2023 Contraceptive Security Indicators Report

Publication date: 2024

2023 Contraceptive Security Indicators Report December 2024 Disclaimer The USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project is funded under USAID Contract No. AID-OAA-I-15-0004. GHSC-PSM connects technical solutions and proven commercial processes to promote efficient and cost-effective health supply chains worldwide. Our goal is to ensure uninterrupted supplies of health commodities to save lives and create a healthier future for all. The project purchases and delivers health commodities, offers comprehensive technical assistance to strengthen national supply chain systems, and provides global supply chain leadership. GHSC-PSM is implemented by Chemonics International, in collaboration with Arbola Inc., Axios International Inc., IDA Foundation, IBM, IntraHealth International, Kuehne + Nagel Inc., McKinsey & Company, Panagora Group, Population Services International, SGS Nederland B.V., and University Research Co., LLC. To learn more, visit ghsupplychain.org The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. government. 2023 Contraceptive Security Indicators Report ii | Disclaimer http://ghsupplychain.org Table of Contents Acronyms iv Acknowledgements v Executive Summary vi Leadership and Coordination vii Finance and Procurement vii Commodities vii Policies viii Supply Chain viii Quality ix Private Sector ix Impact of COVID-19 Pandemic x Introduction 11 Background 12 Methodology 13 Country Selection 13 Survey Response and Validation Process 15 Analysis 16 Changes in Methodology from Previous Report 16 Limitations 17 Leadership and Coordination 18 Highlights 18 Contraceptive Security Committee 19 Finance and Procurement 20 Highlights 20 Financing Sources and Expenditures for Public-sector Contraceptives 21 Government Expenditures 21 In-Kind Donations and Global Fund Grants 25 Budget Line Item 27 Financing Gap for Procurement of Public-sector Contraceptives 27 Commodities 28 Highlights 28 Methods Offered by Sector 29 Public Sector 29 NGOs 30 Commercial/Private Sector 30 Social Marketing 30 Policies 31 Highlights 31 National Strategy with Objectives for Contraceptive Security 32 Policy Barriers Impacting Access or Provision to Contraceptives 32 Provider skills in implant and IUD insertion and removal 35 Policies that impact the ability of sub-populations to access family planning services and contraceptives 35 Cultural and operational practices that impact the ability of sub-populations to access family planning services and contraceptives 36 Charges to Clients 37 National Essential Medicines List 38 Promotion of Family Planning 38 FP2030 Commitments 38 Global Financing Facility 39 Supply Chain 40 Highlights 40 LMIS 42 Procurement 42 Supplier Delivery Points 42 Product Availability 43 Quality 51 Highlights 51 Registration Requirements 52 Quality Control 52 Private Sector 55 Highlights 55 Impact of the COVID-19 Pandemic 58 Highlights 58 Conclusions 61 References 63 Annex A. Contraceptive Security Indicators Survey Questionnaire 65 Annex B. Contextual Reference Measures 73 Acronyms CHW community health worker COC combined oral contraceptive CS contraceptive security DRC Democratic Republic of the Congo EC emergency contraceptive pills FP family planning FY fiscal year GHSC-PSM Global Health Supply Chain Program-Procurement and Supply Management ISO International Organization of Standards IUD intrauterine device LAC Latin America and the Caribbean LMIS logistics management information system mCPR modern contraceptive prevalence rate MOH Ministry of Health NEML National Essential Medicines List NGO nongovernmental organization NMRA national medicines regulatory authority NQCL national quality control laboratory POP progestin-only pill PSE private-sector engagement QA quality assurance RH reproductive health SDP service delivery point SF substandard and falsified SRA stringent regulatory authority USAID United States Agency for International Development WHO-PQ World Health Organization-prequalified 2023 Contraceptive Security Indicators Report iv | Acronyms Acknowledgements We would like to thank the many contributors to this survey who participated in the complex survey design, data gathering, validation, and analysis processes over the course of many months. The Ministries of Health and USAID missions in the following countries made invaluable contributions to this effort to better understand contraceptive security through collecting, validating, and sharing data and crucial contextual information to enable interpretation of the findings: Angola, Bangladesh, Benin, Botswana, Burkina Faso, Burundi, Cape Verde, Côte d’Ivoire, Dominican Republic, Democratic Republic of the Congo, El Salvador, Ethiopia, Ghana, Guatemala, Guinea, Haiti, Honduras, Kenya, Kyrgyz Republic, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Nepal, Nigeria, Pakistan, Peru, Philippines, Rwanda, Senegal, Sierra Leone, South Sudan, Tanzania, Togo, Uganda, Yemen, Zambia, and Zimbabwe. In the Commodity Security and Logistics Division of USAID’s Bureau for Global Health, Office of Population and Reproductive Health, we would like to acknowledge Wezi Munthali, Denise Harrison, Tiffany Marshall, Kevin Pilz, Sharmila Raj, and John Vivalo for their contributions throughout the process, from survey design to implementation, analysis, and reporting. We would also like to thank the many partner organizations that facilitated and participated in data collection in many country offices. In particular, FP2030 and UNFPA were instrumental in facilitating connections to points of contact in countries that may otherwise have been difficult to reach. v | Acknowledgements 2023 Contraceptive Security Indicators Report This 2023 CS indicators report updates the 2021 report building upon the CS indicators first developed in 2009 and presented in the USAID | DELIVER PROJECT paper, Measuring Contraceptive Security in 36 Countries.1 Since then, CS indicators have been collected, measured, and reported since 2010 and starting biennially in 2017. The USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project, a follow-on to USAID | DELIVER and USAID’s Supply Chain Management System project, has now assumed the role of collecting data and disseminating this survey — now in its tenth round — to benefit the global health community. This report presents data from 42 countries,2 which includes updates in question wording, response options, and/or additional questions in the Finance and Procurement, Commodities, Policies, Supply Chain, Private Sector, and Impact of COVID-19 Pandemic sections. Changes to previous questions, and the addition of new questions, aim to continually increase the methodological rigor and relevance of the survey. A data collection and usage manual helps guide responses. To help data users to better interpret results within a larger country context, data for select contextual measures (formerly part of the Contraceptive Security Index) can be found in Annex B of this document. The survey enables program managers, advocates, and decision-makers in countries as well as in the global health community to monitor progress toward contraceptive security, inform program planning, and advocate for improved policies and resources. vi | Executive Summary 2023 Contraceptive Security Indicators Report 1. USAID | DELIVER PROJECT, Task Order 1. 2010. 2. A limited number of countries were removed from the dataset pending data sharing approval. Data for those countries has been anonymized and contributes to aggregate “all country” results (therefore, numerators and denominators reflect the anonymously included data from those countries). Executive Summary 01. Contraceptive Security (CS) exists when every person can choose, obtain, and use quality contraceptives, whenever he or she needs them, for family planning/reproductive health (FP/RH). Governments are increasingly recognizing the importance and value of contraceptive security and regularly monitoring its progress. PH O TO C RE D IT : G H SC -P SM vii | Executive Summary 2023 Contraceptive Security Indicators Report This report presents findings on leadership and coordination, finance and procurement, policies, supply chain, quality, private sector, and the impact of the COVID-19 pandemic on contraceptive security. Key findings include: Leadership and Coordination – In 2023, 95 percent of countries have a national committee that works on CS (consistent with 96 percent of countries in 2021); 90 percent of those committees have formal written terms of reference. – 82 percent of CS committees developed policies, procedures, recommendations, and/or action plans (an increase from 76 percent in 2021), and 100 percent of those reported adhering to policies and procedures or implementing action plans. – The commercial/private sector participates in 45 percent of CS committees (18 of 40), up from 33 percent in 2021. – More than half of the CS committees met four or more times in the previous year. Finance and Procurement – 29 respondent countries (71 percent), have a government budget line item specifically for contraceptives, 81 percent of countries allocated government funds for contraceptive procurement in the most recently completed fiscal year, and 71 percent spent government funds on contraceptives in the most recently completed fiscal year. – An average of 34 percent of financing comes from government sources and 66 percent from in-kind donations. – Expenditures on contraceptives in about half the countries reporting (49 percent, or 19 out of 39 countries) exceeded or met the country’s forecasted demand. The remaining 51 percent had a funding gap between funding spent and estimated contraceptive need. Commodities3 – Countries offer on average 9 of the 13 assessed contraceptive methods across all sectors: 10 in public-sector facilities, 10 through the commercial/private sector, 9 in nongovernmental organizations (NGOs), and 7 through social marketing. – 100 percent of reporting countries offer combined oral contraceptives (COCs) and intrauterine devices (IUDs) in the public sector, while 100 percent offer male condoms in both the commercial/private sector and NGO sectors. – In the public sector, 98 percent of countries offer the five most common contraceptive methods (male condoms, COCs, injectables, IUDs, and contraceptive implants), and 95 percent offer at least 8 of the 13 assessed contraceptive methods. – The commercial/private sector offers the five most common contraceptives in 86 percent of reporting countries (36 out of 42 countries). 3. There were 13 assessed contraceptive methods including: combined oral contraceptives (COCs), intrauterine devices (IUDs), injectable contraceptives, contraceptive implants, emergency contraceptive pills (ECs), progestin-only pills (POPs), male condoms, female condoms, tubal ligation, vasectomy, calendar-based awareness methods, contraceptive patches, and vaginal contraceptive rings. Policies – 98 percent of countries have either a CS or reproductive health commodity security strategy or a strategy that includes objectives for contraceptive security. – In 57 percent of countries (24 of 42 reporting), FP commodities are subject to duties in at least one sector (public, commercial/private, NGO, or social marketing). – 87 percent of countries have policies that enable the private sector to provide contraceptives, while 10 percent of countries (4 out of 39) have policies that hinder that ability. – More than half of the countries (61 percent) have at least 50 percent of their providers trained to remove or insert implants and IUDs. In 2021 this was 65 percent but 41 percent in 2019. – 15 percent of countries restrict access to contraceptives by unmarried people ages 15–19, and 10 percent by married people ages 15–19. – On average, countries included nine FP methods on their National Essential Medicines List (NEML). – Mobile phone outreach (92 percent) and community mobilization/engagement (90 percent) are the most popular channels for promoting family planning. – 88 percent of surveyed countries (37 out of 42) made or plan to make a Family Planning 2030 (FP2030) commitment. Among those,100 percent committed to improving domestic financing for contraceptives. Supply Chain4 – 93 percent of countries (39 out of 42) have a logistics management information system (LMIS) that includes contraceptives. Among those, 95 percent capture contraceptive stock data at the service delivery provider (SDP) level. – Of the 34 countries providing information on central-level stockouts, 26 percent reported zero stockouts in the most recent complete year5 for any of the following most common FP/RH products: COCs, injectable contraceptives, contraceptive implants, copper-bearing intrauterine devices, and male condoms. – 15 percent of countries reported zero central-level stockouts of any contraceptive commodity in the most recent complete year. – Average annual stockout rates at the central level for the most common FP/RH methods6 ranged as follows among countries reporting stockout rates above 0 percent: – COCs: For 10 countries the stockout rate ranged from 8 percent (Kenya) to 100 percent (Côte d’Ivoire). – Injectable contraceptives: For 14 countries the stockout rate ranged from 8 percent (Dominican Republic) to 100 percent (Côte d’Ivoire). – Implants: For 17 countries the stockout rate ranged from 3 percent (DRC) to 100 percent (Botswana). Seven countries that offer two formulations of implants had no stockouts of either (Benin, Ethiopia, Mali, Mozambique, 4. Stockout rates are reported at the country/method level only and not aggregated across countries, as interpreting the data becomes difficult at higher levels of aggregation. 5. The most recent complete year refers to the latest 12-month period for which both contraceptive commodity forecast data and expenditure data are fully available for the public sector. 6. An FP/RH method can consist of multiple FP/RH products; for example, the implant method includes one-rod and two-rod implants. For this report, the term “method” refers to the group of one or more common product formulations. The term “product” will be used to refer only to a single formulation. viii | Executive Summary 2023 Contraceptive Security Indicators Report Nigeria, Togo, and Zimbabwe). – IUDs: Stockouts in 12 countries had rates ranging from 7 percent (DRC) to 92 percent (Côte d’Ivoire). – Male condoms: The 10 countries that reporting stockouts had rates ranging from 5 percent (El Salvador) to 100 percent (Côte d’Ivoire) stocked out. – Average annual stockout rates at the service delivery point (SDP) level for the most common FP/RH methods ranged as follows among countries reporting stockout rates above 0 percent: – COCs: 26 countries had stockout rates ranging from 1 percent (Haiti and Togo) to 59 percent (DRC) – Injectables: For the remaining 29 countries with data, stockout rates ranged from 1 percent (Haiti and Togo) to 64 percent (Zambia). – Implants: For the remaining 27 countries, stockouts rated ranged from 0.23 percent (Bangladesh) to 90 percent (Botswana). – IUDs: Twenty-seven countries ranged from 0.06 percent (Bangladesh) to 59 percent (Zambia) stocked out. One country with data reported no stockouts (Cape Verde) – Male condoms: Twenty-six countries with data ranged from 0.05 percent (Bangladesh) to 59 percent (Kenya). Cape Verde was the only country with data reporting no stockouts. Quality – 98 percent (40 of 41 countries) require registration of locally manufactured or imported contraceptives by the in- country national medicines regulatory authority (NMRA). – The average lead time for registration of contraceptives is less than six months for 56 percent of countries (20 countries out of 36 reporting). This reflects an upward trend since 2019, when the average lead time for 50 percent of countries was six months to one year ; in 2021, 49 percent of countries reported an average lead time of less than six months. – 79 percent of countries require testing of contraceptives at the national quality control laboratory (NQCL). – The testing of contraceptives, excluding condoms, has increased since 2021. In 2023, 58 percent of responding countries reported that ‘most’ or ‘some’ contraceptives were tested, compared to 42 percent in 2021. – The percent of countries in which the NMRA conducts field surveillance monitoring to identify substandard and falsified (SF) contraceptives rose from 32 percent to 61 percent between 2021 and 2023, with nine new countries confirming NMRA monitoring. Private Sector – 82 percent (27 of 33 countries) have more than three wholesalers registered in the country to distribute FP products. – By FP product, the percent of countries where there were no WHO-prequalified or SRA-approved products registered for distribution ranged from 5 percent (COCs) to 30 percent (female condoms). ix | Executive Summary 2023 Contraceptive Security Indicators Report – 58 percent (19 of 33 countries) have established private-sector engagement plans to expand private-sector FP products or services. Of those, 79 percent have taken at least some actions to implement the plan. Impact of COVID-19 Pandemic – 84 percent of countries (32 of 38) reported having an emergency preparedness plan in place for pandemics that includes impact on FP, similar to in 2021, with Peru since adding a plan. Yemen reported having a plan in 2021 but not in 2023. – Out of the 37 reporting countries, 86 percent have an emergency preparedness plan in place for other types of emergencies that includes impact on FP, which represented an additional 4 countries that confirmed having a plan, when they had no plan, or it was unknown in 2021 (Ghana, Mali, Nigeria, and Togo). Yemen reported having a plan in 2021 but not in 2023. – 82 percent of countries reported having FP/RH supplies prepositioned for emergencies. – 72 percent of the countries surveyed reported no impact of the COVID-19 pandemic on frequency of CS committee meetings in 2023 (up from 50 percent in 2021), 23 percent (down from 40 percent in 2021) reported reduced frequency of CS committee meetings, while 5 percent reported the pandemic prevented their ability to meet (down from 10 percent in 2021). – 75 percent of countries reported no impact of the COVID-19 pandemic on the approved budget line for contraceptives (up from 63 percent in 2021). All or most of the contraceptive budget was shifted to COVID-19 response in 8 percent (3 countries), down from 5 countries (12 percent) in 2021. – 62 percent of countries reported no impact of the COVID-19 pandemic on the amount of government spending for contraceptives (up from 59 percent in 2021). x | Executive Summary 2023 Contraceptive Security Indicators Report PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 11 | Introduction Multiple factors across several sectors contribute to the availability and accessibility of contraceptives within countries, including political commitment, financial capital, partner coordination, capacity, client demand and use, and commodity availability. As demand for family planning continues to grow (from 900 million women in 2000 to nearly 1.1 billion in 20207), and other health priorities compete for scarce resource needs, the ability of governments and other stakeholders to direct resources and legislation in support of supply chains and family planning service delivery increases in importance. The CS Indicators can assist national family planning programs and other stakeholders in obtaining data and monitoring progress in support of such initiatives as Family Planning 2030 (FP2030) and in achieving the United Nations Sustainable Development Goals and country-specific family planning goals. Introduction 02. The globally recognized concept of contraceptive security (CS) is the condition in which everyone can choose, obtain, and use a wide range of high quality and affordable contraceptive methods, when they need them, for family planning/reproductive health (FP/RH). PH O TO C RE D IT : G H SC -P SM PHOTO CREDIT: GHSC-PSM 7. United Nations Department of Economic and Social Affairs, Population Division (2020). World Family Planning 2020 Highlights: Accelerating action to ensure universal access to family planning (ST/ESA/SER.A/450). 2023 Contraceptive Security Indicators Report 12 | Introduction Background The CS Indicators and CS Index both originated under the USAID | DELIVER PROJECT to help countries and global aid managers and decision-makers measure and track country progress in several different areas toward improving access to contraceptives. The CS Indicators build on the Strategic Pathway for Reproductive Health Commodity Security (SPARHCS8) framework as an approach to assess, identify, and prioritize reproductive health (RH) issues around the “7 Cs”: context, commitment, coordination, capital, capacity, commodities, and client demand and use. The CS Indicators were designed to complement the CS Index (collected every three years between 2003 and 2015, and biennially starting in 2017 in the form of the Contextual Measures). The former CS Index, now presented as individual secondary metrics (called Contextual Measures), provides insight into a mix of higher-level indicators to help countries identify strengths and weaknesses across four components— financing, health and social environment, access, and utilization. It has guided stakeholders in determining which countries are most in need, where to focus resources, and what type of assistance is needed. Data for the Contextual Measures are obtained from secondary sources such as the World Bank and UNICEF and are intended to complement the survey’s findings with additional context. The data are collected at the same time as the CS Indicators and can be found on the online dashboard and in the downloadable dataset. The CS Indicators and Contextual Measures are reported together starting in 2017 under the USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project. This report updates the 2021 report, which can be found on the GHSC website (www.ghsupplychain.org). The knowledge gleaned from the CS Indicators and similar research is intended to improve the effectiveness of public RH programs and private-sector health initiatives, to ensure that these programs’ end users, including populations around the world, can access a wide variety of affordable, high-quality contraceptives, whenever they choose. 8. Hare, L., et al., 2004. PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 13 | Methodology Country Selection The country selection approach for the CS Indicators Survey is purposive, focusing primarily on USAID FP priority countries and USAID FP transitioned countries (countries that have transitioned away from receiving USAID FP procurement funding), as well as on countries that have or plan to make an FP2030 commitment or which are part of the Ouagadougou Partnership. The following list of countries represents the 41 USAID FP priority countries (updated in 2023), the eight USAID FP transitioned countries, and three other countries (Cape Verde, Kyrgyz Republic, and Lao PDR) in which the survey was conducted in 2021 and/or in 2023. Among those three countries, Kyrgyz Republic and Lao PDR are FP2030 commitment countries. Out of the 47 countries that were contacted for the survey in 2023, 40 countries both completed the survey and agreed to share the data publicly, representing an 85 percent response rate. This includes 28 in the Africa region, 6 in Asia and Middle East, and 6 in Latin America and the Caribbean (LAC). Countries that were recently added to USAID’s FP priority list, including Cambodia, Jordan, and Timor-Leste, were not included in this survey round, but may be selected in future rounds. Methodology 03. The 2023 CS Indicators methodology has been updated since the last round in 2021. Changes are described in the following pages. As in previous rounds, the survey incorporates a combination of quantitative and qualitative elements, collected through key informant interviews and document review within each focus country. GHSC-PSM personnel led data collection and initial validation in countries where the project has a presence. In non-presence countries, these activities were led by USAID, Ministry of Health (MOH) officials, or representatives of another donor or implementing partner. PH O TO C RE D IT : G H SC -P SM Out of the 47 countries that were contacted for the survey in 2023, 40 countries both completed the survey and agreed to share the data publicly, representing an 85 percent response rate. PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 14 | Methodology Country USAID FP Priority Countries USAID FP Transitioned Countries Ouagadougou Partnership Countries FP2030 Commitment Countries CS Indicators 2021 Respondent Countries CS Indicators 2023 Respondent Countries Afghanistan  Angola    Bangladesh     Benin      Botswana    Burkina Faso      Burundi     Cambodia  Cameroon    Cape Verde   Côte d'Ivoire     Dominican Republic   DRC     Egypt  El Salvador    Ethiopia     Ghana     Guatemala    Guinea      Haiti    Honduras     India   Indonesia   Jordan  Kenya     Kyrgyz Republic    Lao PDR   Liberia     Madagascar     Malawi     Mali      Mauritania      TABLE 1 Characteristics of selected and respondent countries 2023 Contraceptive Security Indicators Report 15 | Methodology Country USAID FP Priority Countries USAID FP Transitioned Countries Ouagadougou Partnership Countries FP2030 Commitment Countries CS Indicators 2021 Respondent Countries CS Indicators 2023 Respondent Countries Mozambique     Nepal     Niger     Nigeria     Pakistan     Peru    Philippines     Rwanda     Senegal      Sierra Leone    South Africa  South Sudan     Sri Lanka   Tanzania     Timor-Leste  Togo      Uganda     Yemen    Zambia     Zimbabwe    Survey Response and Validation Process The survey tool was created in MS Excel and incorporates drop-down menus and free-text response elements. Responses to questions were collected through key informant interviews and document reviews within each focus country. In countries with project presence, GHSC personnel led the data collection and initial validation. Elsewhere, this was done by USAID, MOH officials, or representatives of another donor or implementing partner (e.g., UNFPA). The survey was disseminated in June 2023, and responses were received between August and December 2023. Validation took place between August 2023 and April 2024. Depending on local data collection opportunities and constraints, key informants may include staff at the MOH; Ministry of Finance; other government officials, managers, and policymakers for FP/RH programs; representatives from associations of pharmacists or health providers; representatives of NGOs or donor agencies; and representatives of private-sector retailers or manufacturers, or associations. Key informants in some cases may be able to cite official documents such as policies, budgets, or strategies in their responses. Survey respondents are requested to cite the sources they consulted to the extent possible for each response, and whether these sources are organizational entities and/or documents, databases, or information systems. These sources are captured in the documentation, which can be found in the downloadable database and listed in columns O and P of the surveys. The GHSC-PSM and GHSC-Technical Assistance (GHSC-TA) Francophone Task Order home offices coordinated with in-country survey leads to validate the responses. This included ensuring that there is internal logic, consistency, and completion within each survey and with previous CS surveys completed 2023 Contraceptive Security Indicators Report 16 | Methodology by the country. Secondary sources were referenced for some indicators, most notably the GHSC-PSM ARTMIS database for USAID procurement values, the Global Family Planning Visibility and Analytics Network (GFPVAN) for UN and other donor procurements, and the FP2030 website for details on country commitments. Analysis Responses for each section were aggregated across countries, within countries, or, where country aggregation is not meaningful, using other descriptive (non-inferential) methods. To present the commodity mix and stockout rates, for example, data are presented by FP method rather than by country. Percentages as well as the underlying numerators and denominators are presented in the summary tab of the online downloadable dataset. Quantitative results for a selection of indicators are presented in the dashboard through descriptive statistics that allow users to view results by survey section and by indicator at a country or cross- country (global) level. A downloadable database with additional aggregated results as well as full country-by-country results is available for users to conduct additional analysis themselves, as needed. Qualitative data are analyzed thematically and discussed throughout the survey report. Some qualitative indicators are depicted in frequency charts in the dashboard, while others are presented by country in the downloadable database summary tab. Full qualitative responses can be found in the country survey tabs of the downloadable database. Changes in Methodology from Previous Report GHSC-PSM, in close collaboration with USAID, reviewed the survey tool and made changes and updates to improve the clarity and utility of the survey. The main changes to note are found in Section C (Commodities), and Section H (Impact of the COVID-19 pandemic). In Section C, the 2023 survey more explicitly measures the conditions under which a contraceptive method is ‘offered’ within a sector (public, commercial, NGO, and social marketing). To be ‘offered’, a method must meet at least one of the following two conditions: 1) The method is required to be offered by a formal written policy, or 2) The method has been procured and/ or distributed in the previous 12 months. In Section H, the survey follows up on the status of operational practices intended to facilitate access to FP/RH services and commodities during the peak of the COVID-19 pandemic, which were first reported in 2021, and asks a new question about whether FP/RH commodities have been pre-positioned for emergency preparedness. A few other minor changes were made throughout the survey to clarify question wording, response options, and skip patterns. The full survey tool can be found in Annex A. Quantitative results for a selection of indicators are presented in the dashboard through descriptive statistics that allow users to view results by survey section and by indicator at a country or cross-country (global) level. Qualitative data are analyzed thematically and discussed throughout the survey report. PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 17 | Limitations Most of the data provided are from secondary sources. This is a centrally and remotely collected survey where the principal authors did not have direct access to many of the data sources. When possible, indicators were validated against other secondary data sources, though most relied on the key informants and their sources. As with all data provided by key informants, these data rely on respondent knowledge and may be affected by reporting biases. Where responses were unknown or not applicable at the time of survey completion, they have been removed from the denominator when calculating percentages. The FP commodity funding gap in countries is depicted as the percent of U.S. dollars spent on FP commodities for the public sector out of the total FP commodity forecast for the public sector. This measure can be difficult to interpret due to exchange rate fluctuations, changes in inflation rates and commodity costs, differing methodologies for commodity forecasting, and different ways government budgets account for contraceptive commodity costs. All of these could artificially increase or decrease the FP funding gap. In some cases, a government may not have visibility into all public sector FP commodity donations (for example, when donations go directly to social marketing organizations, as these commodities are included in public sector expenditures but not often captured in forecasts), thereby reflecting a larger-than- expected spending-to-forecast ratio (and therefore an artificially low funding gap). Other factors affecting this gap could include commodity deliveries planned for one year but occurring in a later period, forecasts that exclude commodities currently available in the pipeline (which could mask the true annual demand for contraceptives), or FP forecasts that do not include condom needs that are forecast under HIV programs. Regional comparisons and comparisons between countries have not been drawn in this survey, due to the limited numbers of respondent countries in several regions and the non-random selection of the countries responding in each region. Although a comprehensive data collection and use manual was made available to respondents, interpretations of questions may still vary. Due to differences in reporting countries, revisions to some questions and additions of others, comparisons with previous CS Indicators surveys are limited. Some indicator percentages intended to total 100 percent have been rounded in the narrative for ease of reading and therefore may not total 100 percent. In graphs, decimal places are hidden, enabling percentages to correctly sum to 100. Limitations 04. Data presented in this survey reflect the most recently completed fiscal or calendar year in each country, provided by key informants based on the information they had access to at the time of the survey. Therefore, time periods reflected in the data between countries may vary due to availability of the most recent data and the rolling survey completion dates. PH O TO C RE D IT : G H SC -P SM Additional information on specific country data can be found in the full data set on the GHSC-PSM website, or by contacting the GHSC-PSM project. https://www.ghsupplychain.org/ 2023 Contraceptive Security Indicators Report 18 | Leadership and Coordination Leadership and Coordination 05. Effective and strong leadership is necessary for effective coordination among in-country partners in the public, NGO, social marketing, and commercial/private sectors to ensure resources, financing, and information are used to strengthen CS. The survey collected data on the existence of a contraceptive security committee, composition of its membership, frequency of meetings, legal status, terms of reference, and whether the committee has started, developed, and/or implemented FP action plans or policies. PH O TO C RE D IT : G H SC -P SM 95% of countries have a national committee that works on CS, and 90 percent of those committees have formal written terms of reference. 45% The commercial/private sector participates in 45 percent of CS committees, up from 33 percent in 2021. 51% More than half of the CS committees met four or more times in the previous year. 82% of CS committees developed policies, procedures, recommendations, and/ or action plans (an increase from 76 percent in 2021), and 100 percent of those reported adhering to policies and procedures or implementing action plans. Highlights 2023 Contraceptive Security Indicators Report 19 | Leadership and Coordination Contraceptive Security Committee Of 42 countries, 95 percent (40) have a committee that works on CS (Exhibit 1). This number has remained relatively stable since 2017. These committees continue to be prevalent in countries and remain highly active in terms of meeting frequency: 87 percent of committees met at least twice in the previous year, and 82 percent of committees developed policies, procedures, recommendations, and/or action plans. Of the countries with CS committees, 78 percent have legal or administrative status, and 90 percent have a formal written terms of reference. The MOH is represented on the committee in all countries. NGOs participate in 90 percent of CS committees; UN agencies, 95 percent; social marketing sector, 77 percent; central medical store/central warehouses, 90 percent; donors, 85 percent; other entities, 61 percent; Ministry of Finance or Planning, 35 percent; and the commercial/ private sectors, 45 percent. The share of CS committees in which the commercial sector participates has been hovering at around one-third for the past several rounds of the survey. In this iteration, it reached 45 percent of countries reporting. Eighty-two percent of the CS committees have developed policies, procedures, or action plans, and 100 percent of these responded that there is evidence that these policies and plans are taking place or being implemented (Exhibit 2). Fifty-one percent of the CS committees met four or more times per year, while 36 percent met two to three times, 8 percent met once, and 5 percent did not meet at all (Exhibit 3). The primary functions of CS committees among respondent countries continue to be: – Monitoring FP stock levels and coordinating supply chain interventions, particularly forecasting and quantification (24 countries), – Overseeing implementation of national FP strategies (23 countries), – Making technical or policy recommendations (17 countries), and – Increasing communication and collaboration among FP stakeholders (16 countries). EXHIBIT 1 Percentage of countries that have CS committees, and their composition EXHIBIT 2 Activity of CS committees EXHIBIT 3 Frequency of CS committee meetings in the previous year (n=39) 4 or more times 2-3 times 1 time 0 time Existence of CS committee (n=42) Committee developed policies, procedures, or action plans (n=39) Committee adhering to policies, procedures, or action plans (n=29) 95% 100% 82% 51% 36% 8% 5% 2023 Contraceptive Security Indicators Report 20 | Finance and Procurement In the survey, a combination of indicators gauging a country’s contraceptive- related forecasting, allocation, and actual expenditures is used to obtain an overall country-level picture of contraceptive financing from a variety of sources and to assess the country’s sustainability of CS. The average total expenditures on FP commodities across countries have decreased by nearly 10 percent from a reported $8,888,428 in 2021 to $8,056,996 reported in 2023, when comparing the 40 countries that reported in both survey rounds. The reported total expenditures do not account for inflation, which may account for some of the observed decrease in government spending. The potential influence of inflation, which jumped from 1.9 to 8 percent worldwide between 2020 and 2022, coupled with exchange rate fluctuations and other factors that may have influenced spending trends, warrants further investigation.9 Finance and Procurement 06. A sufficient and reliable stream of financing for procuring contraceptives is essential to achieving contraceptive security. Tracking the different sources of financing, including government, in-kind donations, and grants from year to year reveals the availability of funding to cover estimated need and any financing gaps. PH O TO C RE D IT : G H SC -P SM 34% An average of 34 percent of financing comes from government sources and 66 percent from in-kind donations. The government share of total spending represents a decrease from both 2021 and 2019 when governments spent a total of 47 and 48 percent, respectively. This large decrease was driven by five countries which previously spent government funds but did not release funds on time this assessment year, i.e. within the most recently completed 12-month period for which both contraceptive commodity forecast data and expenditure data are available. 9. High inflation rates in some of the respondent countries may in part explain expenditure trends. A World Bank Inflation, Consumer Price Index table showing inflation rates in the 2023 CS Indicators Survey respondent countries between 2018 and 2022 can be found in Annex C. 71% of respondent countries have a government budget line item specifically for contraceptives (down slightly from previous years). 51% More than half of reporting countries had a funding gap between their forecast and spending, the same as in 2021. However, the amount of the funding gap greatly increased. In 2023, FP commodity funding across countries covered 78 percent of the demand, down from 92 percent in 2021. 81% of countries allocated government funds for contraceptive procurement in the most recently completed fiscal year, and 71 percent spent government funds. Highlights 2023 Contraceptive Security Indicators Report 21 | Finance and Procurement Financing Sources and Expenditures for Public-sector Contraceptives Countries were asked to provide the government funding sources used toward procuring contraceptives. Government funding sources comprise internally generated funds and other funds, which can include World Bank credits or loans, basket funds, and other funds provided to the government from a donor. Because governments count these World Bank credits, basket funds, and other funds as part of their national budget and they decide how to allocate and spend these funds, they are considered part of government funding. Government Expenditures Of 42 country responses, 81 percent allocated funds toward public-sector contraceptive procurement, and 71 percent spent government funds on contraceptives for the most recently completed fiscal year. Country Internally generated funds spent All other government funds spent Total government funds spent Internally generated funds as a percent of total government funds spent Angola $0 $751,539 $751,539 0% Bangladesh $1,434,952 $18,571,429 $20,006,381 7% Benin $327,600 N/A $327,600 100% Botswana $1,969,668 $0 $1,969,668 100% Burkina Faso $1,272,981 $0 $1,272,981 100% Burundi $60,876 $1,027,320 $1,088,196 6% Cape Verde $288,525 $0 $288,525 100% Côte d'Ivoire $800,000 $0 $800,000 100% Dominican Republic $2,099,869 $0 $2,099,869 100% DRC $2,097,680 $0 $2,097,680 100% El Salvador $0 $0 $0 N/A Ethiopia $1,895,064 $13,164,357 $15,059,422 13% Ghana $0 $590,381 $590,381 0% Guatemala $2,175,777 $0 $2,175,777 100% Guinea $1,300,000 $0 $1,300,000 100% Haiti $0 $0 $0 N/A Honduras $1,697,902 $0 $1,697,902 100% Kenya $0 $0 $0 N/A Kyrgyz Republic $83,720 $11,562 $95,282 88% EXHIBIT 4 Government spending by source, 2023 assessment year (U.S. dollars) Government funding sources comprise internally generated funds and other funds, which can include World Bank credits or loans, basket funds, and other funds provided to the government from a donor. PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 22 | Finance and Procurement Country Internally generated funds spent All other government funds spent Total government funds spent Internally generated funds as a percent of total government funds spent Liberia $0 $0 $0 N/A Madagascar $203,000 $0 $203,000 100% Malawi $647,872 $1,236,582 $1,884,454 34% Mali $441,208 $0 $441,208 100% Mauritania $0 $0 $0 N/A Mozambique $241,584 $0 $241,584 100% Nepal $1,080,840 $0 $1,080,840 100% Nigeria $0 $0 $0 N/A Pakistan $11,430,704 $0 $11,430,704 100% Peru $20,290,780 $0 $20,290,780 100% Philippines $6,668,837 $0 $6,668,837 100% Rwanda $0 $656,883 $656,883 0% Senegal $769,230 $0 $769,230 100% Sierra Leone $0 $0 $0 N/A South Sudan $0 $0 $0 N/A Tanzania $1,382,890 $0 $1,382,890 100% Togo $166,667 $0 $166,667 100% Uganda $0 $0 $0 N/A Yemen $0 $0 $0 N/A Zambia $0 $0 $0 N/A Zimbabwe $1,700,000 $0 $1,700,000 100% Of the countries that did use government funds to procure contraceptives, the proportion of government financing ranged from 1 percent (Mozambique) to 99 percent (Pakistan), with the median rate being 24 percent. The government share of total spending constituted nearly the entire amount spent in the Philippines (97 percent), Peru (94 percent), and Bangladesh (91 percent). It also made up the majority of total spending in Cape Verde (86 percent), Botswana (85 percent), Guatemala (60 percent), Ethiopia (53 percent), and Guinea (50 percent). In twelve countries, no government funds were utilized for public-sector contraceptive procurement, including: Uganda, Nigeria, Zambia, Mauritania, Kenya, El Salvador, Haiti, Liberia, Sierra Leone, South Sudan, and Yemen. Five of these countries—Haiti, Liberia, Sierra Leone, South Sudan, and Yemen—spent 0 percent of government funds in both 2021 and 2023, resulting in their exclusion from Exhibit 5. In contrast, six countries—El Salvador, Kenya, Mauritania, Zambia, Nigeria, and Uganda—had government spending in 2021 but not in 2023; these countries still appear in Exhibit 5. In twelve countries, no government funds were utilized for public-sector contraceptive procurement PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 23 | Finance and Procurement EXHIBIT 5 Total government spending as a share of total spending on public-sector contraceptives, 2021 and 202310 10. Excludes Haiti, Liberia, Sierra Leone, South Sudan, and Yemen where government spending was 0 percent in both 2021 and 2023. Pakistan Philippines Peru Bangladesh Cape Verde Botswana Guatemala Ethiopia Guinea Angola Dominican Republic Honduras Burundi Kyrgyz Republic Nepal Senegal Burkina Faso Côte d’Ivoire Zimbabwe Malawi Rwanda Mali Tanzania Benin Ghana Togo DRC Madagascar Mozambique El Salvador Kenya Mauritania Zambia Nigeria Uganda 0% 40%20% 60% 90%10% 2023 Survey 2021 Survey 50% 80%30% 70% 100% 2023 Contraceptive Security Indicators Report 24 | Finance and Procurement EXHIBIT 6 Share of government spending on contraceptives by government funding source (n=28)11 11. Excludes El Salvador, Haiti, Kenya, Liberia, Mauritania, Nigeria, Sierra Leone, South Sudan, Uganda, Yemen, and Zambia where government funding was 0 percent, and Benin, where other government funding was unknown. Of the 28 countries that used government funds for contraceptives, in 20 countries (71 percent) internally generated funds were the only source of government funds used toward the purchase of contraceptives. When looking at government funding sources as a total of contraceptive spending, internally generated funds made up 23 percent and other government funds made up 11 percent. An go la H on du ra s Bo ts wa na Se ne ga l To go Ba ng lad es h N ep al D om in ica n Re pu bl ic Rw an da M ali Ca pe V er de M ala wi Pe ru G ua te m ala G ha na M ad ag as ca r Bu rk in a Fa so Ta nz an ia Zi m ba bw e Et hi op ia Pa ki st an D RC Bu ru nd i M oz am bi qu e Cô te d ’Iv oi re Ky rg yz R ep ub lic Ph ilip pi ne s G ui ne a 2023 Contraceptive Security Indicators Report 25 | Finance and Procurement In-Kind Donations and Global Fund Grants Of 40 country responses, all received in-kind donations (Exhibit 8). For 11 countries, in-kind donations were the sole funding source for procuring contraceptives. For 21 countries, in-kind donations comprised 50 percent to 99 percent of total contraceptive funding. In the remaining 8 countries, funding from in-kind donations ranged from 1 percent (Pakistan) to 47 percent (Ethiopia). Donations from the UN accounted for the largest amount (37 percent), followed by USAID (20 percent), Global Fund and other donations (each 4 percent), and other bilateral organizations (1 percent). UN and USAID donations have increased since 2021 from 29 percent and 14 percent, respectively. EXHIBIT 8 In-kind donations and grants as a percentage of total spending on public-sector contraceptives (n=40) EXHIBIT 7 Percentage of other government spending as a share of total government spending on contraceptives, non-zero countries shown (n=28) For the eight countries that used other government funds (basket funds, World Bank credits or loans, and other funds donors provided to the government, such as direct budget support), this source accounted for 12 percent (Kyrgyz Republic) to 100 percent (Angola, Ghana, and Rwanda) of total government funding (see Exhibit 7). In other words, among countries that utilized other government funds, the proportion of these funds varied within the overall government financing. 2023 Contraceptive Security Indicators Report 26 | Finance and Procurement The Asia and Middle East region used the greatest amount of total government spending toward procuring public-sector contraceptives (84 percent, down from 91 percent in 2021), followed by LAC (69 percent, up from 66 percent in 2021) and Africa (15 percent, down from 23 percent in 2021). The Africa region used mainly in- kind donations (86 percent), while in-kind donations made up 31 percent in the LAC region. In terms of total spending, 34 percent of financing for contraceptives came from government sources and 66 percent from in-kind donations (Exhibits 9 and 10). These percentages are similar to those from 2019, where contraceptive financing was composed of 38 percent government financing and 62 percent in-kind donations. In 2021, there was a shift toward a greater share of government financing (47 percent) compared to in-kind donations (53 percent). EXHIBIT 10 Total contraceptive spending by source and region (n=40) EXHIBIT 9 Percentage of total spending on public-sector contraceptives by funding source (n=40) 2023 Contraceptive Security Indicators Report 27 | Finance and Procurement Financing Gap for Procurement of Public-sector Contraceptives Of 39 countries, 20 (51 percent) had a funding gap between the forecasted need and available financing (Exhibit 11).13 Even though the number of countries with a funding gap remained constant from 2021, the total gap in funding widened. This was due to the large drop in government spending, offset slightly by an increase in donations (from an average of $4.3 million in 2021 to $5.2 million in 2023). Five countries that previously spent government funds on contraceptives (Zambia, Kenya, Nigeria, El Salvador, and Mauritania) did not do so in the current assessment year due to governments not releasing funds on time. purchase of FP commodities. Seventy-one percent of countries spent government funds on FP commodities, similar to the share of government spending in 2021 (70 percent).12 Six countries have a budget line item but did not use government funds (Haiti, Kenya, Mauritania, Nigeria, Uganda, Zambia), while another six used government funds to procure contraceptives, but did not have a dedicated budget line (Botswana, Dominica Republic, Ghana, Mali, Philippines, Tanzania). Five countries do not have a budget line item and did not spend government funds (El Salvador, Liberia, Sierra Leone, South Sudan). Budget Line Item The existence of a budget line item for procuring contraceptives is a demonstration of a country’s commitment to contraceptive security but does not necessarily guarantee funds will actually be spent to purchase contraceptives. In 2023, 29 out of 41 reporting countries had a budget line item for FP commodities. This was 32 out of 44 reporting countries in 2021. Of those countries that reported in both survey rounds, Liberia and Tanzania only reported having budget line items for contraceptives in 2021 while Madagascar and Zimbabwe only reported having a budget line item for contraceptives in 2023. Eighty-one percent of countries allocated government funds toward the 12. Spending on contraceptives in this survey is defined as the value in U.S. dollars of contraceptives actually delivered (in cases where delivery data were available) in the country’s most recently completed 12-month period for which data were available at the time of the survey. Commodities delivered in one year may have been planned for an earlier or later year. Similarly, commodities may have been planned for a year but not actually delivered in that year. 13. The Limitations section discusses some of the explanations for the fluctuations in this indicator result. 14. Outliers not shown: Honduras 262 percent, Dominican Republic 284 percent, Nepal 410 percent. EXHIBIT 11 Percentage of quantified need covered by any source of funding (n=38)14 Key: Red = 0–94 percent of funding need met, Grey = 95–105 percent of funding need met, Blue = 106+ percent of funding need met. 2023 Contraceptive Security Indicators Report 28 | Commodities The survey gathered information on the following 13 methods: Male condoms Combined oral contraceptives (COCs) Intrauterine devices (IUDs) Injectables Implants Emergency contraceptive pills (ECs) Progestin-only pills (POPs) Female condoms Long-acting permanent methods for females (tubal ligation) Long-acting permanent methods for males (vasectomy) Calendar-based awareness methods Contraceptive patches Vaginal contraceptive rings Commodities 07. Having a range of contraceptive methods gives clients the ability to choose a method that best meets their needs. Respondents were asked which contraceptive methods are offered through the public, commercial/ private, NGO, and social marketing sectors. PH O TO C RE D IT : G H SC -P SM 86% The commercial/private sector offers the five most common contraceptives (male condoms, COCs, injectables, intrauterine devices, and contraceptive implants) in 86 percent of reporting countries. 100% of reporting countries now offer combined oral contraceptives and IUDs in the public sector, while 100 percent offer male condoms in both the commercial and NGO sectors. 9 Countries offer on average 9 of the 13 assessed contraceptive methods: 10 in public-sector facilities, 10 through the commercial/private sector, 9 in NGOs, and 7 through social marketing 98% In the public sector, 98 percent of countries offer the five most common contraceptive methods, and 95 percent offer at least 8 of the 13 assessed contraceptive methods. Highlights 2023 Contraceptive Security Indicators Report 29 | Commodities Methods Offered by Sector Short-term methods such as male condoms, COCs, and injectables are commonly offered across all four sectors. Long-term methods such as IUDs are offered in 100 percent of countries through the public sector, through NGOs in 98 percent of countries, and through the commercial/private sector in 95 percent of countries, while implants are offered in the public sector in 98 percent of surveyed countries and through NGOs in 95 percent of the countries. Permanent methods—vasectomy and tubal ligation— are more often offered through the public sector than through any other sector. Emergency contraceptives are more commonly offered in the commercial/ private sector than in other sectors. Public Sector Of all countries surveyed, an average of 10 methods are offered in the public sector, and at least 8 methods are offered in the public sector in 95 percent of countries. Furthermore, 98 percent provide all five of the most offered methods in public- sector facilities (male condoms, COCs, injectables, IUDs, and implants) (Exhibit 12). In 2021, this was 89 percent and 91 percent, respectively. All countries offer COCs and IUDs in the public sector. Nearly all countries offer POPs. Only the Kyrgyz Republic does not offer injectables, implants, or male condoms in the public sector. Most countries offer tubal ligation and vasectomy (both 97 percent), emergency contraceptive pills (83 percent), female condoms (78 percent), and calendar-based methods (68 percent) in the public sector. Only a small percentage offer vaginal contraceptive rings (6 percent) and contraceptives patches (5 percent). EXHIBIT 12 Method mix by sector (percentage of countries that offer the following contraceptive methods by sector) (n=42) 2023 Contraceptive Security Indicators Report 30 | Commodities NGOs The NGO sector is another good source of a variety of contraceptives for clients. In most countries, male condoms (100 percent), COCs and implants (both 95 percent), IUDs and injectables (both 98 percent), ECs (88 percent), female condoms (87 percent) and POPs (93 percent), can be found through the NGO sector. Countries with NGOs providing female condoms increased from 71 percent in 2021 to 87 percent in 2023. Calendar-based methods (64 percent), contraceptive patches (13 percent), and vaginal contraceptive rings (6 percent) are not as commonly found at NGO facilities. An average of 9 of 13 methods are available in the NGO sector, and the five most common methods can be found in the NGO sector in 88 percent of reporting countries. Commercial/Private Sector COCs and male condoms are available through the commercial/private sector in almost all countries (98 percent and 100 percent, respectively). ECs (95 percent), POPs (98 percent), injectables (90 percent) and IUDs (95 percent) are also commonly offered. Implants have shown a substantial increase in the commercial/ private sector (from 79 percent in 2021 to 90 percent in 2023), as has vasectomy (from 68 percent to 82 percent in the same period). Calendar-based methods offered in this sector have also increased, from 37 percent of countries in 2021 to 60 percent in 2023. Female condoms (76 percent), vaginal contraceptive rings (21 percent), and contraceptive patches (23 percent) are offered less frequently in the commercial/private sector. An average of 10 of 13 methods are available in the commercial/private sector, and all five of the most common methods can be found in the commercial/private sector in 86 percent of reporting countries, an increase from the reported 73 percent for all five methods in 2021. Social Marketing Male condoms (95 percent), COCs and IUDs (both 85 percent), and injectables (88 percent) are offered through social marketing in most countries. The percentage of countries in which IUDs and injectables are offered in this sector has increased from 76 percent and 77 percent in 2021, respectively. Availability of implants, POPs, ECs, and female condoms can be found in 65 percent to 82 percent of countries. Calendar-based methods (42 percent), contraceptive patches (9 percent), and vaginal contraceptive rings (3 percent) are less commonly found through social marketing, as are vasectomy (37 percent) and tubal ligation (42 percent). An average of 7 of the 13 methods are available in the social marketing sector, and the five most common methods can be found in the social marketing sector in 71 percent of reporting countries. The number of countries offering vasectomy and tubal ligation in the social marketing sector has nearly tripled since 2021 (from 5 and 6 countries to 14 and 15 countries, respectively). Countries with NGOs providing female condoms increased from 71 percent in 2021 to 87 percent in 2023. PH O TO C RE D IT : G H SC -P SM 2023 Contraceptive Security Indicators Report 31 | Policies A supportive (or enabling) CS environment is defined15 as one in which: – Laws and executive orders mandate provision of products and services without imposing undue restrictions on providers or eligibility requirements on clients. – Government and civil society leaders speak openly in favor of FP/RH care and healthy practices. – Public and private resources are adequate to ensure full population coverage. – The policy formulation process is characterized by good planning principles and broad participation. Policies 08. Policies supportive of contraceptive security are essential to provide an enabling environment for client access and awareness of contraceptives, and to allow health workers to provide and prescribe them as needed. Supportive policies demonstrate a government commitment to strengthen contraceptive security. PH O TO C RE D IT : G H SC -P SM 98% of countries have either a CS or reproductive health commodity security strategy or a strategy that explicitly mentions increasing contraceptive access. 57% In 57 percent of countries, FP commodities are subject to duties in at least one sector (public, commercial/ private, NGO, or social marketing). 87% of countries have policies that enable the private sector to provide contraceptives, while 10 percent of countries have policies that hinder that ability. 15% of countries have laws, policies, or regulations that make it difficult for unmarried people ages 15–19 to access family planning services or contraceptives, and 10 percent of countries reported this for married people ages 15–19. 61% of countries have at least 50 percent of their providers trained to remove or insert implants and IUDs. In 2021 this was 65 percent but 41 percent in 2019. 9 On average, countries included 9 FP methods on their NEML. 15. USAID Data for Impact project, Policy Environment overview, Family Planning and Reproductive Health Indicators Database, (https://www.data4impactproject. org/prh/health-systems/policy-environment/). Highlights 2023 Contraceptive Security Indicators Report 32 | Policies National Strategy with Objectives for Contraceptive Security Most national FP/RH strategies (specifically their contraceptive security components) aim to influence overall family planning outcomes, such as increasing the availability of and access to FP services and commodities; reducing unmet need; increasing demand for FP and ultimately increasing the modern contraceptive prevalence rate (mCPR); improving maternal and child health; and reducing maternal, neonatal, and child mortality. The strategies and sub-objectives for achieving these higher-level goals are varied, but a common theme is health system strengthening, especially through capacity building. Within this overarching theme, several countries cited objectives to improve service delivery and FP product quality, strengthen aspects of the supply chain, and improve monitoring and evaluation. Policy Barriers Impacting Access or Provision to Contraceptives Duties Fifty-seven percent of countries reported that FP commodities are subject to duties for at least one sector (Exhibit 13). In 20 percent of countries (8 of 40), public- sector FP commodities are subject to duties. Duties are applied to the social marketing sector in 45 percent of the countries and the NGO sector in 32 percent of the countries. The percentage of countries subject to duties on FP commodities in the commercial/private sector increased from 49 percent in 2021 to 56 percent in 2023; DRC and El Salvador reported private sector duties in 2023 but not in 2021. EXHIBIT 13 Percentage of countries where FP commodities are subject to duties by sector 24% 33% 38% 49% 51%20% 32% 45% 56% 57% 2023 Contraceptive Security Indicators Report 33 | Policies Policies that impact the ability of the private sector to provide contraceptives Of all country respondents, 10 percent (4 of 39) reported there are policies that hinder the ability of the private sector to provide contraceptives (Exhibit 14). The percentage of countries reporting the existence of policies hindering the private sector’s distribution of contraceptives has declined over the survey years from 43 percent of countries in 2010 (15 of 35) to 10 percent in 2023 but has remained relatively steady since 2017. Examples of such barriers include specific permission needed to import contraceptives, branding or advertising restrictions, high taxes on contraceptives, price controls, and bans on mass media promotion. National governments continued the trend of coordinating with the private sector to expand contraceptive access. Most countries (87 percent) reported having enabling policies, while only 4 countries cited policies that hinder the private sector’s provision of contraceptives. Some of the specific enabling policies cited include governments supporting training for private sector providers, subsidizing contraceptives in the private sector, facilitating private imports, such as through tax exemptions, public/private provider networks and franchises, accreditation services and regulations allowing for over-the-counter sale of contraceptives. However, the number of countries that impose duties on FP commodities in the private sector has increased; two countries that did not report that duties were imposed in 2021 now reported duties in 2023. In 87 percent of surveyed countries (34 of 39), there are policies that enable or support the private sector provision of contraceptives. This was 93 percent (38 of 41) in 2021, 90 percent (35 of 39) in 2019, 94 percent (30 of 32) in 2017, and 73 percent (33 of 45) in 2015. EXHIBIT 14 Policies that enable or hinder private-sector provision of contraceptives (n=39) EXHIBIT 15 Trend over time in policies that impact private-sector distribution of contraceptives 2023 Contraceptive Security Indicators Report 34 | Policies Dispensing restrictions Restrictions on those who can dispense certain contraceptives can be barriers preventing clients from easily accessing the method of their choice. In the commercial/private sector, a greater percentage of countries reported that community health workers (CHWs) were authorized to distribute condoms, combined oral contraceptives (COCs), progestin-only pills (POPs), and (emergency contraceptive pills) ECs compared to in 2021. In the public sector, the authorizations have stayed roughly the same since 2021 for these methods, except a greater percentage of countries reported CHWs were authorized to distribute condoms in 2023. In the public sector, CHWs were the most cited lowest level provider across all methods (6 out of 13 methods), mostly short-term methods. For long-acting reversible methods—implants and IUDs—clients must go to higher-level providers in the public sector in most countries to receive the method. In the private sector, nurses and CHWs were the most frequently cited lowest level providers for 4 methods out of the 13 each; for CHWs, these were mostly short-term methods while nurses were the lowest-level providers for ECs, injectables, implants, and contraceptive patches. For short-term methods, CHWs are the lowest-level provider who can sell or dispense male and female condoms (90 percent and 81 percent, respectively) in the public sector (Exhibit 16). COCs can be provided by CHWs in most countries through the public sector (71 percent), although less frequently in the private sector (34 percent). For COCs in the private sector, the percentage of auxiliary nurse midwives as the lowest level provider has shown a consistent rise from 5 percent in 2019 to 15 percent in 2023. Subcutaneous (54 percent) and intramuscular injectables (28 percent), a popular method, are less frequently reported to be dispensed by CHWs in the public sector, and even less in the private sector (26 and 16 percent, respectively). The percentage of countries where CHWs can provide subcutaneous injectables in the public sector has nearly doubled since 2021 (29 percent of countries). Exhibit 16. Lowest level provider allowed to dispense/sell contraceptive methods in the public sector Exhibit 17. Lowest level provider allowed to dispense/sell contraceptive methods in the private sector 2023 Contraceptive Security Indicators Report 35 | Policies Provider skills in implant and IUD insertion and removal The survey asked the approximate percentage of public-sector FP providers trained in implant and IUD insertion and removal (Exhibit 18). Seventeen percent said 81–100 percent of providers are trained, 14 percent responded 71–80 percent, and another 14 percent responded that 61–70 percent are trained, 17 percent said 51–60 percent are trained, 6 percent said 41–50 percent, 8 percent responded that 31–40 percent are trained, 3 percent said 21–30 percent are trained, 8 percent responded that 11–20 percent are trained, and 14 percent said 1–10 percent are trained. In 2021, 57 percent of countries had at least 61 percent of public sector FP providers who could place and remove implants and IUDs. In 2023, that percentage decreased to less than half of reporting countries (45 percent). EXHIBIT 18 Approximate percentage of public sector FP providers trained in implant and IUD insertion and removal Policies that impact the ability of sub-populations to access family planning services and contraceptives The survey asked whether there are laws, regulations, or policies that either increase or decrease access to family planning services and commodities for sub-populations: unmarried youth, married youth, rural, disadvantaged sub-regions, populations with lower educational attainment, lower-income populations, disabled, minority populations (ethnic or religious groups), and other (e.g., migrants, internally displaced populations). Most countries have supportive policies for family planning among the sub-populations (Exhibit 19). These include for unmarried youth in 78 percent (ages 15–19 years) and 83 percent (ages 20–24 years) of countries, and for married youth in 88 percent (ages 15–19 years) and 90 percent (ages 20–24 years) of countries. Ninety percent of countries reported having policies to enable access to FP for the rural population, 87 percent for those in disadvantaged sub-regions, 85 percent for those with lower education, 88 percent for those with lower incomes, 85 percent for those who are disabled, 82 percent for minority populations, and 76 percent for those who are considered migrants or internally displaced populations. These data are similar to 2021, except for a decrease in 2023 of policies for migrants or internally displaced populations from 83 percent to 76 percent. There are countries that have policies hindering access to FP for those between 15 and 19 who are either unmarried (15 percent) or married (10 percent) and those who are unmarried between the ages of 20 and 24 (2 percent, or one of 41 countries — Bangladesh). The latter shows a decrease from 7 percent, or three of 45 countries — Bangladesh, Honduras and Yemen in 2021. 2023 Contraceptive Security Indicators Report 36 | Policies The most commonly cited policy approach to increasing access to contraceptives among sub-populations is to focus on adolescents and youth (cited by 17 countries). Many countries have specific youth-focused RH or reproductive, maternal, newborn and child health (RMNCH) strategies or policies. Other common policies aimed at increasing access include offering free family planning services and/or commodities (five countries) and community health worker or health extension programs designed to better reach rural populations (five countries). Only a few countries cited laws or policies that negatively impact FP/RH access among sub-populations. Seven countries cited these barriers, which included policies limiting access to contraceptives below a minimum age (five countries), or a nominal marriage requirement for accessing contraceptives (two countries: Bangladesh and Pakistan). In the case of Pakistan, however, this requirement is reportedly not enforced in practice. Cultural and operational practices that impact the ability of sub-populations to access family planning services and contraceptives The survey also asked if there are operational, cultural, or other practices that may either increase or decrease access to FP services for the same sub-populations as noted in the above section. Eighty-three percent of countries have supportive practices toward unmarried youth (ages 15–19) and 79 percent for unmarried youth ages 20–24. Supportive practices exist for married youth ages 15–19 in 83 percent of responding countries and for married youth ages 20–24 in 79 percent (Exhibit 20). Practices exist that increase access to FP for rural populations (82 percent), disadvantaged sub-regions (76 percent), lower education (79 percent), lower income (77 percent), disabled and minority populations (both 76 percent), and migrants or internally displaced populations (67 percent). Less than half of the countries responded that there are cultural practices that hinder access for unmarried youth ages 15–19 (46 percent). These cultural and operational barriers were also noted in 40 percent of the countries for married youth in the same age group. For the 20–24 age group it is 33 percent for unmarried youth, and 25 percent for married youth. In 29 percent of the countries, practices hinder access for rural populations, 33 percent for disabled, 30 percent for minority populations, and 32 percent each for those with lower education or lower income. Similar percentages exist for disadvantaged sub-regions (34 percent) and migrants or internally displaced populations (31 percent). The most commonly cited practices that countries implement to increase access to FP/RH are those aimed at education, awareness-raising, and behavior change (cited by 12 countries). This may include collaborating with traditional leaders (such as religious or other local leaders), making communication materials more accessible to under-reached populations (such as disseminating information in Braille and in sign language), implementing awareness- raising campaigns (whether through large gatherings, radio campaigns, or through social networks), employing CHWs or mobile health clinics, or targeting youth through peer-to-peer and school-based communication, among other strategies. The main cultural or operational barriers to accessing FP/RH services and commodities continue to be religious institutional barriers or beliefs (cited by 11 countries); and social norms, misconceptions, or taboos (nine countries); in addition to negative perceptions specifically about youth access to FP (eight countries). Other frequently cited barriers were geographic access difficulties (seven countries), inaccessibility of services for people with disabilities (six countries), and a lack of knowledge about FP services (four countries). EXHIBIT 19 Laws, regulations, or policies that enable or hinder access to FP services among sub-populations (n=41) 2023 Contraceptive Security Indicators Report 37 | Policies EXHIBIT 20 Operational and cultural practices that enable or hinder access to FP services among sub-populations Charges to Clients Fees are charged to clients for family planning services in 29 percent of countries, and for commodities in 20 percent of countries. In comparison, in 2021, 31 percent of countries charged fees to clients for FP services and 24 percent for commodities. In 2019 this was 31 and 37 percent, respectively; in 2017 this was 33 and 31 percent, respectively; 23 for both in 2015, and 15 and 24 percent, respectively, in 2010. Government health insurance covers FP fees in 31 percent of countries, which is in line with the 33 percent of countries in 2021. This was not applicable in 26 countries where no fees were charged. National Essential Medicines List An average of nine contraceptives are on the NEML of reporting countries. All countries include COCs and injectables on their NEML, while nearly all countries include IUDs (copper bearing) (98 percent), POPs and implants (both 95 percent), and male condoms and ECs (both 93 percent) (Exhibit 21). Fewer countries include female condoms (71 percent), hormone-releasing IUDs (67 percent), contraceptive patches (15 percent), vaginal contraceptive rings (17 percent), calendar-based methods (53 percent), and other contraceptives (8 percent). The data remains largely constant relative to that reported in the 2021 survey, with all percentage changes being within six percent. EXHIBIT 21 Percentage of countries with methods included in the NEML, 2015–2023 surveys Combined oral contraceptives Progestine-only pills Injectables Contraceptive implants Copper-bearing IUDs Male condoms Emergency contraceptive pills Female condoms Calendar-based awareness methods Hormone-releasing IUDs Other contraceptives Contraceptive patches Vaginal contraceptive rings 2023 Contraceptive Security Indicators Report 38 | Policies Promotion of Family Planning The survey asked if FP is actively promoted through social marketing, mass media, mobile phone outreach/education, or community mobilization/engagement channels either extensively, somewhat, or not at all (Exhibit 22). Respondents could indicate multiple channels. When looking at channels used either “extensively” or “some,” mobile phone outreach/ education is the most popular channel (92 percent), followed by community mobilization/engagement (90 percent), social marketing (85 percent), and mass media (85 percent). Fifteen percent do not do any promotion through social marketing or mass media, 10 percent do not do any promotion through community mobilization/engagement, and 8 percent do not promote through mobile phone outreach/education. There was a 11-percentage point reduction between 2021 and 2023 in the share of countries using mass media as a channel for promoting family planning. Use of all other channels remained about the same. FP2030 Commitments The majority of reporting countries (88 percent) made or plan to make an FP2030 commitment. As noted in the methodology section, this was one of the main criteria for countries to be selected for the survey. All the countries reporting on specific commitment areas in their existing or planned FP2030 commitment reported that improving domestic financing for contraceptives and improving access to or availability of contraceptives are key areas of their commitment (Exhibit 23). Among countries that made or plan to make an FP2030 commitment, all of them (100 percent) committed to improving domestic financing for contraceptives and improving access or availability of contraceptives, while 92 percent committed to increasing affordability of contraceptives for clients (see Exhibit 24). Two countries that already provide free or highly subsidized contraceptives to clients (Pakistan and Sierra Leone) were excluded from the denominator for the commitment to increase affordability of contraceptives. EXHIBIT 23 Percentage of countries that made or plan to make an FP2030 commitment EXHIBIT 24 Areas of FP2030 commitments among countries that made or plan to make an FP2030 commitment EXHIBIT 22 Promotion of FP by channel 2023 Contraceptive Security Indicators Report 39 | Policies Global Financing Facility In 2023, 62 percent of countries surveyed are Global Financing Facility (GFF) partners (Exhibit 25). Of these, 62 percent include the partnership area technical assistance for the transition to domestic financing of contraceptives and 65 percent include provisions for supply chain management. Countries with Global Financing Facility partnerships have a higher rate of inclusion of provisions for family planning included in the partnership (83 percent) compared to the previous survey in 2021 (63 percent), as well as procurement provisions for contraceptives (67 percent, compared to 65 percent in 2021). EXHIBIT 25 Global Financing Facility partnership areas among GFF partner countries (n=26) Note: Among the 26 GFF partner countries, the percentages for each partnership area are based on countries that had information to report on those areas. 2023 Contraceptive Security Indicators Report 40 | Supply Chain Questions in this section regarding the LMIS gauge the level of visibility into the public health supply chain for FP commodities, including the extent to which the public sector LMIS captures data from other sectors, the lowest supply chain level captured in the LMIS, and if applicable, how data is reported at the service delivery point level (i.e., the extent of electronic or paper reporting). The survey reports contraceptive commodity stockout rates by FP product at both the central medical stores and service delivery point (SDP) levels and asks about potential factors driving high stockout rates. Stockout rates should be interpreted with care for several reasons: – The duration of the stockouts is uncertain. – A stockout could be recurrent for a particular method. – A stockout at the central level does not necessarily mean a stockout at the SDP level, and vice versa. – Country LMISs differ in the proportion of health facilities covered, including some that include only public-sector facilities, and others that also include some private and/or public facilities. – The frequency of stock status reporting varies by country. Supply Chain 9. A reliable supply chain is essential for commodities to reach the intended destination. This section encompasses questions on country logistics management information systems (LMIS), contraceptive stock availability, channels for procurement, frequency of forecasts and delivery levels within the supply chain. PH O TO C RE D IT : G H SC -P SM 15% of countries reported zero central-level stockouts of any contraceptive commodity. 26% Of the 34 countries providing information on central- level stockouts, 26 percent reported zero stockouts at the central level of any of the following most common FP/ RH products: COCs, injectable contraceptives, contraceptive implants, copper-bearing intrauterine devices, and male condoms. 93% of countries have an LMIS that includes contraceptives. Among those, 95 percent capture contraceptive stock data at the service delivery provider (SDP) level. Highlights 2023 Contraceptive Security Indicators Report 41 | Supply Chain Annual stockout rates at the SDP level for the most common FP/RH methods ranged as follows: COCs For 10 countries the stockout rate ranged from 8 percent (Kenya) to 100 percent (Côte d’Ivoire). COCs 27 countries had stockout rates ranging from 0.041 percent (Bangladesh) to 59 percent (DRC) IMPLANTS For 17 countries, the stockout rate ranged from 3 percent (DRC) to 100 percent (Botswana). Seven countries that offer two formulations of implants had no stockouts of either (Benin, Ethiopia, Mali, Mozambique, Nigeria, Togo, and Zimbabwe). IMPLANTS Of the 27 countries reporting stockouts, ratesranged from 0.23 percent (Bangladesh) to 90 percent (Botswana). INJECTABLE CONTRACEPTIVES For 14 countries, the stockout rate ranged from 8 percent (Dominican Republic) to 100 percent (Côte d’Ivoire). INJECTABLE CONTRACEPTIVES For the 29 countries reporting stockouts, rates ranged from 0.03 percent (Bangladesh) to 71 percent (El Salvador). IUDs Stockouts in the 12 countries with stockouts had rates ranging from 7 percent (DRC) to 92 percent (Côte d’Ivoire). IUDs For the 27 countries reporting stockouts, rates ranged from 0.06 percent (Bangladesh) to 74 percent (El Salvador) stocked out. MALE CONDOMS The 10 countries with stockouts had rates ranging from 5 percent (El Salvador) to 100 percent (Côte d’Ivoire) stocked out. MALE CONDOMS Of the 26 countries reporting stockouts, rates ranged from 0.05 percent (Bangladesh) to 59 percent (Kenya) stocked out. Annual stockout rates at the central medical store level for the most common FP/RH methods ranged as follows among countries reporting: 2023 Contraceptive Security Indicators Report 42 | Supply Chain LMIS Out of 42 countries, 93 percent have an LMIS that includes contraceptives, and 95 percent of those countries capture stock data at the SDP level. When asked how commodity data is collected at the SDP level, 84 percent report that at least some sites report electronically, up from 68 percent in 2021. Only eight percent of countries with facility-level stock data have exclusively manual reporting at the SDP level, including Bangladesh, Botswana, and Sierra Leone. Procurement This section discusses the 30 countries that did use government funds to procure contraceptives. Procurement of government- financed contraceptives takes place at the central level in all 30 of these countries. (Exhibit 26). Only 11 percent and 4 percent of countries responded that procurement takes place at either the intermediate (regional or district) or service delivery level, respectively. Pakistan and Nepal are some of the countries which procured at an intermediate level. Procurement can take place in more than one location. Only countries where government financed procurement occurred in the assessment year are included in this indicator. Supplier Delivery Points The survey asked, regardless of central or decentralized procurement, the level(s) to which suppliers deliver commodities (for government-financed procurement only). Delivery may be to more than one level. For 90 percent of countries, the supplier delivers to the central level (Exhibit 27). For 28 percent, the supplier also delivers to an intermediate level (regional or district), 7 percent of suppliers deliver directly to the SDP, and 10 percent report to an “other” delivery point (“other“ delivery points may vary by country and were not specified). EXHIBIT 27 Supplier delivery points for government-procured contraceptives (n=30) EXHIBIT 26 Locations of government-financed procurement (n=30)16 16. Procurement can occur at more than one location in a country, so percentages may not add up to 100 percent. 2023 Contraceptive Security Indicators Report 43 | Supply Chain Product Availability Having products available is essential to meeting client needs. Respondents were asked to report on the number of stock status observations where there was a stockout during the most recent year when data was available, at both the central and SDP levels, for the following contraceptive methods: – COCs – POPs – Injectables – Implants Of the 34 countries providing information on central–level stock availability, 15 percent reported zero stockouts among all products offered within the eight methods at the central level. This section provides information on stockout rates at the central and SDP level by contraceptive method by country. Central-level product availability Combined oral contraceptives For COCs, 20 countries that offer one formulation (levonorgestrel/ethinyl estradiol 150/30 mcg +Fe 75mg) reported zero stockouts. For 10 countries, the stockout rate of COCs ranged from 8 percent (Kenya) to 100 percent (Côte d’Ivoire) (Exhibit 28). Guatemala had stockouts of both formulations (levonorgestrel/ethinyl estradiol 150/30 mcg +Fe 75mg and levonorgestrel/ethinyl estradiol 150/30 mcg). One country, Madagascar, reported no stockouts of COCs in either formulation. Eleven countries had no data. EXHIBIT 28 Central-level stockout rates of combined oral contraceptives, non-zero responses shown – IUDs – Condoms (male and female) – Emergency contraceptive pills – Calendar-based methods 2023 Contraceptive Security Indicators Report 44 | Supply Chain Injectable contraceptives For injectables among the three formulations (DMPA 104mg subcutaneous, DMPA 150mg intramuscular, and norethisterone enanthate), 14 countries of 32 with data (44 percent) reported stockouts (Dominican Republic, Rwanda, Botswana, DRC, Sierra Leone, El Salvador, Pakistan, Madagascar, Malawi, Côte d’Ivoire, Ghana, Guatemala, Angola, and Togo) (Exhibit 30), with annual stockout rates ranging from 8 percent (Dominican Republic for DMPA 150mg intramuscular) to 100 percent in Côte D’Ivoire (DMPA 104mg subcutaneous and norethisterone enanthate) and Ghana and Angola (norethisterone enanthate). DRC and Malawi had stockouts of both DMPA 104mg subcutaneous and DMPA 150mg intramuscular. Ghana and Guatemala reported stockouts of DMPA 150mg intramuscular and norethisterone enanthate. Angola had stockouts of DMPA 104mg subcutaneous and norethisterone enanthate. Côte d’Ivoire had stockouts of all three formulations. A total of 18 countries (56 percent) did not have any stockouts of injectables at the central level. Ten countries did not report data. EXHIBIT 30 Central-level stockout rates of injectable contraceptives (n=32) Progestin-only pills Among seven countries with reported stockout rates greater than zero, the stockout rate for POPs (Exhibit 29) ranged from 8 percent (Guatemala and Zimbabwe) to 67 percent (Bangladesh and Côte d’Ivoire). The remaining 17 reporting countries reported a stockout rate of zero for POPs at the central level: Botswana, Burundi, Cape Verde, Dominican Republic, DRC, Ghana, Haiti, Kyrgyz Republic, Madagascar, Malawi, Mali, Nepal, Pakistan, Senegal, South Sudan, Togo, Yemen. EXHIBIT 29 Central-level stockout rates for progestin-only pills (levonorgestrel 30 mcg), non-zero values shown (n=24) 2023 Contraceptive Security Indicators Report 45 | Supply Chain Contraceptive implants For 17 countries of 31 that had data, the annual stockout rates among both formulations of implants (levonorgestrel 75mg/rod [two-rod implant] and etonogestrel 68mg/rod [one-rod implant]) ranged from 3 percent (DRC, two-rod implants) to 100 percent (Botswana, both formulations) (Exhibit 31). Seven countries that offer two formulations of implants had no stockouts of either (Benin, Ethiopia, Mali, Mozambique, Nigeria, Togo, and Zimbabwe). Nine countries had stockouts of one formulation (Dominican Republic, Ghana, Rwanda, Kenya, Burkina Faso, Nepal, Tanzania, Angola, and Guatemala), and eight had stockouts of both (Malawi, Uganda, DRC, Madagascar, Zambia, Côte d’Ivoire, El Salvador, and Botswana). In total, 14 countries (45 percent) did not have stockouts of implants. Eleven countries did not have data. EXHIBIT 31 Central-level stockout rates of contraceptive implants, non-zero values shown (n=31) Copper-bearing intrauterine devices For 12 countries of 31 that had data and a non-zero stockout rate, the stockout rate for IUDs ranged from 7 percent (DRC) to 92 percent (Côte d’Ivoire) (Exhibit 32). A total of 19 countries (61 percent) reported no stockouts of IUDs. Eleven countries did not have data. Apart from Botswana, which showed an increase in stockouts of 17 percent from 2021 to 2023, central-level stockout rates of copper-bearing intrauterine devices generally improved. EXHIBIT 32 Central-level stockout rates of copper-bearing intrauterine devices, non-zero values shown (n=31) 2023 Contraceptive Security Indicators Report 46 | Supply Chain Condoms Twenty of 30 countries with data had zero central-level stockouts of male condoms in the last 12–month period. The male condom stockout rate for the other 10 countries ranged from 5 percent (El Salvador) to 100 percent (Côte d’Ivoire) (Exhibit 33). Twelve countries did not have available data. EXHIBIT 33 Central level stockout rate of male condoms, non-zero values shown (n=30) For female condoms, the stockout rate ranged from 8 percent (Ghana) to 100 percent (Angola, Botswana, and Côte d’Ivoire) (Exhibit 34). A total of 17 countries had a stockout rate of zero for female condoms: Benin, Burkina Faso, Burundi, Cape Verde, Dominican Republic, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, Sierra Leone, Uganda, Zambia, and Zimbabwe. Seventeen countries did not report on this method. EXHIBIT 34 Central level stockout rates for female condoms at the central level, non-zero values shown (n=25) 2023 Contraceptive Security Indicators Report 47 | Supply Chain Emergency contraceptives In 13 countries of 22 reporting, the stockout rates among both formulations of emergency contraceptives (levonorgestrel 0.75mg, two tablets; and levonorgestrel 1.5mg, one tablet) at the central level ranged from 24 percent (DRC) to 100 percent (Botswana, Angola, and Senegal) (Exhibit 35). Angola reported 100 percent stockouts of both products. A total of nine countries had stockout rates of zero for the one formulation they reported on. Twenty countries did not report data. EXHIBIT 35 Central-level stockout rates for emergency contraceptives, non-zero values shown (n=22) Service Delivery Point Product Availability Countries provided stockout data for the SDP level for the most recently completed twelve-month period, where available. This report presents stockout data for COCs, injectables, implants, IUDs, male condoms, and progestin only pills. Combined oral contraceptives Of 28 countries with data, one (Cape Verde) had zero stockouts of COCs (Exhibit 36). Stockout rates for the other 26 countries ranged from 0.04 percent (Bangladesh) to 59 percent (DRC) among two formulations. Fourteen countries did not provide data. EXHIBIT 36 Service delivery point stockout rates of combined oral contraceptives, non-zero values shown (n=28) 2023 Contraceptive Security Indicators Report 48 | Supply Chain Injectable contraceptives For 29 of the 31 countries with data, the injectable stockout rates for a single product at the SDP level ranged from 0.03 percent (Bangladesh) to 71 percent (El Salvador) among three formulations (DMPA 104mg subcutaneous, DMPA 150mg intramuscular, and norethisterone enanthate) (Exhibit 37). Two countries did not have any stockouts: Madagascar and Cape Verde. Benin, Ghana, Nigeria, and Zambia offer all three formulations, all of which reported stockouts of all three contraceptives. Eleven countries did not have data. EXHIBIT 37 Service delivery point stockout rates of injectable contraceptives, non-zero values shown (n=31) Contraceptive implants Of the 28 countries that offer and reported on implants, one country reported zero stockouts (Cape Verde). For the other 27 countries, the stockout rates ranged from 0.2 percent (Bangladesh and Togo, two-rod implant) to 90 percent (Botswana, one-rod implant). Fourteen countries did not have data. EXHIBIT 38 Service delivery point stockout rates of contraceptive implants, non-zero values (n=28) 2023 Contraceptive Security Indicators Report 49 | Supply Chain Copper-bearing intrauterine devices One out of 28 countries with data reported zero stockouts for copper-bearing IUDs at the SDP level (Cape Verde). For the remaining 27 countries with stockouts, the stockout rates for IUDs (Exhibit 39) spanned from 0.06 percent (Bangladesh) to 74 percent (El Salvador). Fourteen countries did not have data. Condoms For male condoms (Exhibit 40), out of 27 countries that had data, 1 country reported zero stockouts (Cape Verde). Among the remaining 26 countries that had stockouts, rates ranged from 0.05 percent (Bangladesh) to 77 percent (El Salvador). Sixteen countries did not have available data. EXHIBIT 40 Service delivery point stockout rates of male condoms, non-zero values shown (n=27) EXHIBIT 39 Service delivery point stockout rates of copper-bearing intrauterine devices, non-zero values (n=28) 2023 Contraceptive Security Indicators Report 50 | Supply Chain Progestin-only pills For progestin-only pills (levonorgestrel 30 mcg), 2 of the 23 countries (Cape Verde and Madagascar) that offer this product reported zero stockouts (Exhibit 41). For the remaining 21 countries with data, stockout rates ranged from 1 percent (Togo) to 55 percent (Zambia). Nineteen countries did not have data available. EXHIBIT 41 Service delivery point stockout rates of progestin-only pills, non-zero values shown (n=23) 2023 Contraceptive Security Indicators Report 51 | Quality Quality 10. Closely monitoring contraceptive quality ensures that the products provided by all sectors meet specific standards. By ensuring that FP commodities are consistently produced and monitored, quality assurance (QA) of FP commodities protects patient safety and helps achieve reliable results and maximum benefits. QA includes registering drug manufacturers, QA testing of commodities post-shipment, conducting field surveillance to identify substandard and falsified (SF) commodities, and using recognized and trusted suppliers who provide good-quality products and backup services. PH O TO C RE D IT : G H SC -P SM 61% The percent of countries in which the NMRA conducts field surveillance monitoring to identify SF contraceptives rose from 32 percent to 61 percent between 2021 and 2023, with nine new countries confirming NMRA monitoring. 79% require testing of contraceptives at the NQCL. <6 months The average lead time for registration of contraceptives is less than six months for 56 percent of countries. This reflects an upward trend since 2019, when the average lead time for 50 percent of countries was six months to one year ; in 2021, 49 percent of countries reported an average lead time of less than six months. 98% of countries require registration of locally manufactured or imported contraceptives by the in-country NMRA. Of the countries providing information on quality: 3x The testing of most contraceptives (excluding condoms) nearly tripled from 17 percent in 2021 to 46 percent in 2023. Highlights 2023 Contraceptive Security Indicators Report 52 | Quality Registration Requirements Most countries (98 percent) require registration of locally manufactured or imported contraceptives by the in-country NMRA. The Dominican Republic is the only country that currently does not have registration requirements for contraceptives. Similarly, 97 percent strictly adhere to drug registration requirements. The level of adherence in Peru was not known. And South Sudan does not adhere to registration requirements; The Drug and Food Control Authority (DFCA) Act 2012 requires the registration of all regulated products, but its implementation has been delayed due to limited capacity. Additionally, there are no locally manufactured contraceptives. The average registration lead time is less than six months for 56 percent of countries, while 28 percent take six months to one year, 14 percent take one year to 18 months, and 3 percent take more than 18 months (Exhibit 42). Quality Control The requirement for contraceptives, whether imported or locally manufactured, to be tested by the in-country NQCL is in place for 79 percent of countries (Exhibit 43). The rates of the NQCL testing either most or some contraceptives (excluding condoms) rose in 2023 to 58 percent, an increase from 41 percent in 2021. The NQCL tested most or some condoms post-shipment in 75 percent of countries in 2023 (Exhibit 45), an increase from 21 percent in 2021. In 46 percent of the countries, the NQCL tested most contraceptives (excluding condoms), 12 percent tested some, and 42 percent tested no contraceptives post-shipment (Exhibit 44). In 2021, 17 percent tested most contraceptives (including condoms), while 58 percent tested none. EXHIBIT 42 Average lead time for registration of contraceptive products (n=36) EXHIBIT 43 Requirement to test contraceptives at the national quality control laboratory (n=39) EXHIBIT 44 Extent to which the NQCL tested contraceptives, excluding condoms, post-shipment in the past year (n=26) Yes Most were tested No None were tested Some were tested 21% 79% 46% 42% 12% Less than 6 months 6 months to under 1 year 1 year to 18 months 56% 3% 28% 14% More than 18 months 2023 Contraceptive Security Indicators Report 53 | Quality The NQCL tested most condoms post-shipment in 46 percent of countries, while 29 percent tested some, and 25 percent tested none (Exhibit 45). In 2021, most or some condoms were tested post-shipment in 21 percent of countries, and 59 percent tested none. The NQCL is both ISO 17025 certified and WHO- prequalified in 14 percent of the countries (6 of 42) (Exhibit 46). The NQCL in 12 percent of countries is ISO certified only, while 7 percent are WHO-prequalified only, and 67 percent have neither qualification. In 61 percent of countries, the NMRA conducts field surveillance monitoring to identify SF contraceptives (Exhibit 47), an increase from 32 percent in 2021. Nine new countries confirmed NMRA monitoring (Liberia, Madagascar, Mali, Nepal, Nigeria, Peru, Tanzania, DRC, and El Salvador). EXHIBIT 45 Extent to which the NQCL tested condoms post-shipment in the past year (n=28) EXHIBIT 46 National quality control laboratory ISO 17025 certified and/or WHO-prequalified (n=42) EXHIBIT 47 National Medical Regulatory Authority conducts field surveillance monitoring to identify SF contraceptives (n=31) Most were tested None were tested Some were tested 25% 46% 29% Yes No39% 61% 2023 Contraceptive Security Indicators Report 54 | Quality In 25 percent of countries, extensive regulatory enforcement actions are taken following field surveillance of contraceptives. In 50 percent of countries some enforcement takes place, while 8 percent of countries take limited action, and 17 percent take no action (Exhibit 48). In the 2021 report, among the 10 countries where NMRA conducted field surveillance monitoring, 50 percent took extensive enforcement actions, 20 percent took some, 10 percent took limited actions, and 20 percent took none. EXHIBIT 48 Extent of regulatory enforcement actions taken following field surveillance of contraceptives (n=12) 2023 Contraceptive Security Indicators Report 55 | Private Sector Private Sector 11. Collaboration and coordination with the private sector give clients additional access to contraceptives, brand choice, and expanded price points to help meet the population’s varied demands. The private sector—defined as all the providers, suppliers, and ancillary and support services that lie outside the public sector—is a vital partner in global efforts to provide FP/RH services and commodities. The private sector includes for-profit or commercial/private entities, NGOs, community groups, informal vendors, and private providers such as doctors, pharmacies, drugstores, and hospital staff. PH O TO C RE D IT : G H SC -P SM 5-30% By FP product, the percentage of countries where there were no WHO-prequalified or SRA-approved products registered for distribution ranged from 5 percent (COCs) to 30 percent (female condoms). 58% of countries have established private-sector engagement plans to expand private- sector FP products or services. Of those, 79 percent have taken at least some actions to implement the plan. 82% have more than three wholesalers registered in the country to distribute FP commodities. Key to a total market approach is working with the private sector to expand the provision of health services. Of the countries providing information on the private sector : Highlights 2023 Contraceptive Security Indicators Report 56 | Private Sector Most countries (82 percent) have more than three wholesalers registered for distributing FP products in the countries (Exhibit 49). Twelve percent have two to three, six percent have one, and zero countries have no wholesalers registered to distribute FP products. In 2021, 89 percent of countries had more than three wholesalers registered as FP distributors. The percentage of countries with zero wholesalers has dropped from six percent in 2019 and three percent in 2021 to zero in 2023. Two out of seven countries (29 percent) stated that 76–100 percent of the wholesalers in the country report to the government on their FP commodity sales and FP services (Exhibit 50), down from 42 percent in 2021. Of the remaining countries, 43 percent responded that 26–50 percent of the wholesalers report to the government, and 29 percent responded that 0–25 percent report this information. Countries were asked about WHO-PQ and SRA-approved products registered for distribution among the following eight FP methods: COCs, POPs, injectables, implants, IUDs, male and female condoms, and ECs. A range of 46–56 percent of countries have WHO-PQ-only implants, injectables, COCs, POPs, ECs, and IUDs for distribution in the country (Exhibit 51). WHO-PQ-only male and female condoms are registered in 43 and 41 percent, respectively. The percentage of countries with products that are both WHO-PQ and SRA-approved range from 24–35 percent across all eight methods. Those with only SRA range from 5 to 14 percent among the eight methods. Those with neither WHO-PQ or SRA range 5–30 percent among the eight methods. EXHIBIT 49 Number of wholesalers registered in the country to distribute FP commodities (n=33) EXHIBIT 50 Approximate proportion of wholesalers reporting to the government on their FP commodity sales and FP services (n=7) EXHIBIT 51 WHO-PQ and/or stringent regulatory authority-approved products registered for distribution in the country 76-100% 51-75% 26-50% 29% 29% 43% 0-25% 2023 Contraceptive Security Indicators Report 57 | Private Sector Countries were asked how many in-country local manufacturers exist (0, 1, or 2 or more) for each of the following FP methods: COCs, POPs, injectables, implants, IUDs, male and female condoms, and ECs. Zero to 18 percent of countries reported the existence of two or more manufacturers for any of the methods, and zero to 8 percent of countries reported the existence of one manufacturer. Meanwhile, 77 to 100 percent of countries reported that there were no in-country local manufacturers for any of the eight methods (Exhibit 52). There was a notable increase in the number of countries reporting brokering public-private partnerships in the previous two years to expand private-sector FP products or services, from 41 percent of countries in 2021 to 71 percent in 2023. The percentage of countries whose governments have developed a private-sector engagement (PSE) plan to expand private-sector FP products is 58 percent. For those countries with a PSE plan that includes a FP/RH component, 32 percent are implementing most actions, 47 percent are implementing some actions, 16 percent are implementing few actions, and 5 percent are taking no action9 percent have a PSE plan in place but it does not include a FP/RH component, and 33 do not have any PSE plan in place. (Exhibit 53). EXHIBIT 52 Number of in-country local manufacturers that produce the FP method EXHIBIT 53 FP/RH PSE plan developed by government and extent of implementation (n=33) 2023 Contraceptive Security Indicators Report 58 | Impact of the COVID-19 Pandemic Impact of the COVID-19 Pandemic 12. In 2021, the CS Indicators Survey provided a high-level assessment of the perceived impact of the COVID-19 pandemic on a few aspects of access to contraceptives, including changes in frequency of CS committee meetings and in FP commodity budgets and expenditures, the existence of emergency plans that account for access to FP/RH, and operational practices put in place to enable continued access to FP/RH in the face of COVID-19. In 2023, the survey examined how these same dynamics have evolved since 2021. PH O TO C RE D IT : G H SC -P SM 74% of the countries surveyed reported no impact of the COVID-19 pandemic on frequency of CS committee meetings in 2023, 24 percent (9 countries) reported reduced frequency of CS committee meetings, and 3 percent (1 country, El Salvador) reported that the pandemic prevented their ability to meet. 75% of countries reported no impact of the COVID-19 pandemic on the approved budget line for contraceptives. All or most of the contraceptive budget was shifted to COVID-19 response in 8 percent of surveyed countries (3 countries). 84% of countries reported having an emergency preparedness plan in place for pandemics that includes impact on FP. Of the 37 reporting countries, 86 percent have an emergency preparedness plan in place for other types of emergencies that includes impact on FP. The COVID-19 pandemic is still having substantial residual effects on the frequency of CS committee meetings, government budgets for FP, and government spending on FP. 62% of countries reported no impact of the COVID-19 pandemic on the amount of government spending for contraceptives. Highlights 2023 Contraceptive Security Indicators Report 59 | Impact of the COVID-19 Pandemic Emergency preparedness plans Emergency preparedness plans are essential to ensure continued contraceptive access during emergencies. Eighty- four percent of countries reported having an emergency preparedness plan in place for pandemics that includes impact on FP (Exhibit 54), an increase from 76 percent in 2021. Sixteen percent did not have a pandemic emergency preparedness plan. Most countries now also have emergency plans in place for other types of emergencies (86 percent) that take into account impact on FP, and slightly fewer countries (82 percent) had FP/RH supplies prepositioned. Excluding the countries that responded “don’t know,” 86 percent of the 37 responding countries had an emergency preparedness plan that includes the impact on family planning for other types of emergencies, as shown in Exhibit 55. This is an increase from 76 percent in 2021. CS committees Nearly one-quarter of countries (24 percent) reported that the COVID-19 pandemic reduced the frequency of CS committee meetings in 2023. This was down from 40 percent at the peak of the pandemic, but the impact of the pandemic is still evident (Exhibit 56). The COVID-19 pandemic did not affect the frequency of CS committee meetings in 74 percent of countries. EXHIBIT 54 Emergency preparedness plan in place for pandemics (that includes impact on FP) (n=38) EXHIBIT 55 Emergency preparedness plan in place for other types of emergencies (that includes impact on FP) (n=37) EXHIBIT 56 Impact of the COVID-19 pandemic on frequency of CS committee meetings in 2023 (n=38) Yes Yes No impact No No Reduced frequency of meetings Prevented ability to meet 16% 14% 84% 86% 73.7% 23.7% 2.6% 2023 Contraceptive Security Indicators Report 60 | Impact of the COVID-19 Pandemic None of budget shifted (no impact) No impact Some of budget shifted Low impact All/most of budget shifted to COVID-19 response Medium impact High impact Contraceptive budgets Of 36 reporting countries, 75 percent reported no impact on contraceptive budgets resulting from the COVID-19 pandemic (Exhibit 57). Three countries (7 percent, Angola, Côte d’Ivoire, and Liberia) reported that all or most of the budget for FP had been shifted to the COVID-19 response in the most recent year. An additional six countries (17 percent) reported some of the budget having shifted. This was a decrease from 2021 but remained high. The COVID-19 pandemic impacted government spending for contraceptives in 38 percent of countries in 2022, the most recent complete year prior to the survey (Exhibit 58). Of the 39 reporting countries, 18 percent reported low impact on government spending for contraceptives. Three countries (7 percent, Côte d’Ivoire, DRC, and Guatemala) reported that COVID-19 had a high impact on the level of government spending on contraceptives in the most recent year, while an additional five countries reported medium impact. COVID-era practices to facilitate access to FP Since 2020, most countries have maintained or scaled up their COVID-era practices, which were initially designed to provide continuity of FP services during COVID-19 but may now be helping to further expand access to FP and safeguard access in case of future emergencies. Among the 75 practices to safeguard FP services cited by 37 countries, 55 (73 percent) were maintained or scaled up in 2023, 13 (17 percent) were scaled back or eliminated, and the current status of the remaining seven practices (9 percent) is unknown. The practices most likely to be scaled back or eliminated were those directly related to preventing the spread of COVID-19. However, other practices that were scaled back or eliminated include high- cost alternative commodity distribution methods, such as house-to-house delivery in Ethiopia and Peru, distribution of free commodities (in Benin and Guatemala), or multi- month dispensing (in Guatemala). Multi-month dispensing was maintained or scaled up in three countries (Kenya, Mozambique, and Peru). The type of practices most commonly maintained or scaled up include encouraging self-care interventions (nine countries), providing mobile family planning clinics (eight countries), and providing telehealth services (five countries). However, three countries scaled back telehealth services (Guinea, Peru, and Zambia) and one country, Guinea, scaled back the promotion of self-care. EXHIBIT 57 Impact of the COVID-19 pandemic on the approved budget line for contraceptives (n=36) EXHIBIT 58 Impact of the COVID-19 pandemic on the amount of government spending for contraceptives (n=39) 17% 13% 18%62% 75% 8% 8% 2023 Contraceptive Security Indicators Report 61 | Conclusions Conclusions 13. Consistent collection of CS data provides insight into developments across the multiple components needed to improve the availability of contraceptives at all levels of the health system. The 2023 CS Indicators Survey shows steady progress in several indicators and others that need continued investment and attention. PH O TO C RE D IT : G H SC -P SM Leadership and Coordination Contraceptive security committees continue to be prevalent in countries (95 percent) and remain highly active in terms of meeting frequency. In the 2023 survey, 87 percent of committees met at least twice in the previous year, and 82 percent of committees developed policies, procedures, recommendations, and/or action plans. The share of CS committees in which the commercial sector participates has been hovering at around one-third for the past several rounds of the survey. In this iteration, it reached 45 percent of countries reporting. The primary functions of CS committees continue to be monitoring FP stock levels and coordinating supply chain interventions (24 countries), particularly forecasting and quantification, overseeing implementation of national FP strategies (23 countries), making technical or policy recommendations (17 countries), and increasing communication and collaboration among FP stakeholders (16 countries). Finance and Procurement Even though the number of countries with a funding gap remained the same in 2023, there was a drop in government spending, with the share of government spending falling from 47 percent in 2021 to 34 percent in 2023, while the average value of donations increased slightly. In the 2021 survey, Zambia, Kenya, Nigeria, El Salvador, and Mauritania spent government funds. For the 2023 survey, Zambia reported that the funds were allocated but the procurement process was delayed; these funds were carried over to 2023. For Kenya, Nigeria, El Salvador, and Mauritania, government funds were allocated for contraceptives but not released in time to spend them in the assessment year. Furthermore, the reported total expenditures do not specifically account for inflation. Worldwide inflation jumped from 1.9 to 8 percent between 2020 and 2022, with many surveyed countries recording even higher rates. Some of the decrease in government spending, therefore, may have been due to inflation, exchange rate variations, or other factors. Commodities 100 percent of reporting countries now offer combined oral contraceptives and IUDs in the public sector, while 100 offer male condoms in both the commercial and NGO sectors. The number of countries offering vasectomy and tubal ligation in the social marketing sector has nearly tripled since 2021 (from 5 and 6 countries to 14 and 15 countries, respectively). Policies Most national FP/RH strategies (specifically their contraceptive security components) aim to influence overall FP outcomes, such as increasing the availability of and access to FP services and commodities; reducing unmet need; increasing demand for FP and ultimately increasing mCPR; improving maternal and child health; and reducing maternal, neonatal, and child mortality. The strategies and sub-objectives for achieving these higher-level goals are varied, but a common theme is health system strengthening, especially through capacity building. Within this overarching 2023 Contraceptive Security Indicators Report 62 | Conclusions theme, several countries cited objectives to improve service delivery and FP product quality, strengthen aspects of the supply chain, and improve monitoring and evaluation. National governments continued the trend of coordinating with the private sector to expand contraceptive access. Most countries (87 percent) reported having enabling policies, while only four cited policies that hinder the private sector’s distribution of contraceptives. Among some of the specific enabling policies cited include governments supporting training for private-sector providers; subsidizing contraceptives in the private sector; facilitating private imports, such as through tax exemptions; public/private provider networks and franchises; accreditation services; and regulations allowing for over- the-counter sale of contraceptives. The hindering policies cited include: specific permission needed to import contraceptives, branding or advertising restrictions, high taxes on contraceptives, price controls, and bans on mass media promotions. The number of countries that impose duties on FP commodities in the commercial sector increased in 2023. The main cultural or operational barriers to accessing FP/RH services and commodities continue to be religious institutional barriers or beliefs (cited by 11 countries), social norms, misconceptions, or taboos (9 countries), in addition to negative perceptions specifically about youth access to FP (8 countries). Other frequently cited barriers were geographic access difficulties (7 countries), inaccessibility of services for people with disabilities (6 countries), and a lack of knowledge about FP services (4 countries). There was a 11 percent reduction between 2021 and 2023 in the share of countries using mass media as a channel for promoting family planning. Use of all other channels remained about the same. The majority of reporting countries (88 percent) made or plan to make an FP2030 commitment. All of the countries reporting on specific commitment areas in their existing or planned FP2030 commitment reported that improving domestic financing for contraceptives and improving access to or availability of contraceptives are key areas of their commitment. Countries with Global Financing Facility partnerships include family planning much more frequently (83 percent) compared to the previous survey in 2021 (63 percent), as well as procurement provisions for contraceptives (67 percent, compared to 65 percent in 2021). Supply Chain Ninety-three percent of countries reported having an LMIS that includes data on contraceptives; of these, 95 percent track contraceptive stock data down to the SDP level. Since the previous survey, there has been a large uptick in electronic reporting at the SDP level, from 68 to 84 percent of reporting countries. Quality The percent of countries in which the NMRA conducts field surveillance monitoring to identify SF contraceptives rose from 32 percent to 61 percent between 2021 and 2023, with nine new countries confirming NMRA monitoring (Liberia, Madagascar, Mali, Nepal, Nigeria, Peru, Tanzania, DRC, and El Salvador). The testing of most contraceptives (excluding condoms) nearly tripled from 17 percent in 2021 to 46 percent in 2023. The rates of NQCL testing either most or some contraceptives (excluding condoms) post-shipment rose in 2023 to 58 percent of countries, an increase from 41 percent of countries in 2021. The NQCL tested most or some condoms post-shipment in 75 percent of countries in 2023, an increase from 21 percent in 2021. Private Sector There was a notable increase in the number of countries reporting brokering public-private partnerships in the previous two years to expand private-sector FP products or services, from 41 percent of countries in 2021 to 71 percent in 2023. Impact of COVID-19 Pandemic The COVID-19 pandemic continues to have substantial residual effects on the frequency of CS committee meetings, government budgets for FP, and government spending on FP. Nearly one-quarter of countries (24 percent) reported that the COVID-19 pandemic reduced the frequency of CS committee meetings in 2023. This was down from 40 percent in the peak of the pandemic, but the influence of the pandemic is still evident. Three countries (8 percent, Angola, Côte d’Ivoire, and Liberia) reported that all or most of the budget for FP had been shifted to the COVID-19 response in the most recent year. An additional six countries (17 percent) still reported some of the budget having shifted, a decrease from 2021, but still high. Three countries (Côte d’Ivoire, DRC, and Guatemala) reported that COVID-19 had a high impact on the level of government spending on contraceptives in the most recent year, while an additional five countries reported medium impact. Ninety-three percent of countries reported having an LMIS that includes data on contraceptives; of these, 95 percent track contraceptive stock data down to the SDP level. PHOTO CREDIT: GHSC-PSM 2023 Contraceptive Security Indicators Report 63 | References References Hare, L., Hart, C., Scribner, S., Shepherd, C., Pandit, T. (ed.), and Bornbusch, A. (ed.). 2004. SPARHCS: Strategic Pathway to Reproductive Health Commodity Security. A Tool for Assessment, Planning, and Implementation. Baltimore, Maryland: Information and Knowledge for Optimal Health (INFO) Project/Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. United Nations Department of Economic and Social Affairs, Population Division (2020). World Family Planning 2020 Highlights: Accelerating action to ensure universal access to family planning (ST/ESA/SER.A/450). USAID Global Health Supply Chain Program-Procurement and Supply Management Single Award IDIQ. 2017. Contraceptive Security Indicators Data Collection and Usage Manual. Washington, D.C.: Chemonics International Inc. USAID Data for Impact project, Policy Environment, Family Planning and Reproductive Health Indicators Database, https://www. data4impactproject.org/prh/health-systems/policy-environment/. USAID | DELIVER PROJECT, Task Order 4. 2012. Measuring Contraceptive Security Indicators in 2011. Arlington, Virginia.: USAID | DELIVER PROJECT, Task Order 4. USAID | DELIVER PROJECT, Task Order 1. 2010. Measuring Contraceptive Security Indicators in 36 Countries. Arlington, Virginia.: USAID | DELIVER PROJECT, Task Order 1. https://www.data4impactproject.org/prh/health-systems/policy-environment/ https://www.data4impactproject.org/prh/health-systems/policy-environment/ 2023 Contraceptive Security Indicators Report 64 | Annexes Annexes 2023 Contraceptive Security Indicators Report 65 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 66 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 67 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 68 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 69 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 70 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 71 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 72 | Annexes ANNEX A | Contraceptive Security Indicators Survey Questionnaire 2023 Contraceptive Security Indicators Report 73 | Annexes ANNEX B | Annex B. Contextual Reference Measures (Formerly from the Contraceptive Security Index) 2023 Contraceptive Security Indicators Report 74 | Annexes ANNEX B | Annex B. Contextual Reference Measures (Formerly from the Contraceptive Security Index) 2023 Contraceptive Security Indicators Report 75 | Annexes ANNEX C | Table of Inflation Rates

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