National Reproductive Health Commodities Forecasting Bangladesh

Transcription

1 National Reproductive Health Commodities Forecasting Bangladesh June 2017

2

3 National Reproductive Health Commodities Forecasting Bangladesh M. Sheikh Giashuddin Mohammad Golam Kibria June 2017

4 National Reproductive Health Commodities Forecasting Bangladesh This report is made possible by the generous support of the American people through the US Agency for International Development (USAID), under the terms of cooperative agreement number AID-OAA-A The contents are the responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the United States Government. About SIAPS The goal of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program is to assure the availability of quality pharmaceutical products and effective pharmaceutical services to achieve desired health outcomes. Toward this end, the SIAPS result areas include improving governance, building capacity for pharmaceutical management and services, addressing information needed for decision-making in the pharmaceutical sector, strengthening financing strategies and mechanisms to improve access to medicines, and increasing quality pharmaceutical services. Recommended Citation This report may be reproduced if credit is given to SIAPS. Please use the following citation. Giashuddin MS, Kibria MG National Reproductive Health Commodities Forecasting Bangladesh Submitted to the US Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health. Key Words reproductive health, forecasting, quantification Systems for Improved Access to Pharmaceuticals and Services Pharmaceuticals & Health Technologies Group Management Sciences for Health 4301 North Fairfax Drive, Suite 400 Arlington, VA USA Telephone: Fax: Web: ii

5 CONTENTS Acronyms and Abbreviations... iv Introduction and Background... 1 Scope of Exercise... 3 Process Followed... 3 Objectives of Exercise... 3 Data and Methods... 4 Assumptions and Input Data... 5 Base Population (Population and Housing Census 2011)... 5 Life Expectancy by Sex... 5 Projection Scenarios Forecasting Results Forecasted Users and Acceptors by Method: Scenario Forecasted Contraceptive Commodities Requirements: Scenario Forecasted Users and Acceptors by Method: Scenario Forecasted Contraceptive Commodities Requirements: Scenario Forecasted Users and Acceptors: Scenario Forecasted Contraceptive Commodities Requirements: Scenario Forecasted Users and Acceptors: Scenario Forecasted Contraceptive Commodities Requirements: Scenario Comparison of Reported and Forecasted Requirements for Contraceptive Commodities Forecasting of Emergency Contraceptive Pills Challenges and Recommendations Challenges Recommendations Conclusion Bibliography iii

6 ACRONYMS AND ABBREVIATIONS CPR CYP DGFP ECP FP FWG HPNSP IUD LAPM LMIS MSH MWRA NIPORT OCP RH SDP SIAPS TFR WHO WRA Bangladesh Demographic and Health Survey contraceptive prevalence rate couple year protection Directorate General of Family Planning emergency contraceptive pill family planning Forecasting Working Group Health, Population, and Nutrition Sector Program intrauterine device long-acting permanent method Logistics Management Information System Management Sciences for Health married women of reproductive age National Institute of Population Research and Training oral contraceptive pill reproductive health service delivery point Systems for Improved Access to Pharmaceuticals and Services total fertility rate World Health Organization women of reproductive age iv

7 INTRODUCTION AND BACKGROUND Bangladesh has made huge strides in reducing fertility by increasing access to and use of safe, affordable, and quality contraceptives in past decades. The demand for family planning (FP) services has proportionally increased as population size and the number of women at risk of unwanted pregnancy continues to rise. The FP services in Bangladesh are provided through both the public and private sectors. The coordinated efforts of government and nongovernmental organizations contributed to a steady decline in the total fertility rate (TFR) from 2.7 in 2007 ( 2007) to 2.3 ( 2014) (which plateaued) in This result is consistent with the increased use of contraception among married women from 61% in 2011 ( 2011) to 62% in On the other hand, unmet need decreased among currently married women from 14% in 2011 to 12% in The FP program, implemented by the Directorate General of Family Planning (DGFP) has built a nationwide, community-based service delivery system that relies primarily on nonclinical methods, such as oral pills and condoms. The fourth Health, Population, and Nutrition Sector Program (HPNSP) (MOHFW 2011a) of Bangladesh adopted strategies for making FP services available, accessible, acceptable, and affordable to all women and men of reproductive age. This sector program aims at reducing the TFR from 2.3 to 2.0 per woman and the maternal mortality rate by 2022 by increasing contraceptive prevalence rate (CPR) from 62.4% to 75% with 20% share of long-acting, reversible contraceptive and permanent methods. Meanwhile, Bangladesh joined the FP2020 global initiatives and further committed to reducing the TFR to 2.0 by USAID has been providing support to ensure the availability of contraceptives and other reproductive health (RH) commodities in Bangladesh for over 25 years. This support has included assistance to the public sector to improve systems for supply chain management of RH commodities and ensuring contraceptive security at each tier, including the service delivery point (SDP) level. Because DGFP is the entity responsible for contraceptive security for the whole country, they must know the total requirement, including private sector needs. The USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program worked with DGFP to strengthen the procurement system, address supply chain management issues related to FP and other essential health commodities, and achieve the committed goals of the public sector program and FP2020. With the technical assistance from SIAPS, DGFP has been successfully implementing a nationwide, web-enabled SDP dashboard module ( to track the stock situation for contraceptives at over 29,000 SDPs. The SDP dashboard includes simplified charts, maps, and tables for monitoring and has a short messaging service system for reminders and tracking report submissions, and has alerts for stock imbalances and impending stock-outs. In 2012, SIAPS supported DGFP in conducting a five-year ( ) forecasting exercise for RH commodities and built the technical capacity of DGFP officials to manage the forecasting processes and analyze the FP2020 indicators pertinent to stock availability. SIAPS also assisted DGFP in forming the multi-stakeholder Forecasting Working Group (FWG) to annually review needs and facilitate data-informed procurement decisions. The FWG uses data collected through information management platforms and conducts quantification exercises on the basis of the consumption of RH/FP commodities. The

8 National Reproductive Health Commodities Forecasting Bangladesh forecasting exercise helped DGFP avoid redundant procurement decisions by using goodquality logistics data and saved money. However, after 2016, it had to be updated with the latest data. Therefore, at USAID s request, SIAPS worked with FWG and developed another five-year ( ) forecast of RH commodities to enable evidence-based contraceptive procurement decisions. The goal is to optimize a data driven procurement system and minimize losses through expiry from overstocking. 2

9 SCOPE OF EXERCISE The scope of the forecast is national, covering all FP commodities (condoms, injectables, intrauterine devices [IUDs], implants, oral contraceptive pills (OCPs), and emergency contraceptive pills [ECPs]). The forecast covers the period January 2017-December The major suppliers of contraceptives for DGFP are the Government of Bangladesh/Essential Drug Company Limited, USAID, and UNFPA. Process Followed 1) Collected secondary data and relevant documents from different institutions (DGFP, NIPORT, UNFPA, Social Marketing Company, FP2020 commitments, etc.) to carry out the exercise 2) Identified an appropriate methodology for forecasting national commodity needs of both public and private sectors to meet set targets for contraceptive mix, CPR, and contraceptive acceptance rates 3) Based on the outcome of bullet 1, determined appropriate tools and data sources required to conduct and regularly update the forecast for RH commodities in Bangladesh 4) Using the methodologies, data sources, assumptions, and appropriate tools agreed to in bullets 1 3, developed a medium-term forecast of RH commodities to include condoms, injectables, IUDs, implants, OCPs Objectives of Exercise The activity aimed at estimating the projected population and developing a mid-term forecast of requirements to support the DGFP for The specific objectives of this assignment were to estimate the following demographic parameters for : Total population Women of reproductive age (WRA) years Married women of reproductive age (MWRA) years Number of current FP method users among MWRA Number of users by specific method Required commodity of specific method Required commodity by different sources Estimate of the number of ECPs Estimated cost of RH commodities The results of the projection will be used in program planning, mobilizing, and securing financial resources for the projection period and will facilitate data-informed procurement decisions for vaccines for the short term. 3

10 National Reproductive Health Commodities Forecasting Bangladesh Data and Methods The method of estimating future needs for FP commodities typically requires multi-year planning and is based on the determination of the target population and the country maternal and child health FP strategic plan. The target population for an FP program represents the number of women within the age group who are targeted as contraceptive users. This report considers the recent population census (BBS 2012) results in order to estimate the target population for the forecasting period. Moreover, a couple of data sources were used to retrieve the necessary inputs in the forecasting modeling. The source includes the Bangladesh Demographic Health Surveys (s) and the Sample Vital Registration System. This projection was also validated with UN projections and other national projections and verified the consistency of the estimate. To estimate the number of WRA during the forecasting period, a population projection was made on the basis of the following parameters: The data from the Bangladesh Population Census 2011 (BBS 2012) was used as base population. Computerized analysis tools, DemProj and FamPlan (both 2008), were used to make commodity projections on the basis of current population and fertility, mortality, and migration rates for the country or a region. A module of Spectrum Policy Model Software, developed by the USAID/Future Institute, was used to calculate the total population by age. 4

11 ASSUMPTIONS AND INPUT DATA Base Population (Population and Housing Census 2011) The base year population is given in table 1. The 2011 census provided only enumerated population. It was not adjusted for under enumeration. We considered only the national figure of % under enumeration for adjusting 2011 census population. Table 1. Age-sex adjusted population 2011 Age Male % Female % Total % 0-4 7,942, ,718, ,660, ,693, ,202, ,895, ,957, ,351, ,308, ,768, ,605, ,373, ,007, ,821, ,828, ,472, ,542, ,015, ,281, ,636, ,917, ,884, ,052, ,936, ,451, ,139, ,590, ,497, ,136, ,633, ,070, ,703, ,773, ,000, ,640, ,640, ,164, ,926, ,090, ,195, ,002, ,197, ,254, ,066, ,320, , , , , , ,679, Total 74,977, ,794, ,772, Source: BBS 2012 Life Expectancy by Sex Based on the trend from the Sample Vital Registration System report (BBS 2016), the life expectancy at birth in 2015 for males is assumed to be 69.4 years and for females is assumed to be 72.0 years with an annual increase of 0.30 years (figure 1). For the final year (2021), the life expectancies are assumed to be 72.7 years and 75.4 years for males and females, respectively. To estimate future life expectancy until 2021, the UN model life table (UN 1982) was used in the projection. Migration Because of the lack of valid data, international migration was assumed to be zero. Sex Ratio The expected sex ratio was 1.05 male births per 1.0 female birth; this ratio was assumed to be constant throughout the projected period. 5

12 National Reproductive Health Commodities Forecasting Bangladesh Figure 1. Projected life expectancy Total Fertility Rate and Age-Specific Fertility Rate The trend lines revealed that Bangladesh was likely to achieve the replacement level of fertility (NRR = 1) by 2016, provided the other population parameter remain unchanged. The TFR is extrapolated for a future point in time using the fitted lines (figures 2 and 3). It is observed that an exponential curve fit best (R 2 = 0.93). Figure 2. Trends in TFR from data (observed and fitted) Table 2. Trends in age-specific fertility rate Survey and approximate time period Age group 1975 BFS 1989 BFS 1991 CPS TFR Source:

13 Assumptions and Data Input The Bayesian median projection indicates that the steady decline will continue to the replacement level of fertility (NRR = 1) by 2018 (UN 2015). In Bangladesh, current fertility is 2.3 for The median Bayesian Projections Model (BPM) projection for 2021 is 1.96 children while the median BPM projection for 2030 is 1.70 children. Comparing the widths of the prediction intervals for Bangladesh shows that the higher the current TFR, the more uncertainty there is in its projections, such that, for 2043, the median width of the 80% prediction interval is around 0.90 children (figure 3). The age-specific fertility rate is given in table 2. Figure 3. Projected TFR (gray) for estimated with probabilistic prediction intervals (UN 2015) Based on the 2011 census population and available input data, the population of WRA and MWRA in Bangladesh for the forecast period was projected (table 3). The forecast of FP commodities was agreed for the MWRA group only. The proportion of the MWRA group that would need FP commodities was determined to be 80.0% of the WRA group. Table 3. Projected total population, WRA and MWRA Year Projected population (million) Projected WRA (million) Projected MWRA (million)

14 National Reproductive Health Commodities Forecasting Bangladesh The use of contraception among married women in Bangladesh has increased gradually from 44.7% in to 62.3% in Most recently, contraceptive use increased by 1 percentage point from 61.2% in 2011 to 62.3% in In this forecast, CPR was calculated on the basis of 2014 figures and the target set for 2021 by the program. For 2021, it was assumed that the total CPR will grow to 68% (table 4); long-acting permanent methods (LAPMs; IUD, implants, and female and male sterilization) are assumed to consist of 10% of the share and short-acting methods 57%. Table 4 shows the projected trends of total CPR and CPR by method. Table 4. Trends and estimated CPR (%) by method Methods Year 2017 Year 2021 Male condom Female sterilization Male sterilization Injections Implant-Norplant IUD Pill Withdrawal Periodic abstinence Other Total Contraceptive Effectiveness and Couple Year Protection Method effectiveness is the proportion of users who do not become pregnant during a year of method use. For estimating commodities, it is necessary to specify an average effectiveness rate, or the extent by which the practice of a method of contraception lowers fecundability. It is determined by both a population s ability to conceive and the extent of contraceptive method failure. Table 5 shows the assumptions made for couple year protection (CYP) and contraceptive effectiveness with their respective sources. Table 5. CYP, contraceptive effectiveness by method Contraceptive effectiveness (%) Methods CYP (USAID) WHO a Stover b Oral contraceptives 15 cycles Male condoms 150 condoms IUD 3.5 years Injectables 4 doses Implant single rod 2.5 years Female sterilization 13 years Male sterilization 13 years a Adapted from WHO 2011 and Trussell 2011 b Stover 2000 The source mix (public and private) of each FP contraceptive was projected mainly on the basis of the average obtained from reports with some adjustments, especially for the short-acting methods (table 6). Generally, the public sector is the major source of 8

15 Assumptions and Data Input contraceptives. In addition, the LAPMs are almost exclusively sourced from the public sector. According to information in 2014, the public-sector contribution is expected to be higher due to the increased number of government fieldworkers available for distributing FP supplies. Table 6. Source mix by method 2014 RH commodity Public source* (%) Private source (%) Oral contraceptives/pills Male condoms IUD 93 7 Injectables Implant single rod 98 2 Female sterilization Male sterilization *Including NGOs In addition to the major assumptions listed earlier, the following assumptions given in table 7 were made for based on reports. Table 7. Post-partum amenorrhea and abstinence insusceptibility, abortion rate, median age of sterility, sterility coefficient 99/ Average Post-partum menorrhea TAR Sterility coefficient Median age for sterility Male sterility 36* *Source: Stover 2000 It was assumed for the forecasting period that the following stock levels will be maintained at the different distribution and storage levels in Bangladesh (table 8). Prices were obtained from DGFP and were assumed to be constant throughout the forecast period. Prices were converted to USD, and USD was used in the calculations to avoid possible price changes due to devaluations. Table 8. Minimum and maximum months of stock for the program Storage level Minimum Maximum Central 2 5 District/region 2 3 Upazila 2 3 SDP 2 3 Total (country/program) 8 14 Shipment intervals (central) 3 Desired stock levels for program 13 Source: Omer

16 PROJECTION SCENARIOS To meet the objectives, the study sets a number of simulations for accurate estimates of FP commodities. Applying the projection tools with the input data, the study explores the number of users and the required commodities in each of the following scenarios. They are: Scenario 1: If the current trend of CPR continues and will be 68% and traditional methods slightly shift to modern methods by 2021 Scenario 2: If CPR will be 72% and traditional methods shift to modern methods by 2021 Scenario 3: If TFR of is 2.1 per woman is achieved by 2021 Scenario 4: Unmet need for FP will be satisfied by

17 FORECASTING RESULTS The objective of this study is to estimate RH commodity requirements, including contraceptive users. Commodity requirements are projected considering various assumptions associated with the demographic goal. On the basis of the data and assumptions adopted, review of documents, and the tools indicated earlier, the total value of forecasted commodities and supplies required for the FP programs for Bangladesh s public sector for the period January 2017 to December 2021 were obtained. Table 9 provides a summary of the values of the various classes and categories of pharmaceuticals required for FP. The forecast is for absolute requirements and wastage only. Buffers, freight and logistics costs, current inventory positions, etc., are not reflected in the figures. These parameters will be used to calculate the final quantities for procurement and cost requirements. Forecasted Users and Acceptors by Method: Scenario 1 If current trend of CPR continues and will be 68% and traditional methods slightly shift to modern methods by 2021 To estimate the required commodities according to the current CPR trend stipulated for scenario 1, some changes in method mix were required for LAPM. The forecasting accuracy of scenario 1 could be assessed by comparing the gap between required commodities with prevailing contraceptive use and commodities for specific programmatic goals. Table 9 shows the number of projected users by contraceptive method mix for different methods. Results indicate an increase in users of pills, injectables, implants, and permanent methods. If the method mix of 2014 continues through , the total method users will increase to 24.2 million in 2017 and 27.0 million in Among them, 21.6 million and 24.1 million couples will be modern method users in 2017 and 2021, respectively. The results also indicate that the total cumulative modern method users during the forecasted period will be million. Among them, 56.4 million will be pill users, 25.9 million injectable users, 13.4 million condom users, 2.8 million IUD users, and 3.8 million implant users; 13.8 million will be permanent method acceptors. Table 9. Forecasted number of users (scenario 1) Total Oral pill 10,484,934 10,977,278 11,397,761 11,877,203 11,698,824 56,436,000 Male condom 2,494,107 2,611,223 2,711,246 2,825,293 2,782,861 13,424,730 Female sterilization 2,130,887 2,230,948 2,316,404 2,413,843 2,377,590 11,469,672 Male sterilization 460, , , , ,343 2,476,407 Injectables 4,818,711 5,044,985 5,238,232 5,458,576 5,376,596 25,937,100 Implant 702, , , , ,524 3,779,779 IUD 532, , , , ,398 2,867,419 Withdrawal 726, , , , ,542 3,910,115 Periodic abstinence 1,791,883 1,876,025 1,947,885 2,029,822 1,999,337 9,644,952 Other 121, , , , , ,685 Total 24,263,058 25,402,385 26,375,420 27,484,891 27,072, ,597,859 11

18 National Reproductive Health Commodities Forecasting Bangladesh Forecasted Contraceptive Commodities Requirements: Scenario 1 Table 10 shows the projected requirements of contraceptive commodities for scenario 1. Under this scenario, the projected commodities are million cycles of pills, 2,013.7 million condoms, and 103 million doses of injectables for By applying the source mix, the required commodities for the public sector are million cycles of pills, million condoms, and 73.6 million doses of injectables. The other commodities required are implants and IUDs at 1.61 million and 961,000, respectively, in the public sector. Table 10. Total commodities required under scenario 1 Commodity Total Public 70,773,304 74,096,624 76,934,888 80,171,120 78,967, ,943,000 Oral pill Private 86,500,704 90,562,544 94,031,528 97,986,920 96,515, ,596,992 Total 157,274, ,659, ,966, ,158, ,482, ,539,992 Public 63,599,724 66,586,184 69,136,760 72,044,968 70,962, ,330,596 Male Private 310,516, ,097, ,550, ,748, ,466,208 1,671,378,784 condom Total 374,116, ,683, ,686, ,793, ,429,168 2,013,709,380 Public 13,685,139 14,327,756 14,876,577 15,502,356 15,269,531 73,661,359 Injectables Private 5,589,705 5,852,182 6,076,349 6,331,948 6,236,851 30,087,035 Total 19,274,844 20,179,938 20,952,926 21,834,304 21,506, ,748,394 Public 307, , , , ,513 1,581,884 Implant Private 6,278 6,446 6,750 6,126 6,684 32,284 Total 313, , , , ,197 1,614,168 Public 188, , , , , ,044 IUD Private 14,184 14,512 15,220 13,448 14,973 72,337 Total 202, , , , ,902 1,033,381 Forecasted Users and Acceptors by Method: Scenario 2 If CPR will be 72% and traditional methods shift to modern methods by 2021 Table 11 shows projected users by contraceptive method mix for different methods. Results indicate an increase in users of pills, injectables, implants, and permanent methods. If the method mix of 2014 continues through , the total method users will increase to 24.9 million in 2017 and 28.8 million in Among them, 22.1 million and 25.6 million couples will be modern method users in 2017 and 2021, respectively. The results also indicate that the total cumulative modern method users during the forecasted period will be million. Among them, 59.1 million will be pill users, 27.1 million injectables users, 14.1 million condom users, 3.0 million IUD users, and 3.9 million implant users; 14.0 million will be permanent method acceptors. Table 11. Forecasted number of users (scenario 2) User by method Total Oral pill 10,749,059 11,391,409 11,967,365 12,612,959 12,423,529 59,144,321 Male condom 2,556,935 2,709,735 2,846,740 3,000,311 2,955,251 14,068,972 Injectables 4,940,099 5,235,313 5,500,013 5,796,718 5,709,659 27,181,802 Female sterilization 2,184,566 2,315,113 2,432,167 2,563,373 2,524,874 12,020,093 Male sterilization 471, , , , ,143 2,595,248 IUD 546, , , , ,219 3,005,024 Implant 719, , , , ,061 3,961,168 Withdrawal 744, , , , ,753 4,097,760 12

19 Forecasting Results User by method Total Periodic abstinence 1,837,022 1,946,800 2,045,231 2,155,564 2,123,190 10,107,807 Other 124, , , , , ,960 Total 24,874,267 26,360,721 27,693,534 29,187,495 28,749, ,865,155 Forecasted Contraceptive Commodities Requirements: Scenario 2 Table 12 shows the projected requirements of contraceptive commodities for scenario 2. Under this scenario, the projected commodities required are million cycles of pills, million condoms, and million doses of injectables during By applying the source mix, the required commodities for the public sector are million cycles of pills, million condoms, and 77.1 million doses of injectables for The other commodities required are implants and IUDs at 1.68 million and 1.03 million, respectively. Table 12. Total commodities required under scenario 2 Commodity Total Public 72,556,144 76,892,008 80,779,712 85,137,472 83,858, ,224,152 Oral pill Private 88,679,736 93,979,128 98,730, ,056, ,494, ,940,656 Total 161,235, ,871, ,510, ,194, ,352, ,164,808 Public 65,201,848 69,098,232 72,591,880 76,507,928 75,358, ,758,776 Male Private 318,338, ,361, ,419, ,538, ,928,704 1,751,587,008 condom Total 383,540, ,460, ,011, ,046, ,287,592 2,110,345,784 Public 14,029,880 14,868,288 15,620,037 16,462,678 16,215,430 77,196,313 Injectables Private 5,730,515 6,072,963 6,380,015 6,724,193 6,623,204 31,530,890 Total 19,760,395 20,941,251 22,000,052 23,186,871 22,838, ,727,203 Public 324, , , , ,801 1,684,488 Implant Private 6,621 6,876 7,278 6,505 7,098 34,378 Total 331, , , , ,899 1,718,866 Public 199, , , , ,252 1,026,378 IUD Private 15,030 15,556 16,486 14,281 15,901 77,254 Total 214, , , , ,153 1,103,632 Almost 12 million cumulative users would be added during the forecasted period if scenario 2 could be achieved. The requirements for contraceptive commodities can be viewed as ambitious in LAPM because it is assumed that the current mix of modern methods will continue into the future and users of traditional methods will shift to modern methods and from short-term modern reversible methods to LAPMs. Forecasted Users and Acceptors: Scenario 3 If TFR of 2.1 per woman is achieved by 2021 To provide consistency, the required commodities were estimated with another programmatic goal of achieving TFR of 2.1 per woman by Table 13 shows the projected users by contraceptive method mix for different methods. Results indicate an increase in users of pills, injectables, implants, and permanent methods. The projected total method users will be 23.3 million in 2017 and increased to 25.5 million in Among them, 20.2 million and 22.7 million MWRA will be modern method users in 2017 and 2021, respectively. The result also indicates that the number of total cumulative modern method users during the forecasted 13

20 National Reproductive Health Commodities Forecasting Bangladesh period will be million out of million. Among them, 53.4 million pill users, 24.5 million injectable users, 12.7 million condoms users, 2.7 million IUD users, 3.6 million implant users, and 13.1 million permanent method acceptors. Table 13. Number of users by methods , scenario 3 User by method Total Oral pill 9,945,584 10,401,406 10,788,620 11,231,036 11,042,314 53,408,960 Male condom 2,367,996 2,476,525 2,568,719 2,674,056 2,629,122 12,716,418 Female sterilization 2,029,711 2,122,736 2,201,759 2,292,048 2,253,534 10,899,788 Male sterilization 439, , , , ,266 2,361,621 Injectables 4,566,850 4,776,156 4,953,959 5,157,109 5,070,451 24,524,525 Implant 676, , , , ,178 3,633,263 IUD 507, , , , ,383 2,724,947 Withdrawal 710, , , , ,737 3,814,926 Periodic abstinence 1,691,426 1,768,947 1,834,799 1,910,040 1,877,945 9,083,157 Other 101, , , , , ,991 Total 23,037,221 24,093,053 24,989,968 26,014,747 25,577, ,712,596 Forecasted Contraceptive Commodities Requirements: Scenario 3 Table 14 shows the projected requirements for contraceptive commodities for scenario 3. On the basis of CYP attributes, it is estimated that million cycles of pills, million condoms, and 99.8 million doses of injectables are required for By applying the source mix, the required commodities for the public sector are million cycles of pills, million condoms, and 70.9 million doses of injectables for The other commodities are implants and IUDs at 1.44 million and 534,000, respectively, for both public and private sectors during Table 14. Total commodities required under scenario 3 (TFR goal 2.05) Commodity Total Public 68,285,656 71,416,168 74,074,760 77,112,400 75,815, ,704,608 Oral pill Private 83,460,240 87,286,424 90,535,824 94,248,488 92,663, ,194,512 Total 151,745, ,702, ,610, ,360, ,479, ,899,120 Public 49,091,376 51,341,940 53,253,240 55,437,032 54,504, ,628,348 Male Private 239,681, ,669, ,001, ,663, ,111,488 1,287,126,640 condom Total 288,772, ,011, ,254, ,100, ,616,248 1,550,754,988 Public 13,204,113 13,809,446 14,323,529 14,910,905 14,660,151 70,908,144 Injectables Private 5,393,229 5,640,478 5,850,456 6,090,370 5,987,949 28,962,482 Total 18,597,342 19,449,924 20,173,985 21,001,275 20,648,100 99,870,626 Public 275, , , , ,796 1,414,495 Implant Private 5,626 5,770 6,036 5,460 5,975 28,867 Total 281, , , , ,771 1,443,362 Public 96,887 99, ,959 94, , ,158 IUD Private 7,293 7,479 7,825 7,078 7,746 37,421 Total 104, , , , , ,579 Forecasted Users and Acceptors: Scenario 4 Unmet need for FP will be satisfied by 2021 Table 15 shows the projected users by contraceptive method mix for different methods. Results indicate an increase in users of pills, injectables, implants, and permanent methods. If 14

21 Forecasting Results the unmet need declines through , the total method users will increase to 22.8 million in 2017 and 24.7 million in Among them, 20.3 million and 22.1 million couples will be modern method users in 2017 and 2021, respectively. The results also indicate that the total cumulative modern method users during the forecasted period will be million. Among them, 52.1 million will be pill users, 23.9 million injectables users, 12.4 million condom users, 2.6 million IUD users, and 3.5 million implant users; 12.8 million will be permanent method acceptors. Table 15. Number of users by methods , scenario 4 User by method Total Oral pill 9,880,490 10,239,238 10,524,707 10,858,706 10,685,286 52,188,427 Male condom 2,350,324 2,435,662 2,503,568 2,583,018 2,544,116 12,416,688 Female sterilization 2,008,044 2,080,954 2,138,971 2,206,850 2,180,671 10,615,490 Male sterilization 433, , , , ,479 2,293,633 Injectables 4,540,918 4,705,793 4,836,990 4,990,491 4,906,509 23,980,701 Implant 661, , , , ,890 3,506,547 IUD 502, , , , ,168 2,653,873 Withdrawal 684, , , , ,235 3,638,742 Periodic abstinence 1,688,583 1,749,893 1,798,680 1,855,761 1,817,226 8,910,143 Other 114, , , , , ,284 Total 22,864,321 23,694,496 24,355,097 25,128,000 24,750, ,792,528 Forecasted Contraceptive Commodities Requirements: Scenario 4 Table 16 shows the projected requirements for contraceptive commodities for scenario 4. Under this scenario, the projected commodities required are million cycles of pills, 11,862.5 million condoms, and 95.9 million doses of injectables during By applying the source mix, the required commodities for the public sector are million cycles of pills, million condoms, and 68.1 million doses of injectables for The other commodities required are implants and IUDs at 1.47 million and 874,000, respectively for public sector. Table 16. Total commodities required under scenario 4 Commodities Total Public 66,693,308 69,114,856 71,041,768 73,296,264 72,125, ,271,876 Oral pill Private 81,514,040 84,473,712 86,828,832 89,584,328 88,153, ,554,528 Total 148,207, ,588, ,870, ,880, ,279, ,826,404 Public 59,933,268 62,109,372 63,840,972 65,866,956 64,874, ,625,512 Male condom Private 292,615, ,239, ,694, ,585, ,742,368 1,545,877,440 Total 352,548, ,349, ,535, ,452, ,617,312 1,862,502,952 Public 12,896,206 13,364,451 13,737,052 14,172,993 13,934,486 68,105,188 Injectables Private 5,267,465 5,458,720 5,610,909 5,788,969 5,691,551 27,817,614 Total 18,163,671 18,823,171 19,347,961 19,961,962 19,626,037 95,922,802 Public 282, , , , ,222 1,446,847 Implant Private 5,775 5,869 6,087 5,811 5,984 29,526 Total 288, , , , ,206 1,476,373 Public 172, , , , , ,735 IUD Private 12,992 13,156 13,667 12,417 13,608 65,840 Total 185, , , , , ,575 15

22 National Reproductive Health Commodities Forecasting Bangladesh From the four scenarios discussed earlier, the scenario that provides the most achievable performance levels should be selected. Because the prevailing method mix of contraceptives is likely to continue during the period of forecasting, the scenario selected should provide the least deviation from the actual figures for the beginning of the projection period; this scenario may also provide the least deviation in subsequent years. If it is assumed that the impact of the socio-economic setting on FP outcomes will remain constant during , options from either scenario 1 or 4 may be adopted. These scenarios are based on the program goals with the least deviation. The share of modern reversible methods will continue as it is now, but there will be a shift from traditional methods to modern, reversible methods, such as pills, condoms, and injectables, and from these methods to LAPMs. There will be a net decline in the share of the method mix of traditional methods. 16

23 COMPARISON OF REPORTED AND FORECASTED REQUIREMENTS FOR CONTRACEPTIVE COMMODITIES To provide reliable estimates of required commodities, the forecasted result must be compared with the consumption trend of data from the Logistics Management Information System (LMIS; table 17). The reported number of condoms was million in 2016, however, the forecasted number is 63.0 million in 2017 under scenario 1. It is assumed that the public share is only 17% ( 2014). If we use the source mix of the previous study (Omer 2013), the estimated number will be 149 million, which is consistent with LMIS data. Similarly, the number of cycles of pills actually distributed in 2016 was 99.2 million, and the current projection is 70 million cycles for The actual number of injectables for 2016 was 12.9 million, but the forecasted figures are 13.6 million doses for 2017, which is consistent with The actual numbers of IUDs and implant acceptors were 243,000 and 367,000 in 2016, respectively, compared to 188,000 IUDs and 307,000 acceptors in Because the use of IUDs and implants is declining, some changes have been made in the method mix to ensure the slight increase in LAPMs is consistent with the program goal. Similarly, the estimates of the scenario 4 are also close to scenario 1. From this discussion, it would seem that scenarios 1 or 4 might be achievable. In addition to the above mentioned long-acting and short-acting methods, forecasting on ECP was also conducted for (table 18) at the request of DGFP. Table 17. Trends in LMIS consumption data a Year Oral pill Condom Injectables IUD Implant ,617, ,674,034 13,833, , , ,935, ,216,594 13,500, , , ,282, ,715,975 12,928, , ,148 a accessed March 27, 2017 Forecasting of Emergency Contraceptive Pills Algorithm for estimating ECPs ECP need for 1 year = Total MWRA Proportion of those aware of ECPs Proportion used last 12 months Table 18. Forecasted number of ECPs Year WRA 46,303,544 47,916,972 49,183,400 50,672,732 49,911,696 MWRA 37,042,836 38,333,576 39,346,720 40,538,184 39,929,356 Required ECP* 288, , , , ,449 *Using rate: 0.78% per MWRA Source:

24 CHALLENGES AND RECOMMENDATIONS Challenges Successful forecasting and quantification remain a challenge because of inconsistent data (consumption data vs. service data that do not match precisely). Therefore, certain assumptions and decisions have to be made to cater to this deficiency. The current forecast only considered FP commodity requirements. Condom requirements must be adjusted for the sexually transmitted diseases (STD) and HIV/AIDS prevention program. The abortion rate is estimated using retrospective history from data, which may affect the number of acceptors. The information on removal and switching of IUDs and implants is lacking. Actual CYP of these commodities needs to be re-estimated or revised. Because the source and prevalence rate of ECPs is not available, it is forecasted using arithmetic progression. The accuracy of this exercise fully depends on the implementation of a successful FP program (as per target in HPNSP, ). Recommendations The FP commodity requirement forecasts should be reviewed and updated bi-annually by the FWG. This will ensure adequate funding for supplies and supply chain operations, especially by supporting donor coordination efforts that will eventually ensure commodity security. The government, nongovernmental organizations, and the private and social marketing sectors need to coordinate among themselves. Continued training of DGFP officials on forecasting and quantification is required to keep abreast on the globally adopted updated tools and methodologies. Comparative analysis of usage between contraceptives and interrelation changes among contraceptives is needed. The domino effect of oral pills should be assessed as well. The output of this exercise should be used for decision making in procurement and resource mobilization for the next five years. A study should be conducted for estimating average CYPs for IUDs and implants, considering frequent removal and switching. 18

25 CONCLUSION The main objective of this assignment was to forecast RH commodity requirements of contraceptives for The forecast is accomplished based on four simulations. The first scenario assumes that the prevailing acceptor method mix will continue to hold during the projection period, whereas the second and third scenarios assume (with target specific goals) an increase in the method mix for LAPMs. This assignment shows that the last scenario provides estimates of contraceptive commodities that are very close to the actual figures of the LMIS consumption report. The successful implementation of forecasting will depend on program achievement and availability of resources. However, if programmatic inputs are provided to accommodate the increase in the number of acceptors of FP methods, then the projected requirements can be modified on the basis of trends in service statistics data during subsequent years. 19

26 BIBLIOGRAPHY Bangladesh Bureau of Statistics (BBS) Bangladesh Population Census, Analytical Report. Dhaka: Bangladesh Bureau of Statistics, Planning Division, Ministry of Planning. BBS Statistical Yearbook of Bangladesh 2010, Dhaka: Bangladesh Bureau of Statistics. Statistics Division, Ministry of Planning. BBS Bangladesh Population and Housing Census, Dhaka: Bangladesh Bureau of Statistics, Statistics and Informatics Division, Ministry of Planning. BBS Sample Vital Registration System 2015; Statistics and Informatics Division (SID), Ministry of Planning. 80b3_78b8d1223e3f/SVRS_REPORT_2016.pdf Bangladesh Demographic and Health Survey () National Institute of Population Research and Training (NIPORT), Mitra and Associates and ORC Macro , Dhaka, Bangladesh, and Calverton, MD, USA NIPORT, Mitra and Associates, and ORC Macro , Dhaka, Bangladesh, and Calverton, MD, USA NIPORT, Mitra and Associates, and ORC Macro , Dhaka, Bangladesh, and Calverton, MD, USA NIPORT, Mitra and Associates, and ORC Macro Dhaka, Bangladesh, and Calverton, MD, USA. BD04%5BFR165%5D.pdf NIPORT, Mitra and Associates, and Macro International Dhaka, Bangladesh, and Calverton, MD, USA NIPORT, Mitra and Associates, and ICF International Preliminary Report. Dhaka, Bangladesh, and Calverton, MD, USA NIPORT, Mitra and Associates, and ICF International Dhaka, Bangladesh and Calverton, MD, USA: NIPORT, Mitra and Associates, and ICF International. 20

27 Bibliography DemProj. Spectrum System of Policy Models A Computer Program for Making Population Projections. USAID Health Policy Initiative. Directorate General of Family Planning Monthly Logistics and Family Planning, Maternal and Child Health and RH Services Reports, 2014, MIS unit, Dhaka: DGFP, Ministry of Health and Family Welfare. Family Planning Logistics Management (FPLM) Contraceptive Forecasting Handbook for Family Planning and HIV/AIDS Prevention Programs. Arlington, VA.: FPLM/John Snow, Inc., for USAID; FamPlan.Spectrum System of Policy Models A Computer Program for Projecting Family Planning Requirements. USAID Health Policy Initiative; Ministry of Health and Family Welfare (MOHFW). 2011a. Strategic Plan for Health, Population and Nutrition Sector Development Program (HPNSDP) , Planning Wing, MOHFW, Government of Bangladesh: Dhaka MOHFW. 2011b. ng=en Omer AM, Giashuddin MS, Kibria MG National Reproductive Health Commodities Quantification Bangladesh SIAPS Program. Arlington, VA: Management Sciences for Health Stover J, Bertrand JT, Shelton JD Empirically Based Conversion Factors for Calculating Couple-years of Protection. Evaluation Review 24 (1): Trussell J. Contraceptive failure in the United States. Contraception 2011; 83: United Nations (UN) Model Life Tables for Developing Countries. Department of International Economic and Social Affairs. Population Studies, No. 77. New York: United Nations; UN United Nations world population projections to United Nations. Department of Economic and Social Affairs. Population Division. United Nation, New York. UN World Population Prospects: The 2015 Revision. New York: United Nations, Department of Economic and Social Affairs, Population Division. (accessed March 30, 2017) World Health Organization Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Knowledge for health project. Family planning: a global handbook for providers (2011 update). Baltimore, MD; Geneva, Switzerland: CCP and WHO;