The Sexual-Health Supply Chain Is Broken

This article is a collaboration between The Atlantic and the Fuller Project.

It took Dimos Sakellaridis about six years to build Kiss condoms into one of Nigeria’s top brands, with approximately 91 million sold in 2019. The prophylactics are available in shops, markets, and kiosks across the country, and a combination of irreverent advertising, a growing population of young people, and a greater understanding of reproductive health within Nigeria has meant his sales have steadily risen.

But if he can’t get a shipment of 12 million condoms (and 4 million packs of birth-control pills) out of the Lagos port soon, those stocks will run out. And unfortunately for Sakellaridis, it makes no difference to the customs authorities, who are working their way through a backlog of containers, that ordinary Nigerians depend on Sakellaridis’s stranded cargo to prevent unwanted pregnancies and stop the spread of sexually transmitted infections. All he can do is wait—and he is not alone.

Sakellaridis is the Nigeria country director for DKT International, one of the largest family-planning providers in the world. Since mid-March, when measures taken to contain the coronavirus cut work at the Lagos port, the process of clearing incoming cargo stretched from two to three weeks to more than three months. During that time, DKT’s central warehouse ran out of condoms.

DKT’s struggles highlight the fragility of a global supply chain in which essential goods and medicines are often sourced from a small handful of countries whose competitive advantage has allowed them to dominate various steps of the production cycle. This is not a challenge limited to reproductive health: All over the world, manufacturing, shipping, and logistics have slowed or halted altogether as governments have closed factories, grounded flights, and sealed off borders in response to the coronavirus. But whereas for most goods, this represents little more than an inconvenience, when it comes to vital sexual- and reproductive-health commodities, such breakdowns can put lives at risk.

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Women who trust a specific brand of contraceptive might find it out of stock at the pharmacy. Couples stuck at home, unable to locate the inexpensive condoms they normally buy, might skip protection. Central warehouses may not be able to supply the mobile clinic vans that travel to rural communities unserved by the national public-health system. The results of a disrupted supply chain in this field could be disastrous. The United Nations Population Fund, or UNFPA, the organization’s sexual- and reproductive-health agency, has flagged stockout risks over the coming months in 46 countries. Marie Stopes International, which provides family-planning services in 37 low-income countries, has warned that up to 9.5 million women and girls are at risk of losing access to contraception and safe abortion services, which could result in 1.3 to 3 million unintended pregnancies, and 1.2 to 2.7 million unsafe abortions. This could, in turn, lead to an estimated 5,000 to 11,000 pregnancy-related deaths.

The effects will differ depending on the individual, Sarah Shaw, the head of advocacy at Marie Stopes, told me—poor people who rely on free services will be worse off than their wealthier peers in the same country, and women in countries with robust health systems will have a wider array of options if a drugstore runs out of condoms. Although high-income countries that manufacture their own drugs import large quantities of active pharmaceutical ingredients, or APIs, from China, meaning they faced a squeeze on supplies at the height of the pandemic, manufacturers are likely to prioritize these more profitable markets over lower-income ones.

At DKT, which distributes contraception and safe-abortion products in 90 mostly low- and middle-income countries, country directors will typically keep about three months’ worth of inventory on hand during normal times, according to Chris Purdy, DKT’s president and CEO. Even though manufacturing across Asia has come back online as the coronavirus outbreak has eased in parts of the continent, early factory closures in countries such as India, Malaysia, and China, combined with shipping delays and port congestion, has cut this margin close.

The majority of the world’s condoms, for example, are made in Malaysia and Thailand, home to natural-rubber industries. The paper for cardboard condom packages then comes from China, Indonesia, and Europe, Paul Liang, the marketing director at Karex Berhad, one of the world’s biggest condom producers, told me. India and China are leading manufacturers of generic pharmaceutical products and cheap drugs, although many Indian drug companies rely on Chinese firms for APIs. Products made in one country might also be shipped to a lab in another for quality testing. Once they’re ready for export, they travel by air or sea, depending on the size of the shipment, the urgency of demand, and other factors. Today, many of these travel routes are closed down, severely restricted, or drastically more expensive.

Even without the coronavirus pandemic, which has spurred new quarantine measures and waiting periods, these products were typically subject to inspection once they landed. In Uganda, for example, condoms must be sampled and tested by a regulator. In Kenya, each three-pack of condoms carries a small sticker saying they’ve met regulatory standards before it can be sold to consumers, which requires unpacking every shipment for manual labeling. Reduced manpower as a result of social distancing and evening curfews in Kenya meant that labeling that normally takes two weeks stretched to more than a month. Had the process been delayed any further, Lauren Archer, the DKT Kenya and Uganda country director, told me, her team would have run out of stock.

Companies such as DKT struggle even to substitute identical products in times of need: Importing countries register drugs, such as injectable contraception or the abortion pill, and medical devices, such as condoms or kits used to provide abortions, by manufacturer and country of origin, not just based on the active ingredient or product category. The process of registering a new drug or medical device with the appropriate national agency can take anywhere from six months to several years. “Let’s say you have a stockout from China. It’s not a simple matter of ‘Well, okay, I’m just going to go buy from India now,’” Purdy told me. “You can’t simply switch to a new manufacturer without undergoing re-registration.”

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Large parts of the world do not have domestic manufacturing capacity for these vital health products, leaving them deeply vulnerable to any glitch or disruption to the supply chain. Even countries that have some domestic capacity are not wholly self-sufficient: Iran does have pharmaceutical production, but does not make its own intrauterine devices, or IUDs, the long-acting reversible contraceptives that prevent pregnancy for several years at a time. When I spoke with Purdy at the end of May, a container holding 50,000 IUDs bound for Iran had been stuck in a Dubai port for nearly three months.

The major global organizations that buy and distribute these goods have tried to anticipate and prevent stocks from running out. Purdy encouraged DKT’s country directors to place large orders back in January after a colleague in China sent him photos of empty streets and supermarket shelves scraped clean. In mid-March, Eric Dupont, the head of UNFPA’s procurement-services branch, implemented fast-track procedures for bidding on important reproductive-health products and gave national offices greater powers to order what they needed. Yet many of these contracts have yet to be delivered: Marie Stopes International’s orders placed in January are still en route, traveling by sea.

These organizations have been using every tool at their disposal to get products to countries where they’re needed, and to push them out from central warehouses. The UNFPA used its diplomatic clout to win an export waiver for Indian-made goods. It is also working more with the World Food Programme, which is managing a global logistics cluster on behalf of multiple U.N. agencies, and the UNFPA also joined with a dozen other U.N. agencies to make a joint tender for personal protective equipment.

On a more local level, DKT’s logistics partners in Uganda, having been able to obtain just a few of the limited number of permits released by the government for transit vans, are supplementing their transport network with motorbikes, though these can carry only small amounts of goods, Archer said. In Madagascar, Marie Stopes has been using its fleet of buses to pick up maternity patients—while complying with government-required social distancing—and take them to clinics, after public transport was shut down, according to Shaw. Manuelle Hurwitz, the director of the programs division at the International Planned Parenthood Federation, told me that one way to help meet demand was through calling for policy or regulatory changes, such as classifying family-planning and sexual-health services as “essential,” and allowing telemedicine. IPPF’s member association in India, for example, is using a hybrid model of telemedicine for counseling and follow-up care and clinic visits scheduled at intervals to keep a safe distance between clients. “There’s adaptations like that evolving all the time, but the reality is we’re not reaching as many women,” Shaw said.

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These extra efforts have strained organizational budgets. To ensure the consistent flow of supplies—both downstream to pharmacies, clinics, and supermarkets by extending credit to his buyers; and upstream by placing large orders that will take months to arrive—Purdy said he has had to float more than the $10 million a month that he normally does, forcing him to dig into DKT’s endowment (a $1.9 million grant from the Swedish government helped defray some of these extra costs). Others I spoke with said they were also spending more on the purchase of supplies—both sexual- and reproductive-health products and PPE for staff.

“I never thought in a million years I would be getting requests to say, ‘Can we use our advocacy budget to buy hand sanitizer?’” Shaw said.

While manufacturing has resumed in India, China, and Malaysia, factories there face long backlogs of orders. New safety measures such as thrice-daily sanitization mean that production will be slow, Liang said, and he is still dealing with interruptions in supplies. Because of restrictions on movement and on large gatherings, many people still won’t get the care they need, or will have to adjust their contraceptive method to avoid doctor’s visits. Shaw said that in the short term, women in the developing world are likely to shift from highly effective long-acting reversible contraceptives such as injectables, implants, and IUDs, to condoms or oral contraceptive pills. These methods typically leave more room for human error, because they must be taken daily or used correctly every time for the highest efficacy.

All of this means that in a few months’ time, there may well be an increase in demand for abortion care. “Whether we’ll be able to meet that demand,” Hurwitz said, “is something else.”