Expanding Services for Injectables

CONTENTS

Home (Key Points)

Injectables Today and Tomorrow
Box: Injectables Tomorrow: Subcutaneous DMPA and Home Injection
Web Table 1. Knowledge and Current Use of Injectable Contraceptives Reported by Married Women 15–49, All Surveys 1990–2006
Web Table 2. Knowledge and Current Use of Injectable Contraceptives Reported by Married Women 15–49, Most Recent Surveys 1990–2006
Web Figure. Donor Shipments of Injectables Increasing

Supply Meets Demand With Forecasting and Ingenuity
Web Table 3. Key Resources for Program Managers and Providers

Training to Meet Demand

Box: With Training, a Range of Providers Can Give Contraceptive Injections

Give Injections and Dispose of Waste Safely

Community Programs Can Safely Increase Access to Injectables

Meeting Rising Demand Efficiently

Communication Helps Women Try and Use Injectables

Questions and Answers About Injectables

Box: Women With HIV/AIDS Can Use Injectables

Bibliography

Credits

Coming Soon: "Injectables Toolkit" Web site. Go to http://www.injectablestoolkit.org for job aids and information about injectable contraceptives.

• Table 1: Estimated Worldwide Use of Injectables Among Married Women Ages 15–49, 2006
• Table 2: Formulations, Injection Schedules, and Availability of Injectable Contraceptives
• Table 3: Key Resources for Program Managers and Providers

Tools for Program Managers
• Checklist: Good-Quality Injectables Services
• Checklist: Improving Access to Injectables

Tools for Providers are in the companion INFO Reports. See also Population Reports, "When Contraceptives Change Monthly Bleeding," Series J, No. 54, August 2006.

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See Companion INFO Reports on "Injectable Contraceptives: Tools for Providers"
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Supply Meets Demand With Forecasting and Ingenuity

"No product, no program," say logistics professionals (53). Increasing demand for injectables challenges programs to maintain a steady flow of supplies and to respond quickly as more clients ask for injectables. Maintaining a continuous supply of injectables—vials of the contraceptive, needles, syringes, and sharps containers for disposal of used equipment—requires adequate supplies at the warehouse and a well-run logistics system to distribute supplies to clinics and other service delivery locations (see Population Reports, "Family Planning Logistics: Strengthening the Supply Chain," Series J, No. 51, Winter 2002).

Forecasting Maintains a Steady and Sufficient Flow of Injectables

Forecasts of demand for injectables enable programs to place accurate and timely orders to manufacturers, donors, or procurement agents. With demand rising, accurate forecasting is especially important. The most accurate forecasts use several types of information. These include expected increases in use of injectables (for example, as a result of a communication campaign), past trends in use, numbers of new and returning clients, and changes in population due to migration. Forecasting needs to be done at least once a year and adjusted every six months based on actual use. Stock levels and trends in use of injectables should be reviewed every month at service sites and additional orders placed to maintain supplies (53). Many countries have computerized logistics management information systems at the central warehouse to help with forecasting (85, 94) (for forecasting tools, see Table 3).

Table 3: Key Resources for Program Managers and Providers
Resource	Availability
Ensuring Reliable Supplies
Title: Pocket Guide to Managing Contraceptive Supplies Organization: U.S. Centers for Disease Control and Prevention Description: A quick reference guide for staff who manage contraceptive supplies and logistics. Includes logistics formulas and principles.	PDF available online.* To order print copies, contact: U.S. Centers for Disease Control and Prevention Division of Reproductive Health, MS K-22, 4770 Buford Hwy., NE Atlanta, GA 30341, USA E-mail: jtj2@cdc.gov
Title: PipeLine Software Tool Organization: John Snow, Inc. (JSI) Description: A tool to help program managers monitor stock and plan procurement through forecasting, maintaining consistent stock levels, and preventing stockouts.	Tool available online.* To request the PipeLine CD, contact: John Snow, Inc./DELIVER Project 1616 N. Fort Myer Drive, 11th Floor Arlington, VA 22209, USA E-mail: deliver_pubs@jsi.com Web site: www.jsi.com
Title: Procuring Single-Use Injection Equipment and Safety Boxes: A Practical Guide for Pharmacists, Physicians, Procurement Staff and Programme Managers Organization: World Health Organization (WHO) Description: A guide to help programs procure injection equipment and safety boxes and to develop a monitoring system to ensure quality and reliability.	PDF available online.* To order print copies, contact: World Health Organization Department of Essential Health Technologies 20 Avenue Appia 1211, Geneva 27, Switzerland E-mail: eht@who.int Web site: www.who.int/eht
Title: UNFPA Procurement Services Organization: United Nations Population Fund (UNFPA) Description: UNFPA is the largest public sector procurer of contraceptives. UNFPA accepts standard orders of US$6,000 or more, and also accepts emergency procurement orders.	For more information, contact: UNFPA Procurement Services Section Midtermolen 3, P.O. Box 2530 2100 Copenhagen, Denmark Web site: www.unfpa.org/procurement/index.htm
Safe Injections and Waste Management
Title: Safe Injection and Waste Management: A Reference for Logistics Advisors Organization: JSI Description: A reference guide to help design and support programs for safe injections and waste disposal. Includes assessment tools and additional references.	PDF available online.* To order print copies, contact: John Snow, Inc./DELIVER Project 1616 N. Fort Myer Drive, 11th Floor Arlington, VA 22209, USA E-mail: deliver_pubs@jsi.com Web site: www.jsi.com
Title: Management of Waste from Injection Activities at the District Level: Guidelines for District Health Managers Organization: WHO Description: A guide to help develop an action plan to reduce improper disposal of injection waste.	PDF available online.* To order print copies, contact: World Health Organization Press 20 Avenue Appia 1211, Geneva 27, Switzerland E-mail: bookorders@who.int Web site: www.who.int
Title: Do No Harm: Injection Safety in the Context of Infection Prevention and Control: Training Tools and Job Aids (forthcoming) Organization: JSI and WHO Description: A tool for implementing national injection safety training program strategies. Includes sample handouts and job aids.	For more information, contact: John Snow, Inc./DELIVER Project 1616 N. Fort Myer Drive, 11th Floor Arlington, VA 22209, USA E-mail: deliver_pubs@jsi.com Web site: www.jsi.com
Training and Supervision
Title: Comprehensive Family Planning and Reproductive Health Training Curriculum Module 6: DMPA Injectable Contraceptive Organization: Pathfinder International Description: An adaptable module to train health care workers to provide injectables.	PDF available online.* To order print copies, contact: Pathfinder International 9 Galen Street, Suite 217 Watertown, MA 02472, USA E-mail: information@pathfind.org Web site: www.pathfind.org
Title: Standards-Based Management and Recognition (SBM-R)—A Field Guide, Facilitator's Handbook, and CD-ROM Organization: JHPIEGO Description: A guide for improving performance and the quality of health care services.	For more information, contact: JHPIEGO 1615 Thames Street Baltimore, MD 21231, USA E-mail: orders@jhpiego.net Web site: www.jhpiego.org
Title: A Guide for Supervising Injections Organization: WHO Description: A guide for supervisors to observe injection practices, provide feedback about safe and unsafe practices, and help resolve problems contributing to unsafe injections.	PDF available online.* To order print copies, contact: World Health Organization Department of Essential Health Technologies 20 Avenue Appia·1211, Geneva 27, Switzerland E-mail: eht@who.int
Improving Efficiency
Title: CORE: A Tool for Cost and Revenue Analysis Organization: Management Sciences for Health, Inc. (MSH) Description: CORE helps managers analyze and compare a facility's current and projected costs and revenues.	For more information, contact: Elizabeth Lewis, Management Sciences for Health, Inc. 748 Memorial Drive Cambridge, MA 02139, USA E-mail: core@msh.org Web site: www.msh.org
Title: COPE: A Process for Improving Quality in Health Services Organization: EngenderHealth Description: The COPE technique helps supervisors and staff assess the quality of services, identify problems, and recommend and implement solutions.	PDF available online.* To order print copies, contact: EngenderHealth 440 Ninth Avenue New York, NY 10001, USA E-mail: info@engenderhealth.org Web site: www.engenderhealth.org
Title: Maternal and Reproductive Health Costing Model, Version 1.1 (Millennium Project Version) Organization: UNFPA Description: A tool to help program managers estimate the personnel, drug, and supply costs associated with providing injectables and other reproductive health services.	Excel spreadsheet available online.* For more information, contact: Millennium Project One United Nations Plaza 21st Floor Rm. 2160 New York, NY 10017, USA E-mail: Eva Weissman (weissman@unfpa.org)    or Janneke Saltner (saltner@unfpa.org)
Title: International Drug Price Indicator Guide Organization: MSH Description: This guide provides prices from pharmaceutical suppliers and procurement agencies, international development organizations and government donor agencies.	PDF available online.* To order print copies, contact: Management Sciences for Health, Inc. 748 Memorial Drive Cambridge, MA 02139, USA Web site: www.msh.org
Helping Clients Make an Informed Choice
Title: Decision-Making Tool for Family Planning Clients and Providers Organization: WHO and the INFO Project, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs Description: An evidence-based counseling resource for providers to help clients make informed choices about family planning.	PDF available online.* To order print copies, contact: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs 111 Market Place, Suite 310 Baltimore, MD 21202, USA E-mail: orders@jhuccp.org
Title: Medical Eligibility Criteria for Contraceptive Use Organization: WHO Description: A guide for the safe use of 19 methods for women and men with known medical conditions.	PDF available online.* To order print copies, contact: Department of Reproductive Health and Research, WHO 1211 Geneva 27, Switzerland E-mail: rhrpublications@who.int
Title: Family Planning: A Global Handbook for Providers (forthcoming) Organization: WHO and the INFO Project Description: A guide for providing family planning methods, including counseling and managing side effects. Also covers prevention and identification of sexually transmitted infections, including HIV, and numerous health topics related to family planning.	To order print copies, contact: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs 111 Market Place, Suite 310 Baltimore, MD 21202, USA E-mail: orders@jhuccp.org Web site: www.infoforhealth.org/pubs/globalhandbook/
Communicating About Injectables
Title: Media/Materials Clearinghouse (M/MC) Organization: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs Description: A resource for health communication materials from around the world, with over 200 items pertaining to injectables.	For more information, contact: Media/Materials Clearinghouse Johns Hopkins Bloomberg School of Public Health Center for Communication Programs 111 Market Place, Suite 310 Baltimore, MD 21202, USA Web site: www.m-mc.org/
*See Web Table 3 for URL. Additional information at http://populationreports.org/k6/k6tables.shtml

Forecasting several years into the future alerts programs to potential shortfalls and helps governments and donors plan procurements. For example, the Kenya Ministry of Health (MOH) projects that the share of injectables in the contraceptive method mix will increase from 40% in 2002 to 50% in 2010. In 2003 the MOH's reproductive health advisory board projected a shortfall of injectables beginning in mid-2004 and recommended that the MOH seek more funds from the government and donors (158). As a result of the forecasting, the government for the first time allocated funds in the budget specifically for injectables and covered part of the shortfall. Also, a donor agreed to provide funding for injectables and the MOH ordered injectables from UNFPA (97).

Choosing which injectables to offer. Programs forecast demand for each type of injectable that they offer. A number of organizations involved in international family planning suggest carrying one or at most two injectables (142). Carrying multiple injectables complicates forecasting,distribution of supplies, training, and service delivery. Differing injection schedules can confuse providers and clients (18, 156). To avoid confusion IPPF recommends that programs offer one progestin-only injectable and, if available, one combined injectable (84).

Some programs offer DMPA and NET-EN because donors supply them or clients ask for both (121, 156, 177). The two injectables differ in several ways. NET-EN requires more frequent injections than DMPA, which increases costs (177). Injections of NET-EN may be more painful because, in contrast to the water-based DMPA, NET-EN is oil-based and a larger-gauge needle is appropriate. NET-EN can be injected with a narrower needle, but the injection takes longer to administer and, as a result, may also be painful (175, 176).

At times, switching a client's injectable may be necessary due to supply shortages. Switching injectables is safe and does not decrease effectiveness. Switching clients routinely between injectables is not recommended, however (215). When clients switch to a different injectable, the schedule for repeat injections changes and side effects may change. Such changes led some women in Nepal to stop using injectables, a country assessment has reported (156).

Cooperation and Conservation Meet Unexpected Demand

Logistics managers can plan their response to unexpected demand for injectables. When supplies run low, managers can:

• Order an emergency shipment. USAID-funded programs can order emergency shipments of DMPA through the USAID Mission in their country to help prevent stockouts (21). UNFPA's Global Contraceptive Commodity Program stores injectables and other contraceptives with their suppliers to facilitate fast shipment in the case of stockouts and emergencies such as earthquakes or wars. The normal, non-emergency lead time for ordering injectables from UNFPA is 10 weeks (91, 197) (see Table 3).
• Borrow supplies. When delayed shipments of contraceptives led to stockouts at a health care facility in Kenya, staff borrowed contraceptives from a nearby district hospital and other facilities. This was one reason that this facility was identified as one of 13 high-performing facilities in Kenya (157).
• Mobilize suppliers, volunteers, and shippers. When stockouts of contraceptives plagued the national family planning program in Nepal in 1993, the Ministry of Health and UNFPA organized 75 graduate students to pack contraceptives and other supplies for maternal and child health. UNFPA supplied DMPA through its commodity distribution program (29). A private shipping company delivered the packages by road, air, and porter, and within 60 days every health facility in Nepal's 75 health districts had reproductive health supplies (196).
• Share clients. If a facility or program is running out of injectables, it can encourage clients to go to other sources for their injections and save its own supplies for those with no other source of supply. Public and private providers can work together to provide injectables when either has a stockout. Providers should be able to give clients directions to other sources of injectables.
• Avoid losses due to passed expiration dates and ruined stock. The First-to-Expire First-Out (FEFO) method—using supplies with the earliest expiry date first—helps to avoid loss through expiration. The shelf-life of progestin-only injectables is three to five years, and of combined injectables, at least three years (45, 98). Injectables should be stored between 20° and 25°C (68° and 77°F) away from direct sunlight and protected from freezing. Changes in temperature can affect the size and solubility of particles in DMPA and the combined injectable Cyclofem. Usually, any sediment at the bottom of a vial dissolves with gentle shaking. If sediment does not dissolve or has collected into a solid mass, perhaps because of low temperatures in the storage area, the vial should be thrown away (92). Injectables should be stored upright so that any sediment settles on the bottom of the vial and can be dissolved again by shaking. Heat can decrease the effectiveness of NET-EN without changing its odor or appearance. Stock that has been exposed to high heat, such as fire, should be thrown away (127).

If injectables are out of stock, providers typically give clients their second or third choice of contraceptive, or they may give them oral contraceptives and ask them to return in a month or more (61). Clients are more likely to stop using a contraceptive that is not the one they wanted, however (132). Faced with rising demand for injectables, programs and providers need to look for ways of supplying clients with their first choice.