Last April, Eless Limani set out on a long and costly bicycle ride to the Mponela Health Center to get a new supply of birth control pills, her usual contraceptive. The 32-year-old mother was not ready to have a second child.

“When I went to the hospital, I was told that they had run out,” says Limani. “I left the hospital devastated and proceeded to a private hospital to ask if they had the pills.”

They were also out of stock.

Limani’s next option was a public hospital, where she hoped to get Norplant, a contraceptive implant that would last five years.

“Unfortunately, at the public hospital, they did not have the Norplant,” she recalls.

While the private hospital did have the Norplant, it was beyond her financial reach.

“Because I did not find the pills at the public hospital and couldn’t afford the Norplant at the private hospital, I went back home without a family planning method. As a result I accidentally got pregnant.”

Limani and her husband live in Kalindang’oma Village, about 4 miles (6.5 km) from the nearest city of Mnopela, in Central Malawi. When she got pregnant with her second child, she knew it would not be easy. 

“At that time I had a little child who was not even two years old. It was painful thinking about my small child,” she says, referring to the stigma her family would face because she was pregnant while her first child was still so young. 

There were also the financial burdens. The family of three, soon to be four, lives on what her husband can earn selling used clothing in town.

“I only had enough money for soap for one child. Thinking about food was also difficult. Expecting another child meant I would have two little children who needed attention,” she recalls. 

Too many women around the world intimately understand Limani’s experience. They want to plan their pregnancies, but contraceptive supplies are not consistently available or affordable, especially in Sub-Saharan Africa. The COVID-19 pandemic further exacerbated women’s plight. The United Nations Population Fund (UNFPA) estimates that 12 million women lost access to contraception in the aftermath of the pandemic, driven by lockdowns, supply chain disruptions, and diversions of resources away from reproductive health programs and to emergency response. Even before COVID-19 upended international family planning, women and girls were expressing a profound need for contraception.

In 2018, White Ribbon Alliance—an advocacy organization that sets its priorities based on women’s and girls’ self-articulated needs—launched the What Women Want campaign. This global effort asked 1.3 million women an open-ended question: What is your one request for quality reproductive and maternal health care? The campaign was based on a simple premise: Ask those who most use reproductive and maternal health services what it is they most need, because health care services are better when informed by the women and girls who use them. Among a sea of possibilities, family planning information, services, and supplies emerged as one of women’s top requests. Supplies, including family planning, was also a top response from a subsequent survey of midwives.

As the responses were calculated, followed-up on, and analyzed, it became clear that global reproductive health supply chains often leave women and their health providers short-handed. Much less clear were the bottlenecks and how to address them. To understand more, we turned to Safia Ahsan and Julia White of the Reproductive Health Supplies Coalition, both experts in public and private sector supply chains for family planning. The coalition is a global partnership of more than 500 public, private, and nongovernmental organizations, including the White Ribbon Alliance. They are dedicated to strengthening markets and supply chains so that all people in low- and middle-income countries can access and use affordable, high-quality supplies to improve their reproductive health. In this article, we focus on family planning supply chains for Sub-Saharan Africa—a region of the world with the greatest unmet need for contraception.

We also spoke with Malawi’s deputy minister of health, Enock Phale, to provide further insights on the unique challenges and solutions for these vital commodities. Over the past five years, the Government of Malawi has focused on strengthening its family planning supply chain as a part of its strategy to promote increased access to and use of contraceptives.

Family planning and the global supply chain

Most people understand the basics of family planning. However, there are some important nuances when delving into its supply chains. The first is that family planning does not refer to a single or uniform product. There are more than 10 types of “reversible” contraception methods. These include intrauterine contraception (IUDs), hormonal contraceptives (implants, injections, pills, patches, rings), and barrier methods (male and female condoms, diaphragms, cervical caps), among others. These methods have different manufacturing processes, involving different raw materials and active ingredients (if any). Some methods require health providers to prescribe or administer them, while others do not. These factors add complexity to family planning products and their supply chains. This complexity is positive because—in principle—it allows women and couples to choose the contraceptive method that is right for them.

The second nuance is that in contrast to other consumer products, family planning is considered an ethical public health product. “You don’t need to care if one country has more shampoo than another country,” says White, who directs the Global Family Planning Visibility and Analytics Network, or VAN. “You do need to care ethically, that one country isn’t, for example, buying all the COVID vaccine in the world. COVAX is the same principle as what we are doing with the VAN,” she says, referring to the World Health Organization’s platform to ensure equitable access to COVID-19 vaccines.

Use of modern contraception reduces unintended pregnancies and, by extension, reduces maternal deaths and unsafe abortions. Family planning, furthermore, has benefits that are central to realizing gender equality. It enables women and couples to decide when and whether to have children, supports women and adolescents in completing their education, and increases women’s autonomy in the household and their earning potential. Women’s and adolescents’ right to contraceptive information and services is also grounded in internationally recognized human rights. There is a moral mandate to ensure that contraception is available to anyone who wants to use it—regardless of where they live and their financial situation—which can exist in tension with political and commercial interests.

With this background, Ahsan, who is the Reproductive Health Supplies Coalition’s senior technical officer, explained that the family planning supply chain for Sub-Saharan Africa is most like that of other consumer and health products. “The main elements include forecasting, manufacturing, procurement, overseas shipping, in-country logistics, inventory management, and distribution,” said Ahsan. “The supply chain actors are many when you look across market sectors—public sector, donor-supported public sector, private sector subsidized through social marketing, and pure commercial sector—and include manufacturers, logistics corporations, warehousers, distributors, and health systems.”

What does separate family planning supply chains for Sub-Saharan African markets from those of other products is who does the procuring. Most family planning methods used in Sub-Saharan Africa are donated through and procured by international agencies, specifically the UNFPA and the US Agency for International Development—USAID.

“What is good about this set up is that UNFPA, USAID, and other UN donors have strict quality assurance for their procurements, while still demanding competitive pricing. Their ability to forecast and order large volumes gives manufacturers much-needed predictability. This contrasts with maternal health medicines and supplies, for example, which are largely purchased by ministries of health that typically do not require as rigorous quality approvals and whose orders are spread around more,” explained Ahsan.

Family planning’s reliance on donors is not without its challenges, however. And some of these challenges feed into the main bottlenecks affecting family planning supply chains.

Four core breakdowns in the family planning supply chain

While breakdowns can occur anywhere along the supply chain, four are particularly thorny.

Prioritization

A challenge that undergirds the entire supply chain is prioritization. “There is always more need than there is family planning product,” says White. “When countries are looking across health investments and prioritizing, historically, family planning isn’t as prioritized as the others.”

This links back up with the broader prioritization of women’s health and rights. We saw this during COVID-19, for example, when the UK government cut international assistance in many areas to free up funds for the pandemic, with one of the largest cuts going to family planning.

Ahsan also raised the downward shift in donor support: “More and more there’s a search for mechanisms that can support national bodies to take over the role that UNFPA and USAID have been fulfilling.”

Phale—who is also a member of the Malawi Parliament—also sees the need for an increased government role. “We need additional funding for procurement and the supply chain. This could be in the form of government funding. If we can do this we can say that we are going to harness and pull the resources meaningfully.” And that, he says, is a matter of prioritization.

Manufacturing

The ultimate goal is to transfer ownership of supply chains to governments. How each government chooses to manage the supply chain it owns is up to it. This requires a close look at all elements, including procurement, production, and delivery. And that requires a close look at manufacturing.

“Producing family planning products is highly complex. They are not easy products to make,” says White. “Each type of contraceptive has its own production process, raw materials, and active pharmaceutical ingredients. And there’s not enough funding for research.”

In addition to the complexity of manufacturing, the financial and logistical hurdles of getting into business can be a deterrent.

“UNFPA and USAID are the main procurers of contraceptives, and they have the highest product quality assurance standards, requiring approval by a stringent regulatory authority or by the WHO [World Health Organization]/UNFPA prequalification program,” Ahsan explains. “The commitment a manufacturer must make in terms of time and money to achieve these approvals is enormous. It often entails making significant changes to manufacturing to bring it up to standard—everything from production process, to the product development cycle, to packaging, to internal quality control, to in-house equipment.”

Let’s take the example of a single family planning commodity—the one-rod contraceptive implant known as Implanon—and one of its procurers—UNFPA. There is currently only one manufacturer (Organon, formerly Merck) with headquarters in the United States and production facilities in the Netherlands. UNFPA sends orders to Organon; the product is shipped by air or ocean, per agreements negotiated between Organon and UNFPA, to different countries in Sub-Saharan Africa. Once the Implanon arrives in port, Organon and UNFPA each has a set of responsibilities to get the shipment through customs. Once cleared, it is shipped to the central medical stores, and then to different regions, communities, and health centers. The supply chains are tightly managed by the procurers and negotiated by the manufacturers.

“There is not much regional ownership,” says Ahsan. “People are asking how to have more of these products manufactured closer to the countries they are going to. Everyone wants to be less reliant on manufacturers located in high-income countries. Especially, at a time like COVID, when supply chains are breaking down and costs are escalating. Everyone saw that high-income countries will take care of themselves first. It was a wake-up call on the continent,” she explains.

“People aren’t necessarily saying ‘we want to manufacture injectable contraceptives in any single country,’ but more broadly, the handful of African countries that are already manufacturing pharmaceuticals want to expand, and to be less reliant on countries outside of the continent,” Ahsan continues.

And for manufacturers already in the game, they must be willing and able to take on some financial risk. If forecasts are poor, or if the numbers come in lower than expected, manufacturers may end up with excess product, leading to a loss, and they need to be able to sustain that.

Data visibility

Good, transparent, and accessible data are the backbone of well-functioning supply chains, but historically this has been a pain point for family planning.

“Procurers need good data to prevent overstocks and shortages. Manufacturers want visibility of data to forecast demand. If supply chains aren’t running smoothly, it is inefficient and more costly for everyone. Having greater visibility for the data to understand future demand benefits everyone,” explains Ahsan.

But sharing data can be tricky when you’re working across public, private, and government actors.

“Sharing data in order to better ‘see’ and unblock the flow of products across an ecosystem of supply chain players is not easy. It requires a network of organizations that are willing to work in partnership—sharing information, redefining processes, and implementing mutually beneficial governance,” says White in a recent blog. “Establishing such partnerships is the true challenge.”

Phale agreed, and noted that the lack of data exacerbates challenges—and solutions—for every part of the supply chain. “Resources are coming from different pockets and spaces,” he said. “We need a proper coordinating mechanism for that.”

Last mile distribution

The last perennial challenge is moving family planning products from the warehouse or health facility to the literal hands of the women who will use them.

“The product may arrive in the country, but do health system actors have the budget and data to know where that product needs to go and when? If the product has arrived at a provincial warehouse but the facilities don’t have a sufficient budget for having the product shipped to them, how will the product get shipped?” raises Ahsan.

“There’s also the actual service delivery element,” adds White. “Some of these products require a skilled health provider to administer. This also necessitates a budget and program for provider training.”

That is a challenge Phale understands in Malawi, who says regular training is needed for health care service providers. “If you talk about system strengthening, you cannot ignore human resource capital,” he says.

The way these challenges practically manifest varies widely by country and context. But the result is often the same: women like Eless Limani in Malawi are not getting the contraceptive they want—or even an alternative option—when and where they need it.

Creating a more resilient—and responsive—family planning supply chain

Individuals, families, health providers, and the public and private sectors value family planning commodities. As we saw in Limani’s story, family planning products have layers of consequences when not available. To meet individual consumers’ needs, and the needs of families and communities, solutions to the major bottlenecks must be addressed. Here, we explore a few.

Market-shaping solutions

With the aforementioned context, family planning supplies exist within a larger market of supply and demand, which makes market shaping solutions a natural place to start when looking to improve access to a variety of affordable, high-quality family planning methods. These include initiatives to reduce prices, streamline regulatory requirements, reduce inefficiencies, and improve information flows.

For example, given high demand for long-acting, reversible contraception, a group of public and private companies collaborated to make two contraceptive implants—Implanon and Jadelle—more accessible for women in targeted, low-income and middle-income countries. This included a 50 percent price reduction; health worker training to counsel, administer, and remove the implants; efforts to alleviate supply chain disruptions; enhanced service delivery; and creating awareness of the products’ risks and benefits.

While market-shaping solutions are enticing to donors, they can have unintended market consequences, and thus make it more challenging for competitors that did not receive guaranteed volumes or other donor advantages.

Global Family Planning Visibility and Analytics Network

At the center of the supply chain are data. That’s where White and her work with the VAN—a group of about 330 users and more than 100 members—comes in.

“The VAN is a collaborative space to track and fine-tune the flow of products into low- and middle-income countries,” says White. “We work with manufacturers, donors, recipient countries, and implementing partners to help them gain access to the data they need for the decisions they need to make. It’s like an airport traffic control tower, providing a bird’s eye view of where the planes are to manage when they land and take off. Similarly, the VAN is needed to provide visibility into product movement so countries don’t end up with too few supplies to meet contraceptive needs or too many supplies to be consumed before they expire.”

This type of coordination is unusual when it comes to health products. White says the VAN started with family planning because there is always more demand than supply. Its work has three main goals: secure more timely and cost-effective delivery of family planning commodities; reach more women with the right product at the right time; and achieve better coordination when allocating limited health resources.

Deputy Health Minister Phale agreed. “To overcome the challenges, we need to have a strong connection between government authorities and implementing partners working in family planning, maternal, newborn and child health,” he said.

That is a big reason why Malawi linked up with the VAN in 2018.

“Previously, there was limited visibility into incoming orders and shipments, and multiple data systems couldn’t easily share information,” said Phale. “We missed opportunities to maximize funding, and we had more frequent stock outs.” He says there is still work to be done, but improved data visibility from port to facility has also helped provide visibility into the flow of products coming into the country. And, he says, the more data that are shared, the more solutions are unearthed. “We must invest, procure, manufacture, and supply based on data.”

Increased and sustained advocacy

“A low-income country like Malawi is almost totally dependent on the public sector,” says Ahsan. And that brings us back to Eless Limani, and the need for advocacy that reflects women’s experiences and needs.

“What I would say to the government is that it should create health posts in villages like ours where people can be assisted with family planning,” says Limani, whose experience reflects a breakdown at the final stage of the family planning supply chain. “During rainy seasons, it is hard to travel long distances to hospitals. And with the lack of transport, people fail to go to the hospital for help, and in the end bear more children than they planned for.”

Advocacy not only helps women get the health care they need; it also furthers the broader goals of self-reliance. After hearing that “improved reproductive health services and supplies” was a top demand of 85,000 women and girls in Malawi, the Malawi government doubled its family planning budget with an eye to reduce stock outs, provide more timely services, and be less dependent on donors.

This advocacy begins with listening to women like Limani.

“Sometimes when we go to the hospital we do not get the help we need. The doctors do not pay proper attention and sometimes they rudely tell us to go home, by saying that the help we need is not available,” she says. “When I got pregnant the second time, the doctors shouted at me because I had recently borne another baby, but this was not intentional. Therefore, we are requesting that the health personnel should be able to talk to us with respect.”

Limani was upset with how she was treated, but she did not know she could report the incident. She soon learned that the White Ribbon Alliance was facilitating conversations between women and the hospital ombudsman. As more women demand and advocate for family planning and other services and supplies, they are prioritized by governments, hospitals, donors, and businesses, which helps drive solutions to all aspects of supply chain breakdowns.

“Securing family planning services and supplies is not only a health issue,” says Phale. “It is an issue requiring efforts by all stakeholders. Whether traditional leaders, politicians like me, editors, reporters, manufacturers, scientists. Let’s look at the bigger picture.”

And when different sectors come together to address an issue that has traditionally been siloed, you can start to imagine a future that allows women to live full, healthy lives—a future that benefits not only women but also their children, their families, their countries, and the world.