Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption

The study addresses how the supply environment for modern contraceptives—particularly stockouts and method availability—affects access and potential use in low- and middle-income settings. Despite global efforts to reduce unmet need, more than 214 million women lacked adequate access to contraception in 2017. Supply-side barriers, including poor facility access, low method availability, and stockouts, may restrict choice and contribute to discontinuation and unmet need. Existing data on stockouts are sparse and irregular, limiting understanding of the relationship between availability and use. The PMA Agile platform provides quarterly, locally representative facility data that can illuminate trends in stockouts, availability, and consumption across urban areas in Burkina Faso, DRC, Kenya, Nigeria, and India. The study’s purpose is to describe these trends by method and sector to inform monitoring of FP2020 goals and guide strategies to reduce and prevent stockouts.

Prior literature highlights substantial unmet need and the importance of contraception for maternal and child health and women’s empowerment. Evidence suggests wide variation in stockouts and method availability across countries and methods, influenced by supply chain challenges and policy environments, including barriers to private sector provision. Stockouts can restrict method choice, leading to mismatches with user preferences and higher discontinuation. Data gaps exist: SPA surveys are infrequent, and routine facility-level stockout monitoring is rare. The private sector often plays a key role for certain methods (e.g., EC in SSA, oral pills in Kenya), and pharmacies/drug shops are important sources for short-acting methods, especially for young and unmarried women. LARC availability is generally limited despite high effectiveness and cost-effectiveness; service readiness for LARCs is more complex, requiring trained providers and equipment.

Design and setting: PMA Agile is a continuous monitoring system collecting quarterly data from public and private service delivery points (SDPs) and semi-annual client exit interviews across selected urban/suburban sites in Burkina Faso (Ouagadougou, Koudougou), DRC (Kinshasa), India (Indore, Firozabad, Puri), Kenya (Uasin Gishu, Migori, Kericho), and Nigeria (Lagos, Kano, Ogun). Data analyzed were collected between Nov 2017 and Dec 2019. Niger was excluded due to data unavailability. Sampling: SDPs were drawn from official Ministry of Health and other government listings. A two-stage cluster design stratified by sector (public/private) was used, sampling facility types with probability proportional to size for those with at least 20 SDPs; smaller areas (e.g., Koudougou) had full censuses. Up to 220 SDPs per site were sampled allowing for 10% non-response. Locally recruited female resident enumerators collected data using ODK on smartphones. Measures: Main outcomes were provision and demand of specific modern contraceptive methods (MCMs): condoms (male/female), emergency contraception (EC), oral pills, injectables, intrauterine devices (IUDs), and implants (no implants in India during study). Stockout was defined as temporary unavailability of a method at an SDP that routinely provides it. Method availability was the percentage of SDPs offering a given method over time. For SDPs offering FP, enumerators ascertained whether specific methods were offered, visually confirmed in-stock status on the survey day, and asked whether any stockout occurred in the prior 3 months. Demand was measured from facility logbooks as total FP visits (new and continuing) in the last completed month per method. Couple-years of protection (CYP): CYPs were estimated by combining quantities distributed and visits/sales, using USAID conversion factors. To standardize across SDPs recording sales vs visits, assumptions per relevant visit were: 6 condoms, 4 pill cycles/sachets, or 1 unit for other methods. Analysis: Analyses were limited to SDPs offering FP and stratified by sector. Quarterly percentages of SDPs with at least one MCM in stock and, by method, percentages offering, currently in stock, currently out of stock, and with stockout in prior 3 months were calculated. Monthly client volumes per method and method contributions to total CYP were estimated by quarter and country. Facility weights were constructed from selection probabilities, accounting for quarterly non-response and any reclassification by sector or facility type. Weighted results were produced using Stata 14.2 SVY procedures with Taylor series linearization to account for stratification, clustering, and selection probabilities.

Overall availability: Across all countries and quarters, the vast majority of SDPs offered at least one modern method. Private facilities outnumbered public ones in most settings; pharmacies were predominantly private. Condoms: Across countries, average stockout rate was 4.2% (range 2.5% in Burkina Faso and India to 6.8% in DRC). Public SDPs averaged 5.3% stockout (2.5% Nigeria to 7.3% Kenya); private SDPs 4.1% (2.2% India to 6.6% DRC). On average, 12.5% of SDPs reported a condom stockout within the prior 3 months (2.8% India to 25.6% DRC). Public SDPs more commonly distributed condoms, with higher client volumes (mean 6,842 monthly public vs 2,018 private; overall mean 7,858; country ranges: Burkina Faso 296–Kenya 25,852 overall). Emergency contraception (EC): In SSA settings, EC distribution was primarily via private SDPs, and almost exclusively private in Burkina Faso and Nigeria. Among private SDPs, the proportion not offering EC averaged 28.4% (DRC) and 22.6% (Kenya), exceeding 50% in Burkina Faso and Nigeria. Client volumes were low and variable in SSA, lowest in Burkina Faso (≈9 monthly). In India, EC provision was mainly public; public in-stock increased from 30.6% to 87.4% while 3-month stockouts declined from 3.1% to 1.1%, though client visits did not rise commensurately. Oral pills: In India, provision was higher in public SDPs; public not offering decreased from 14.8% to 2.3%, while private not offering increased from 39.0% to 57.5%. Average monthly visits: 718 public vs 13 private. In SSA, pill clients were generally higher in public SDPs (public-to-private volume ratios: 2.2 in Burkina Faso to 4.4 in Nigeria). Average pill stockout rates: Burkina Faso 3.8%, Kenya 17% (≈25% public), DRC 19.7% (21.2% public; 17.8% private), Nigeria 10.6% (10.1% public; 10.8% private). Availability improved over time in DRC and Kenya; slight decline in Burkina Faso (not offering 20.7% to 22.2%). Injectables: Public SDPs offered injectables far more than private (average not offering: 15.8% public vs 56.5% private; combined 45.6%). Average stockout across geographies was 13.0% (range 1.6% India to 21.6% DRC). Public SDPs averaged 13.6% stockout vs 11.9% private. In prior 3 months, 5.1% of SDPs reported stockout (0.4% India to 11.9% Kenya). India’s public sector saw >3.5-fold increase in injectable client visits with a 93% reduction in public SDPs not offering, but overall availability remained low due to very limited private-sector provision (≈91% of private SDPs not offering). IUDs: Availability was low overall; 69.2% of SDPs did not offer IUDs (58.8% Nigeria to 88.4% India). Public SDPs were more likely to offer and have IUDs in stock (36.0% public not offering vs 81.2% private). Stockouts among IUD-providing SDPs were modest (combined 5.4%); higher in public (7.3%) than private (3.7%). Only 1.1% of IUD-providing SDPs reported a 3-month stockout. Mean monthly IUD client visits ≈372 (range: DRC 39 to Kenya 776). Implants: On average, 52.0% of SDPs did not offer implants (38.1% Kenya to 61.0% Burkina Faso); public provision exceeded private (17.1% public not offering vs 72.4% private). Average stockout rates across African countries were 11.5% (5.2% Burkina Faso; 14% Kenya and Nigeria; 13.1% DRC), higher and more variable in public SDPs (18.9%) than private (6.6%). In prior 3 months, 6.3% of public vs 1.3% of private SDPs reported stockout. Mean monthly implant client visits ≈1,913 (559 Burkina Faso to 4,815 Kenya). Implants were not offered in India during the study. CYP contributions: LARCs provided a disproportionate share of CYPs. Implants accounted for 58.9% of CYPs in public SDPs across countries offering implants (55.2% Burkina Faso to 61.5% DRC). In Kenya, implants provided the most protection across sectors. In DRC’s private sector, pills contributed the highest share of CYPs (38.6%), with IUDs and implants together at 45.5%. India’s total CYPs were lower than SSA settings, partly due to the absence of implants; IUDs contributed the highest CYPs in India. Overall, stockouts were dynamic, varying by method, sector, and geography, and private pharmacies/drug shops played key roles for short-acting methods, particularly EC.

The findings demonstrate that supply-side dynamics—availability and stockouts—vary substantially by method and sector and change over short intervals. Public facilities generally maintain a broader mix of methods, especially LARCs, while private facilities, especially pharmacies and drug shops, are critical sources for short-acting methods (e.g., EC in SSA, pills in some Kenyan sites). Despite limited availability of LARCs, they provide the largest share of protection (CYP), underscoring their importance to meet FP goals. Differences across countries likely reflect varying supply chain systems, policies, service readiness, and program initiatives (e.g., India’s Antara program for injectables). The dynamic nature of stockouts suggests the need for routine surveillance to anticipate and respond to supply disruptions. Engaging the private sector more fully and enhancing service readiness for LARCs could increase protection against unintended pregnancy. While descriptive, the results align with client-level patterns of contraceptive use and highlight pharmacies/drug shops as underleveraged outlets for addressing unmet need in short-acting methods.

Using quarterly, locally representative PMA Agile data, the study documents substantial within-year variation in contraceptive stockouts, availability, client volumes, and CYPs across five countries. Key contributions include quantifying method- and sector-specific stockouts, highlighting the critical but distinct roles of public facilities (broader method mix, LARC provision) and private outlets (short-acting methods, especially EC), and showing that LARCs yield a disproportionately large share of CYPs despite limited availability. Programmatically, engaging and regulating the private sector, improving LARC service readiness (training, equipment, supply), and adopting flexible, context-specific supply chain solutions (e.g., models like the Informed Push Model) can help reduce stockouts and unmet need. Future research should link routine supply data with procurement and logistics information, investigate causes of stockouts, conduct facility-level longitudinal analyses by facility type, and evaluate the cost-effectiveness of alternative distribution models.

The analysis is descriptive and does not measure causal factors behind stockouts or consumption. PMA Agile did not systematically collect reasons for stockouts or capture programmatic/policy changes and external events (e.g., a public sector strike in Burkina Faso) that may affect supply and demand. Some country–sector samples (e.g., public sectors in Burkina Faso and India) were small. Results may differ slightly from the PMA Agile dashboard because the analytical dataset followed SDPs observed across at least two quarters. Combining diverse SDP types may mask variation by facility type. Logbook-based client volume and sales records could be incomplete or inaccurate. Niger data were unavailable; implants were not offered in India during the study. Survey data are subject to sampling and non-sampling errors.