• Offering only one or two types of injectable,
• Accurately projecting numbers of users,
• Ordering well in advance,
• Training providers in logistics (ordering and managing supplies),
• Shortening the pipeline—the stops on the route from the manufacturer to the provider; and
• Ordering needles and syringes packed with injectables.

Offering only one or two types of injectable. Offering several injectables increases choice but creates logistical problems. The decision about which injectables to offer rests on several factors:

• Source of supply. Most programs obtain injectables from donor agencies. USAID provides only DMPA, while UNFPA and IPPF supply DMPA and NET EN. Donors supporting the same program may supply different injectables; consultation can ensure that programs offer only the appropriate number of injectables. The policy of the Department of Health in the Philippines is to refuse donors' offers of injectables and other products if they would be a burden to the logistics system (113).
• Preference of clients. Users may have preferences based on duration of contraceptive protection or extent of bleeding changes. For example, the Thai National Family Planning Program found that NET EN was less popular than DMPA and thus decided not to offer it (167).
• Training providers. Providers must be able to counsel clients about each injectable that they offer.
• Efficiency of the logistics system. To offer several injectables, programs must be able to supply clinics with amounts that reflect clients' preferences. This requires keeping track of the different types of injectables.
• Cost. The cost of commodities alone—drug, needle, syringe, and swab—is US$3.88 per couple-year of protection (CYP) for DMPA and $6.30 per year for NET EN when given every two months. This calculation uses estimated average commodity costs on the international market: $0.92 per dose of DMPA, $1.00 per dose of NET EN, and $0.05 for needle, syringe, and swab (195). Cyclofem, at $.45 to $.65 per dose, costs an estimated $5.40 to $7.80 per year (108). The comparable commodity cost of OCs is $3.00 per CYP (195). Costs of service delivery are not included in these amounts.
• Ease of injection. Providers may find DMPA easier to inject than the more viscous NET EN. DMPA injection may be less painful because the needle is smaller (167, 281).
• Providing equipment for different injectables. Injections of DMPA are given with a 21- to 23-gauge needle, while the wider-bore 19-gauge needle is better for NET EN. An injection of NET EN with a needle appropriate for DMPA is more difficult for the provider and more painful for the client (281). Both Cyclofem and Mesigyna may be injected with a 21-23 gauge needle (223). Logistics managers must be able to ensure that service sites receive the right needles with each order (134).
• Keeping track of schedules in community-based distribution (CBD) programs. Setting up work schedules may be difficult if field workers are responsible for several injectables at once (134). Program managers in Matlab, Bangladesh, decided not to introduce Cyclofem into the CBD program because of the potential logistical and scheduling problems (211).

Accurately projecting numbers of users. Assumptions that use will always increase by 10% next year are generally inaccurate. More accurate estimates can be based on historical data indicating changes in number of users and numbers of vials dispensed, on current service statistics, or on surveys of the population served by the program, which can identify women intending to use injectables. Such surveys are especially important for DMPA, use of which may increase now that it is becoming more available. Also, programs need to anticipate changes in demand in response to communication campaigns (229, 333).

Ordering well in advance—at least three months and preferably six months (118). The Family Planning Association of Sri Lanka, for example, orders a 1-year supply of DMPA, about 100,000 vials, when they have five months of stock remaining (2). Also, advance orders should be coordinated with communication campaigns.

Training providers in logistics. In some cases clinics run out of injectables because clinic staff fail to reorder until there are no supplies left. Clinic staff can be trained to collect and use the basic information needed to decide when and how much to order: average monthly consumption, losses of stock that has been damaged or whose expiration date has passed, stock on hand (inventory), and lead time—the time between ordering and receiving supplies (37).

Shortening the pipeline. Some programs have speeded the passage of contraceptives from the manufacturer to the provider. The Philippines Department of Health has removed two levels in the distribution chain. Contraceptives and other drugs used to pass from the central warehouse through regional, provincial, and district warehouses and storerooms before reaching the local health unit. In the new chain, drugs and supplies move directly from the central warehouse to the provincial or city warehouse, saving at least six months (260). Some programs speed delivery by ordering DMPA shipped by air rather than by sea (55, 114).

Ordering needles and syringes. Packed separately from contraceptives, needles and syringes may be subject to duties that have been reduced or eliminated for injectables and other contraceptives. Delivery of needles and syringes is then delayed until duties are paid. Packed together, needles and syringes have the same status as injectables.

To make up for diversion to other uses, programs should order extra needles and syringes. Some suggest ordering twice as many needles and syringes as doses of injectable (246).

An efficient logistics system can help providers prevent transmission of infections. If providers run short of needles and syringes, they may be tempted to reuse equipment. At the same time many programs must destroy and dispose of hundreds or thousands of needles and syringes every day. The national family planning program in Bangladesh, for example, uses 250,000 disposable needles and syringes every month (177).