessments and Demographic and Health Surveys will be used for this study. Data on stock availability and monthly family planning consultations over a 4-year period will be collected from 200 health facilities in five regions to perform time series analyses. A process evaluation will be conducted to understand the extent to which the intervention was implemented as originally designed, the acceptability of third-party logisticians within the health system and potential unintended consequences. These will be assessed using monthly indicator data from the implementer and multiple ethnographic methods, including in-depth interviews with key informants and stakeholders at all levels of the distribution system, observations of third-party logisticians and clinic diaries. An economic evaluation will estimate the cost of the intervention, as well as its cost-effectiveness compared to the current supply chain model. DISCUSSION: Given the very limited evidence base, there is an important need for a comprehensive standardised approach to evaluating supply chain management, and distribution specifically. This evaluation will help address this evidence gap by providing rigorous evidence on whether private performance-based contracting for distribution of contraceptives can contribute to improving access to family planning in low- and middle-income countries.

Rapid diagnostic test supply chain and consumption study in Cabo Delgado, Mozambique: estimating stock shortages and identifying drivers of stock-outs.

BACKGROUND: Malaria rapid diagnostic tests (RDTs) are particularly useful in low-resource settings where follow-through on traditional laboratory diagnosis is challenging or lacking. The availability of these tests depends on supply chain processes within the distribution system. In Mozambique, stock-outs of malaria RDTs are fairly common at health facilities. A longitudinal cross-sectional study was conducted to evaluate drivers of stock shortages in the Cabo Delgado province. METHODS: Data were collected from purposively sampled health facilities, using monthly cross-sectional surveys between October 2011 and May 2012. Estimates of lost consumption (consumption not met due to stock-outs) served as the primary quantitative indicator of stock shortages. This is a better measure of the magnitude of stock-outs than binary indicators that only measure frequency of stock-outs at a given facility. Using a case study based methodology, distribution system characteristics were qualitatively analysed to examine causes of stock-outs at the provincial, district and health centre levels. RESULTS: 15 health facilities were surveyed over 120 time points. Stock-out patterns varied by data source; average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost consumption percentage were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each ten-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage indicating that higher rates of stock-outs occurred at higher levels of observed consumption. Causes of stock-outs included inaccurate tracking of lost consumption, insufficient sophistication in inventory management and replenishment, and poor process compliance by facility workers, all arguably stemming from inadequate attention to the design and implementation of the distribution system. CONCLUSIONS: Substantially high levels of RDT stock-outs were found in Cabo Delgado. Study findings point to a supply chain with a commendable degree of sophistication. However, insufficient attention paid to system design and implementation resulted in deteriorating performance in areas of increased need. In such settings fast moving commodities like malaria RDTs can call attention to supply chain vulnerabilities, the findings from which can be used to address other slower moving health commodities.