WHO Protocol for estimating condom availability for distribution at central and peripheral level

Publication date: 1994

WHO/GPA/TCO/SEF/94.1 - Section 4 PROTOCOL FOR ESTIMATING CONDOM AVAILABILITY FOR DISTRIBUTION AT CENTRAL AND PERIPHERAL LEVEL (Measurement of Prevention Indicators 2 and 3) - i - TABLE OF CONTENTS Page 1. Introduction 1 2. Objectives 2 3. Process 4 4. Methodology 5. Staff/Resource requirements for PI 2 and PI 3 9 Annex 1. Data collection form 1 Annex 2. Sequence of data collection Annex 3. Data collection form 2 Annex 4. Summary form 3 Flowchart 3. Management steps for estimating condom availability for distribution at central level WHO/GPA/TCO/SEF/94.1 - Section 4 page 1 1. INTRODUCTION Latex condoms are the only technology available that can prevent sexual transmission of HIV/STD. Persons needing protection in situations that carry risk should have consistent access to high quality condoms. As National AIDS Programmes (NAPs) implement activities to increase both availability of and access to condoms, a mechanism is needed to monitor progress in these areas. The two condom availability indicators (2 and 3) were developed to assist NAPs in evaluating efforts to make condoms available. This mechanism is not intended to evaluate details of the strengths of the forecasting process, the quality of the logistics management system - including the logistics management information system, distribution, warehousing, storage and quality assurance measures -or the accompanying human and other resource requirements. Indicators are intended to highlight areas of weakness and strength at the beginning and at the end of the distribution system so that programmatic resources can be directed appropriately to problem areas. The sources of information used to measure these indicators will be specific to each country, though the process of evaluation will be uniform. As these indicators will be measured periodically, this is a spot-check of progress in the overall implementation of prevention activities. The two indicators are described below. PI 2: CONDOM AVAILABILITY (CENTRAL LEVEL) Total number of condoms available for distribution during the preceding 12 months Population aged 15-49 Prevention Indicator 2 (PI 2) estimates the average number of condoms available per person (aged 15-49) in the past 12 months. A judgement regarding the adequacy of the condom supply cannot be based solely on the indicator. The indicator does not reflect the effectiveness of condom distribution channels; nor does it reflect the proportion of condom need or demand that is met by the supply. It is, however, a reflection of the overall capacity of the supply. The indicator permits: - comparability over time of condom availability, even if there are large shifts in the sources of condoms and the channels for distribution; - comparability of condom availability between countries with a mix of public and private suppliers of condoms; - compatibility with the community assessment where it is not always possible to determine easily the ultimate sources of condom supplies. WHO/GPA/TCO/SEF/94.1 - Section 4 page 2 PI 3: CONDOM AVAILABILITY (PERIPHERAL LEVEL) Number of people who can acquire a condom Population aged 15-49 There are several issues for consideration in relation to Prevention Indicator 3 (PI 3). To achieve maximum effectiveness, NAPs attempt to distribute condoms through as many channels as possible (e.g., family planning clinics, social marketing, private physicians) so that they are available in as many outlets as possible. The goal is to establish and maintain an array of services that begins when condoms arrive or are produced in a country and that culminates in a variety of community outlets effectively serving a broad range of consumers. PI 3 does not, however, measure the extent to which a variety of services is available or the extent to which barriers to condom access - such as issues of affordability, convenience, and hours of operation - exist. It also does not measure the extent to which an outlet can accommodate significant increase in demand. The focus of the indicator is on local condom availability in the broadest sense. If a community has at least one condom outlet that has had a continuous supply of condoms in the past 12 months, it is assumed that the entire population of that community can acquire a condom. It is recognized that barriers to access and lack of outlet capability to manage large shifts in demand exist in many countries. In these countries the estimate will be an overestimate of condom accessibility. In spite of its shortcomings, however, the indicator is extremely valuable. It provides insight into the extent to which at least one condom distribution channel has been effective in reaching each portion of the country. Further interpretation of the indicator can be achieved through additional analyses of data collected at the surveyed outlets and through further analyses of data collected for the community household survey. The methodology thus permits additional analyses of interest to the NAP that could result in programmatic action such as changes in distribution, development of targets for expanded access, or the initiation of studies to reveal distribution inefficiencies. For example, the methodology permits an assessment of the availability of condoms by type of outlet (e.g. medical/family planning outlets, shops and pharmacies, bars and hotels, workplaces). The method also permits NAP managers to monitor the impact of social marketing and other schemes that aim to increase access to condoms outside of regular medical channels. The protocol for the indicator of condom availability at the peripheral level is linked closely to the protocol for the community survey (See community survey protocol). The same communities selected for participation in the community household survey will be used for estimation of the condom availability indicator at the peripheral level. Thus further analysis of reported condom usage, reported knowledge of condom outlets, and estimated condom demand can be performed in light of the findings from the condom availability study. These analyses can provide further insight into the adequacy of the condom supply and into issues of condom accessibility. WHO/GPA/TCO/SEF/94.1 - Section 4 page 3 2. OBJECTIVES PI 2 The primary objective of PI 2 is the following: to estimate how many condoms (per population aged 15-49) were available for use in the country within the past 12 months. The numerator of the indicator is the sum of: - the number of condoms imported into the country by major donors and major commercial distributors during the past 12 months; - the number of condoms manufactured within the country for use in the country during the past 12 months; - the number of unused condoms in stock at the beginning of the 12-month period. Major donors and commercial distributors are defined as those who provide at least 5% of the condoms in the country. Condoms provided by donors to a limited number of districts or regions are included1. The primary objective comprises four sub-objectives: (a) Estimate the number of condoms supplied in the past 12 months: - by donors to the national AIDS control programme; - by donors to the national family planning programme; - by donors to specific regional or district programmes; - through private commercial channels for sale. (b) Estimate the stock of condoms on hand at the beginning of the previous 12-month period (i.e. supplied but unused prior to the 12 month period), including: - condoms in stock at major central condom storage facilities in the month prior to the beginning of the previous 12-month period; - condoms in stock at major regional condom storage facilities in the month prior to the beginning of the previous 12-month period. 1 A better measure of availability might be the sum of all condoms brought into the country by private and public sources divided by the size of the population. However, it is not usually possible to obtain an estimate of the total number of condoms imported into a country, especially when some are imported informally in small quantities for commercial sale. Records of condom imports may be inaccessible or coded ambiguously. WHO/GPA/TCO/SEF/94.1 - Section 4 page 4 (c) Briefly describe the major channels used to distribute condoms, including: - NAP channels to regional and district offices, - family planning channels to regional and district offices, - social marketing channels, - channels targeting groups at increased risk of HIV infection, - nongovernmental organizations (NGOs) and other institutional channels. d) Develop a list of the most common types of outlet in the country, including: - shops, pharmacies, - medical clinics, doctors, hospitals, - bars, guest houses, hotels, brothels, - workplaces. 3. PROCESS The process for collecting information to accomplish these objectives is outlined below. For PI 2 (a) Collect and review available relevant documents; (b) Identify key informants, major condom donors, any condom manufacturers, and major private importers of condoms; (c) Identify government, parastatal, and non-profit agencies providing condoms for AIDS prevention or family planning; (d) Identify central and major regional condom storage facilities; (e) Interview key informants and collect data; (f) Estimate PI 2, condom availability at the central level. For PI 3 (a) Identify the major types of outlet; (b) Interview key informants and collect data; (c) Estimate PI 3, condom availability at the local level. WHO/GPA/TCO/SEF/94.1 - Section 4 page 5 4. METHODOLOGY 4.1 Collection of data for PI 2 4.1.1 Document review Documents that may be available for review include the following: NAP condom and logistics files; Condom and Virucide Services Assessment and Planning documents, prepared by GPA for NAPs; MTPs and other project documents; Status of Contraceptive Supply (including condoms for HIV prevention), USAID; UNFPA planning documents for meeting long-term contraceptive supply; annual budgets of IPPF affiliates; and any other documents examining contraceptives, essential drugs or supplies required for AIDS prevention activities. 4.1.2 Identification of potential key informants, major condom donors, manufactures, and importers and distributors Lists of potential key informants, donors, manufacturers, importers and distributors may be developed by interviewing key NAP staff. It is recommended that at least the following groups should be considered: - the NAP, including the condom coordination committee, IEC personnel and logistics staff, - donors including AID, UNFPA, IPPF, UNICEF, GTZ, SIDA, CIDA, ODA and EC, - family planning association(s), - pharmaceutical and medical supply importers and associations, - private medical associations, including church-based, - standards bureau that undertakes testing of all imported condoms, - any other government, parastatal, and non-profit agencies providing condoms for AIDS prevention or family planning. 4.1.3 Interviews with key informants A letter of introduction from the NAP should be prepared for each person who will conduct an interview. The latter should explain the purpose of the assessment and how the information will be used. Prior to conducting the first interviews, a meeting should be held with the interviewers to review the purpose of the interview, review the forms and arrange transportation. The objectives of the key informant interviews are the following: - to obtain information and contacts necessary for completing the Condom Receipts Assessment Questionnaire for the agency of the key informant; - to confirm data supplied by other informants; - to obtain contacts with or information on other agencies/donors that should be contacted. 4.1.4 Data collection The Condom Receipts Assessment Questionnaire is found in Attachment 1 to this protocol. The Condom Receipts Assessment Questionnaire will be completed by the central office of each WHO/GPA/TCO/SEF/94.1 - Section 4 page 6 donor, manufacturer and service delivery agency identified as having a condom WHO/GPA/TCO/SEF/94.1 - Section 4 page 7 delivery/supply/distribution component. A description of each section of the questionnaire, and how it should be completed, follows. Section A. In Section A, record the date and the name of the agency. Also indicate whether the agency is a donor, manufacturer and/or distributor and whether it is a government agency, NGO institution, or other. Record the name and job title of all persons interviewed at the agency. For example, a Christian Medical Association is identified in the key informants/documents review activity as having condom distribution activities. An appointment is made with the Programme Manager and the Chief Supply Officer to complete this form. Finally, record the 12-month time period relevant to the assessment. This date will be the same for every agency. For example, the period might be July 1992 through June 1993. Section B. Section B can be completed by describing briefly the channels for distribution of condoms. For example, the following would suffice: "There are 22 clinics in county seats where condoms are sent by this programme. These clinics do not distribute to other distributors - condoms are given directly to users from these sites." There may be instances where no information is available about the end distribution point (i.e. user level). In such cases, information about the next level in the distribution chain should be substituted. For example, this section might then read: "The Christian Medical Association distributes to seven District Medical Offices, from where further distribution is carried out." Section C. In Section C, briefly describe the process, if one exists, for estimating condom requirements. Provide a summary of estimates made in the past year. Section D. A review of stock records, confirmed by a physical inventory, will complete Section D. Definitions of each term in Section D are described below: Brand: Name on the condom package. Source: Name of agency that provided the condoms to the agency being interviewed. For example, if AID supplies condoms to the NAP who supplies to the Red Cross, the form for the Red Cross would show the source as the NAP and the form for the NAP would show the source as AID. BOYS: The "Beginning of Year Stock" is the number of condoms that were in stock on the day before the 12-month period. For example, if the 12- month period is July 1992 through June 1993, then the BOYS would be the number of condoms in stock on 30 June, 1992. If the number is not available, make an estimate of the number through discussion with key members of the agency. The number of condoms received in the previous year might be useful in making the estimate. Record the BOYS for each brand of condom if possible. If this is not possible, record an estimate of WHO/GPA/TCO/SEF/94.1 - Section 4 page 8 the total BOYS. Date of receipt: The day, month and year of receipt. Quantity: The number of individual condoms received, not the number of boxes or cartons. 4.1.5 Management and analysis of data Essential information. In Attachment 1, Section D, columns 3, 4 and 5 are essential to the measurement of PI 2. Column 1 (Brand) and Column 2 (Source) are useful for organizing this information. Information from Section C will be used when collecting information to measure PI 3. A list of potential condom outlets will be developed when these forms are summarized. Cross-checking of receipts summaries. Some of the programmes are likely to have received supplies transferred from another programme. It is important that these supplies are not counted twice. Therefore, when one programme lists another programme as a source of supply (e.g. the FPA states that it received 32 000 pieces from Pathfinder) this should be double-checked and only counted once as Receipts. Ranking by programme size. Different programmes will receive different volumes of condoms. Programmes should be ranked from "most important" to "least important" in terms of condom volume. Results. Information from these forms will be compiled by a central statistical clerk, programme administrator or representative of the condom coordination committee. This exercise provides the numerator for PI 2: total number of condoms available for distribution during the preceding 12 months. Two other summary figures are also useful for programme management. These are: - number and listing of condom suppliers to a country, - number and listing of agencies to which condoms are supplied. In addition, enough information may be obtained to estimate what quantity of condoms was forecast to be required for national activities. Though there may be many difficulties in comparing individual forecasts due to different methodologies used in making them (e.g. time periods are not consistent, some are demand based, while others are target based, no rational forecast was made and the order was based on budget), enough information should be available to make a gross determination of the proportion of the programmatic condom requirement that is being met. 4.2 Collection of data for PI 3 4.2.1 Definitions at country level Prior to collection of data for measuring the indicator, a critical decision must be made by programme staff. They must decide what is the longest acceptable distance for a potential condom user to travel to obtain a condom. In urban areas, a much shorter distance is suggested, such as the radius of an average-sized urban cluster of 200 households. WHO/GPA/TCO/SEF/94.1 - Section 4 page 9 By determining this limit in advance, the evaluation of acceptable distances travelled to obtain condoms can be made. 4.2.2 Selection of potential condom outlets Information on sample distribution outlets will be collected in the field during the community survey. There are appreciable gains when such community level data collection is done in conjunction with population surveys. The sample points or clusters become the sample of communities. Interviewers will be issued with a list of major types of condom outlet in the country. The four-stage selection procedure is outlined here: (a) Ascertain any outlets of each major type and the approximate number (1, 2, 3) existing in the cluster or within five kilometres of the cluster centre. This should be done with the help of key informants; (b) Select, for each major type of outlet (e.g. medical/family planning outlets, shops and pharmacies, bars and hotels), a named source that is most likely to stock condoms. Again this is best done with the help of key informants; (c) Visit the most likely source for each type of outlet and complete the second data collection form, the Condom Availability Assessment Questionnaire in Attachment 2, to obtain the necessary information. The Condom Availability Assessment Questionnaire requires an assessment of whether the outlet has condoms physically present on the day of the interview and whether the outlet had an uninterrupted supply of at least one brand of condoms for the last 12 months. If condoms were out of stock on more than 10 days in any month during the last 12 months, this outlet is not considered to have a continuous supply of condoms; (d) Review the results of the visit. If the first source visited has no current stocks of condoms or has not had a continuous supply of condoms in the past 12 months, the second most likely source of the same type should be visited and the Condom Availability Assessment Questionnaire completed in the normal way. If the second source also has no current stocks, proceed to the third most likely source and repeat the process. If all outlets have experienced periods when condoms were out of stock (a maximum of 9 outlets is assessed), this community is not considered to have a supply of condoms regularly available. The table in Annex 2 illustrates the sequence of procedures for a country with three major types of outlet. In this example, the minimum number of visits is three (i.e. 3 types x 1 visit per type) and the maximum number of visits is nine (i.e., 3 types x 3 visits per type). Note that if there are less than three sources for a specified type, the number of visits is necessarily curtailed. During data collection, the group supervisor will ensure that the type of outlet and the number of outlets are selected and assessed in the specified manner, and with all the necessary information collected. The survey of outlets can usually be completed by one person in one day. It is recommended that it be carried out on the second day of the team's stay in a cluster so that information gained during the first day of fieldwork can be made use of. WHO/GPA/TCO/SEF/94.1 - Section 4 page 10 4.2.3 Management and analysis of data for PI 3 Essential information. In Attachment 2, items 1, 2 and 6 of Section B and all items of Section C are essential to measure PI 3. With minimal additional time investment, items 3, 4 and 5 of Section B may be collected. These three items will help the NAP management identify gaps if condoms are not available. This information is obtained by observation, review of records when possible and interview. Compilation of data. The data collection forms will yield the information that is required for formulating the numerator for PI 3. Each cluster is categorized as having condoms available if one of the outlets visited has condoms physically present and has had an uninterrupted supply of at least one brand of condoms for the last 12 months. If condoms have been out of stock for more than 10 days in any month during the last 12 months, this outlet is not considered a regular provider of condoms. If all outlets have experienced periods when condoms were out of stock (a maximum of 9 outlets is assessed), this community is not considered to have a supply of condoms regularly available. The completed recording sheets for all outlets will be compiled by the central statistics clerk. This will be done with the assistance of the Summary Form for Clusters which is found as Attachment 3 to this document. The summary form will be completed by the survey supervisor for each cluster surveyed during fieldwork. Clusters will be categorized either as having a regular supply or as not having a regular supply. The population served by outlets with a regular supply of condoms will serve as the numerator for PI 3. (These data can also be used at a later date by programme management to determine which communities are in need of greater assistance, where the programme can strengthen activities, and so on.) Flowchart 2 indicating the management steps for estimating condom availability at the peripheral level (PI 3) is included in Section 3. 5. STAFF/RESOURCE REQUIREMENTS FOR PI 2 and PI 3 Collection of data for the measurement of PI 2, number of condoms available for distribution, should be carried out by someone familiar with condom distribution. Though few NAPs have a logistics officer, such a person would be ideal. Additionally, there may be a condom coordination committee with a chairperson who could undertake this work. These committees usually have the basic information available on a continuing basis. (The time required is 1-2 person-weeks.) Data collection for PI 3 will already have been be done in the context of the community survey. For each survey group, one person will be designated as responsible for assessing condom requirements. During survey team training, two days will be set aside for the training of these persons in completion of data collection forms, including conducting physical inventories and reviewing outlet records. WHO/GPA/TCO/SEF/94.1 - Section 4 - Annex 1 page 1 Annex 1 DATA COLLECTION FORM 1 Condom Receipts Assessment Questionnaire (One form for each agency, donor and distributor) A. Background information 1. Date: |___|___|___|___| Name of interviewer:__________________|__|__|__| 2. Name of agency:________________________________________________________ 3. Type of agency:________________________________________________________ 4. Name and job/title of person(s) providing information: Name:__________________________________ Title:____________________________ Name:__________________________________ Title:____________________________ 5. 12-month period from: _______ to _________ B. Types of outlet Please indicate from what types of outlet people may obtain condoms distributed by this agency. Where possible, identify the location and number of these types of outlet. (For example, if this were a MOH/FP programme, state the number of clinics per region that are stocked with condoms from this source.) _______________________________________________________________________________________ ______________________________________________________________________________________ _______________________________________________________________________________________ C. Description of process for estimating condom requirements and available estimates Please attach copies of any reports with estimates. _______________________________________________________________________________________ ___________________________________________________________________________________ WHO/GPA/TCO/SEF/94.1 - Section 4 - Annex 1 page 2 D. Status of annual condom receipts Instructions: For the relevant 12-month period, please review your records and indicate the requested information. Enter information even if any or all brands are currently not in stock. Use a separate line for each order or receipt, even if these are of the same brand. If additional space is required, please use a second sheet. 1 2 3 4 5 Brand Source Date of BOYS2 Quantity Receipt Received (Pieces) (Pieces) _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ _____________ ________________ _____________ _____________ __________ 2 Beginning Of Year Stock: Number of condoms in stock as of the day prior to the first day of the 12- month period covered by this form. Example: if the period of interest is July 1992 through June 1993, the stock on hand for June 30, 1992, should be recorded here. Only stock manufactured within the past three years should be included in the figure. _____________ ________________ _____________ _____________ __________ Total _____________ __________ WHO/GPA/TCO/SEF/94.1 - Section 4 - Annex 2 page 1 Annex 2 SEQUENCE OF DATA COLLECTION CLUSTER NUMBER: First contact key informants for the cluster and ask which kinds of outlet exist in the cluster. Classify outlets according to the three following types: 1. shops, pharmacies, street vendors. 2. hospitals, health clinics, clinics, doctors. 3. bars, hotels, nightclubs. Probe for each one of the three types. Obtain an estimate of the number of outlets of each type and enter the number in the second column of the table. Visit at least one outlet of each type (if they exist). Choose the outlet which is most likely to have condoms. Complete Data Collection Form 2 for each outlet visited. If an outlet currently has condoms in stock and did not have them out of stock during the last 12 months, pass to the next type of outlet. If an outlet has no condoms at the time of your visit or had them out of stock at times during the last 12 months, visit another outlet of the same type. TYPE OF OUTLET NUMBER OUTLET 1 OUTLET 2 OUTLET 3 1. SHOPS/ PHARMACIES/ STREET VENDOR Not available |__| --> Available |__| STOP Not available |__| --> Available |__| STOP Not available |__| STOP Available |__| STOP 2. HOSPITALS/ HEALTH CLINICS/ CLINICS/ DOCTORS Not available |__| --> Available |__| STOP Not available |__| --> Available |__| STOP Not available |__| STOP Available |__| STOP 3. BARS/ HOTELS/ NIGHTCLUBS Not available |__| --> Available |__| STOP Not available |__| --> Available |__| --> STOP Not available |__| STOP Available |__| STOP WHO/GPA/TCO/SEF/94.1 - Section 4 - Annex 3 page 1 Annex 3 DATA COLLECTION FORM 2 Condom Availability Assessment Questionnaire (One form must be filled out for each outlet) A. Background information 1. Date: _______________ 2. Place/type of outlet:________________________________ 3. Name of interviewer: ________________________________ 4. Name and job/title of person(s) providing information: ______________________________ B. Status of condom supply Enter information about all brands even if some or all brands are currently out of stock (only condoms manufactured within the past three years should be counted as stock-on-hand). Record quantities (column 2) as individual pieces (units of condoms). Thus, if there are 10 boxes of 5 condoms each, record 50. 1. Brand/ type 2. Actual balance (pieces) 3. Date of last order 4. Frequency of ordering 5. Quantity ordered 6. Quantity received 7. Date received 8. Price 1. 2. 3. 4. 5. WHO/GPA/TCO/SEF/94.1 - Section 4 - Annex 3 page 2 C. Availability over the last 12 months Put a check mark ( ) for the months in which condoms were in stock for at least 20 days. Enter a zero (0) for any month when there were no condoms for more than 10 days. Begin with the last month for which information is available. In the column "Today", enter the actual number of condoms in stock and confirm it with a physical inventory. Record quantities as individual pieces (units of condoms). Thus, if there are 10 boxes of 5 condoms each, record 50. Month Brand 1 2 3 4 5 6 7 8 9 10 11 12 Today B1. B2. B3. B4. B5. To be completed after the visit: if there was stock of any brand enter YES (Y), otherwise NO (N) In-stock Availability assessment Mark YES if there have been condoms in stock for each month of the 12 months. Mark NO if stock has been interrupted. YES ____ NO ____ Were records available at this outlet ? YES ____ NO ____ If no records were available, how was this information obtained ? _____________________________________________________________________________________ WHO/GPA/TCO/SEF/94.1 - Section 4 - Annex 4 page 1 Annex 4 SUMMARY FORM 3 Summary form for condom availability in cluster Cluster number: ______ This summary form should be completed by the supervisor at the end of all the cluster visits. For the three types of outlet visited, check YES or NO. If the outlet was not visited, indicate "NOT APPLICABLE" (NA) PHARMACY/SHOPS Outlet 1 Outlet 2 Outlet 3 1. Uninterrupted supply of condoms during the last months. 2. Condoms in stock on the day of the visit HOSPITALS/HEALTH CLINICS/DOCTORS Outlet 1 Outlet 2 Outlet 3 1. Uninterrupted supply of condoms during the last months. 2. Condoms in stock on the day of the visit BARS/HOTELS/NIGHTCLUBS Outlet 1 Outlet 2 Outlet 3 1. Uninterrupted supply of condoms during the last months. 2. Condoms in stock on the day of the visit If "YES" is answered to both questions for any of the visited outlets, tick "AVAILABLE" below. AVAILABLE |__| COMMENTS:

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