Assessing Contraceptive Security in Bolivia- SPARHCS
Publication date: 2006
[image: image1.emf] Documentation of the Use of SPARHCS: Bolivia Introduction Contraceptive security (CS) is achieved when individuals have the ability to choose, obtain, and use contraceptives and condoms whenever they need them. The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) framework provides countries with a tool to assess contraceptive security and to design plans for advancing it in both the short and long term. In December 2003, with input from Bolivia’s CS committee, a team from POLICY and DELIVER conducted a SPARHCS assessment as part of the Latin America and the Caribbean (LAC) Regional CS Feasibility Study. It was the second of five SPARHCS assessments to be conducted in the region. The overall goal of the study was to analyze and identify barriers and opportunities to achieving contraceptive security at both the country and regional levels. As a follow-on to the study, the DELIVER and POLICY projects are working with USAID on assistance strategies for countries at regional, subregional, and national levels, under the LAC Regional CS Initiative. This technical assistance will build capacity within Bolivia, as well as in the LAC region, to address CS issues in the short, medium, and long term. This brief describes the Bolivia CS context and SPARHCS assessment and provides an overview of the findings and recommendations, lessons learned, activities, and progress made since the SPARHCS application. CS Context in Bolivia The SPARHCS team reviewed the demographic indicators, the history of donor financing of contraceptives, the family planning (FP) market, and the economic and political environment in Bolivia to understand the context related to achieving contraceptive security (Taylor et al., 2003). Demographic indicators. Despite gains made in the last decade in contraceptive prevalence rate (CPR), contraceptive use is low compared with other countries in the LAC region. In 1998, the CPR among married women of reproductive age (15–49) (MWRA) was 48 percent, while the CPR for modern methods was 25 percent. Also at that time, disparities existed between rural and urban areas—CPR for MWRA was 58 percent in urban areas but 30 percent for those in rural areas. Low rates of contraceptive use are linked to the total fertility rate (TFR), which measured 4.2 births per woman in 1998. In rural areas, the TFR measured 6.4 births per woman—a figure that has remained virtually static since 1989. Unmet need for family planning was 26 percent, but as high as 39 percent for women in rural areas (ENDESA, 1998). History of donor financing of contraceptives. In the last decade, USAID, the Department for International Development (United Kingdom) (DFID), and the United Nations Population Fund (UNFPA) have supported the FP programs of the Ministry of Health and Sports (MSD), the Social Security Institute (CNS), and nongovernmental organizations (NGOs). Currently, USAID is the country’s largest provider of donated contraceptives; however, all USAID contraceptive donations go through the social marketing program of the NGO, PROSALUD, which operates through several local NGOs. USAID’s contraceptive donations to CNS ended as of 2000, but USAID will likely continue making contraceptive donations to PROSALUD through 2008. From 1998–2001, UNFPA provided contraceptive donations to the MSD. From 2002–2004, these donations were continued by DFID, with UNFPA serving as the procurement agent (Taylor et al., 2003). FP providers and methods. Begun in the early 1990s, Bolivia’s FP program is relatively new. Since its beginnings, FP provision has not been without challenges, including reaching the many Bolivians residing in rural, mountainous areas with contraceptive methods and a history of experiencing contraceptive stockouts in health establishments. The MSD provides modern contraceptive methods free and has an important role in the Bolivian FP market, serving 33 percent of FP users in 1998 (see Figure 1). The private sector has a large market share (58%), with services and commodities available from private providers (32%), pharmacies (25%) and other sources (1%). PROSALUD’s social marketing program has increased the role of commercial pharmacies in family planning and provided other NGOs with a reliable supply of contraceptives at competitive prices. Finally, the CNS serves 9 percent of FP users; however, since USAID contraceptive donations ended in 2000, it has been unable to provide a reliable supply of contraceptives in its facilities, and its market share has most likely decreased (ENDESA, 1998; Taylor et al., 2003). Traditional methods are popular in Bolivia, constituting 49 percent of the method mix (see Figure 2). Modern methods comprise the remaining half of the method mix and include intrauterine devices (IUDs) (23%), female sterilization (13%), oral contraceptives (OCs) (8%), injectables (2%), and other modern methods (5%) (ENDESA, 1998). [image: image2.emf] Economic and political environment. Prior to 1989, attempts to introduce family planning in Bolivia were met with opposition, in part due to anti-family planning sentiments from the influential Catholic Church. Awareness-raising activities conducted by NGOs and international agencies about the importance of family planning were eventually successful. In 1989, the government launched the National Plan for Infant Survival and Development and Maternal Health, which included family planning in government health facilities. Since the mid-1990s, Bolivia’s health sector has decentralized, transferring financial and management responsibilities to municipal governments and individual health facilities. Family planning is mentioned as a priority in the government’s 2001 Poverty Reduction Strategy Paper. In the last three years, the country’s deteriorating economy and political instability have created major challenges for contraceptive security and threaten its future. Turmoil surrounding the ouster of the former government in 2003—just two months prior to the SPARHCS assessment—resulted in the weakening of the government, making it difficult to plan for the long term, including for contraceptive security (Taylor et al., 2003). About two-thirds of all Bolivians are poor, suffer from poor health and nutrition, and have low levels of education (ENDESA, 1998; INE, 2001). The SPARHCS Assessment in Bolivia Conducted from December 1–14, 2003, the SPARHCS assessment in Bolivia included the national objectives of identifying barriers in the public and private sectors that interfere with achieiving greater contraceptive security; raising awareness among key decisionmakers about coordinating efforts to overcome barriers impeding progress toward contraceptive security; and suggesting interventions to increase independence from donated contraceptives while, at the same time, preserving gains made in the area of reproductive health within the last decade. Key players. The Bolivia SPARHCS team comprised four external consultants and three Bolivians from JSI/DELIVER and Futures Group/POLICY and relied on the collaboration of individuals from two divisions of MSD; the local government; five local NGOs, including a social marketing program; and representatives from the pharmaceutical industry, USAID/Bolivia, and other international agencies. The CS committee in Bolivia, formed after the 2003 LAC Regional CS Conference in Managua, Nicaragua, played a valuable role in planning and preparation for the SPARHCS assessment by identifying key players and arranging meetings for the team. After completing the SPARHCS assessment, the CS committee assisted the team in reviewing the assessment’s findings, providing additional information, and formulating national CS recommendations. Information gathering. The SPARHCS team gathered information through a document review, interpersonal interviews, focus groups, field visits, analyses of service delivery points, and debriefings with USAID and CS committee members. In addition, the team prepared contraceptive commodity and cost projections through 2015 using Spectrum software, with inputs drawn from available national data. The team conducted in-depth interviews with key informants drawn from a wide array of local and national governmental agencies and NGOs, international health and development agencies, and private sector organizations involved in health and family planning in Bolivia. SPARHCS team members conducted field visits to four departments to determine the departmental and municipal-level status on CS activities, as well as barriers and opportunities to future progress—especially important given the extent of decentralization of the Bolivian health system. Findings and dissemination of results. The SPARHCS team wrote an in-depth assessment report in Spanish for limited circulation and a summary report titled “Contraceptive Security in Bolivia: Evaluation of Strengths and Weaknesses” in both Spanish and English. The summary report was distributed at the LAC Regional CS Forum in Lima, Peru, in October 2004 and is available on the websites of POLICY and DELIVER. Overview of SPARHCS Findings The SPARHCS assessment revealed both barriers and opportunities to achieving contraceptive security in the areas of financing, market segmentation, procurement, logistics, policy, and political commitment in Bolivia. Financing. The MSD has not budgeted for or purchased contraceptives, but it purchases large quantities of essential drugs and vaccines each year. The MSD does not have a strategic plan for replacing DFID-donated contraceptives, which ended in 2004. Contraceptive commodity projections reveal that in 2015, the MSD will require between US$900,000 (at low prices ) and US$2.3 million (at intermediate prices ) to pay for contraceptive commodities to satisfy client needs. Bolivia must explore and mobilize all potential financing mechanisms for contraceptives to avoid a serious contraceptive funding gap. A long-term financing option could be Universal Maternal and Infant Health Insurance (SUMI), since the law includes reimbursement of health establishments for contraceptives provided to women, but only up until six months postpartum. Using SUMI to finance all contraceptives will require a change in the SUMI law (to include all women of reproductive age), which is considered feasible in the near future. Market segmentation. The current market structure could be adjusted to better accommodate the FP needs of the poorest Bolivians and also to plan for a future without donated contraceptives. The MSD could target its services to the poorest women and/or to rural areas. While PROSALUD’s social marketing program is a viable option for those who are able to purchase subsidized contraceptives, many Bolivians face cultural, geographic, or economic barriers to accessing PROSALUD products. Private providers and commercial pharmacies serve those from middle and upper economic groups who are able to pay, but these providers are concentrated in urban areas and could be encouraged to expand to other areas. Furthermore, contraceptive manufacturers and importers/distributors find it difficult to compete with the donated products sold at highly subsidized prices by PROSALUD and the free contraceptives provided by the MSD, which could threaten the overall sustainability of the private sector’s involvement in the FP market and its ability to offer products at lower prices to Bolivians of all economic levels. Procurement. Bolivia has more procurement options available compared with other countries in the LAC region due to its decentralized health system and the existence of parastatal, NGO, and commercial procurement agents that currently import or could import contraceptives. But while the existing system for essential drug purchases at the local level has made medicines more available at health facilities, the system is also very expensive. The local procurement of essential drugs has increased costs to the facilities and, in turn, to the client. The local procurement of contraceptives could have the same effect, and, therefore, it is important that the MSD identify the most cost-effective procurement options available; potential options include other national procurement mechanisms or reimbursable mechanisms offered via UNFPA, the International Planned Parenthood Federation, or the Pan American Health Organization. Logistics and information systems. In 2002, the MSD created the Unified National Supply System (SNUS) to integrate its multiple supply systems. Since 2003, all contraceptive logistics functions in the MSD system are carried out in an integrated fashion under SNUS. In addition, the decentralization of the health system requires health establishments or municipal governments to make critical decisions about contraceptive logistics, in some cases without the appropriate training or expertise. It is important that efforts are made to continuously train personnel to effectively manage contraceptive supplies under SNUS and in the context of a decentralized health system. Policy, political commitment, and leadership. By the early 1990s, policy declarations and international agreements recognized reproductive health as a fundamental right. By the mid 1990s, the MSD created norms and standards for FP services, trained health personnel, began to accept contraceptive commodity donations, and established and launched the first National Program for Sexual and Reproductive Health (PNSSR). These developments are promising for the future of family planning, but still, Bolivia’s policy framework could be strengthened. The new iteration of SUMI restricted the financing and provision of free contraceptives to only the postpartum period, when few women actually use contraception. Also, at the time of the assessment, the new PNSSR 2004–2008 was in draft form, which the minister has now approved and launched. Main Recommendations for Achieving Contraceptive Security The Bolivia SPARHCS assessment revealed many interventions for consideration in achieving contraceptive security. These were grouped into seven priority strategies: Increase advocacy for FP/RH policy at the national level for improving access to family planning and the sustainability of contraceptive supplies. Reduce the unmet need for family planning among those not currently being reached with information, services, or contraceptive products—such as those from poor, rural, and ethnic groups. Encourage advocacy and build capacity among local governments, local health boards, and civil society for planning, financing, and delivering RH services. Identify sustainable contraceptive funding sources to replace donor assistance and financing, and put procurement policies and systems in place that ensure a continuous supply of low-cost, high-quality products and reduce barriers to access by the poor. Encourage a more rationally segmented FP market in which the government focuses on those who are least likely to be able to pay for FP commodities, social marketing reaches the middle economic groups, and the commercial sector attends to those who have the ability to pay. Ensure that adequate quantities of all required contraceptives are available in all health facilities at all times. Effectively manage contraceptives under the newly integrated supply system, SNUS. Improve coordination so that government authorities, private sector representatives, and international donors are working together to meet the country’s contraceptive needs in the face of declining donor contributions. Lessons Learned Using SPARHCS in Bolivia Valuable lessons emerged from Bolivia’s SPARHCS assessment that can be used to inform SPARHCS assessments in other countries. Since some members of the Bolivia team went on to be members of SPARHCS teams in the other LAC countries, where possible, members shared experiences and lessons learned to better prepare for and conduct the remaining assessments. Use SPARHCS to create a common understanding of contraceptive security. POLICY and DELIVER presented the SPARHCS framework to country teams from Bolivia, Honduras, Nicaragua, Paraguay, and Peru at the 2003 LAC Regional CS Conference in Managua, Nicaragua. The presentation included a comprehensive review of the main CS concepts and the range of stakeholders that could participate in CS initiatives. As a result, the country teams gained a common understanding of contraceptive security and saw the value of SPARHCS as a consensus-building tool. Adapt SPARHCS locally to achieve a more effective application in the field. SPARHCS was adapted for application in the LAC region and in the field, allowing it to become a more operational and efficient tool. Adaptations for the LAC region included expanding the key CS areas to ten (environment, policy, leadership and commitment, financing, market segmentation, client demand and use, access and quality of services, procurement, coordination, and logistics). For field use, the Peru SPARHCS team created several formats for data collection in Spanish, which were adapted and used in Bolivia. Draw on the SPARHCS framework as a guide. In Bolivia, the SPARHCS team used the framework as a general guide for conducting the assessment rather than a stringent set of instructions. The SPARHCS team found that since themes in the SPARHCS guide are cross-cutting, questions had to be hand picked according to which sector or agency (MSD or CIES) would have the necessary information. The team also chose to conduct free-form interviews, using the questions as guidance and later as an organizational tool for the information collected. Use SPARHCS as a complementary tool. SPARHCS is not a standalone tool; it requires an array of sources and types of information for its proper use; the SPARHCS team relied on notes from interviews and focus groups, health facility data, various cost calculations, Spectrum, and Demographic and Health Survey (DHS) analysis. As such, the assessment generated a large volume of information, and ultimately the greatest challenge to the SPARHCS team was culling the information into specific next steps and recommendations at the country level. A noted limitation was that the SPARHCS tool does not provide a framework for analyzing the information that is collected for use in strategy development. National contraceptive security committee assists in SPARHCS assessments and enhances momentum for planning. In the five LAC countries, CS committees have provided critical assistance to SPARHCS teams in preparing for assessments, revising and fine tuning findings and recommendations, and planning how to use findings and recommendations to move CS activities forward in-country. Activities and Progress since the SPARHCS Application Since the SPARHCS application, Bolivia has focused attention on developing and implementing solutions to achieve contraceptive security. As part of the LAC CS Initiative, Bolivia will continue to take part in activities through 2006 to advance progress toward achieving contraceptive security. DELIVER and POLICY will provide technical assistance to enhance momentum. Selected activities and progress include the following (Saenz, 2005): With eight other countries, Bolivia participated in the CS LAC Regional Forum held in October 2004 in Lima, Peru. The CS committee created an action plan for contraceptive security, which centered around the areas of political commitment and leadership, financing, market segmentation, procurement, and logistics. Planned activities included expanding and increasing the visibility of the CS committee to increase awareness of CS issues; enhancing the market segmentation analysis and disseminating results to national, regional, and local decisionmakers; strengthening and diversifying procurement mechanisms with municipal governments; establishing a legal framework for ensuring the financing of contraceptives; and strengthening the logistics information system. The new 2004–2008 PNSSR was approved and launched. The proposed extension of the SUMI law, which would incorporate the provision of contraceptive methods to all women of reproductive age into universal maternal and child health insurance, has been presented before the senate and approved with some suggested revisions. On December 6, 2005, former president Eduardo Rodriguez expanded SUMI to include 27 new services, and starting April 1, 2006, it will cover women and girls ages 5–60, in addition to children ages 0–5 and pregnant women. It is estimated that 3.5 million women will benefit from SUMI due to this expansion. To determine the MSD’s financial requirements for contraceptives, DELIVER/Bolivia conducted a contraceptive pricing study for the country, as well as an analysis of the costs of contraceptives by municipality. DELIVER conducted a meeting with private providers of contraceptives to encourage them to work with the government and proposed prices they would offer to the MSD for a significant annual allotment of contraceptives, assuming demand for contraceptives does not decrease. DELIVER conducted a market segmentation analysis with the new ENDESA 2003 and presented the findings to the CS committee. The committee is in the process of revising the market segmentation report. The CS committee, with assistance from DELIVER, prepared a market segmentation plan for 2005–2008 that includes directing FP resources to vulnerable groups as a key strategy. The MSD continues to strengthen its logistics functions, principally in continuing the implementation, follow up, monitoring and evaluation, and supervision of the SNUS, which since 2003 is the new management system for all contraceptive logistics functions in the public health system. DELIVER and POLICY conducted an in-depth procurement options analysis for Bolivia, which will form part of a LAC regional procurement options analysis. This analysis will help countries identify the best procurement option and consider advocacy strategies directed at eliminating obstructive laws/regulations. DELIVER worked with the CS committee to finalize a 3-year CS strategy and an accompanying implementation plan. Activities for 2006 include capacity building on CS advocacy and implementation of the CS activities in the strategic plan. These activities will ensure that Bolivia can continue advancing toward contraceptive security beyond 2006. References Instituto Nacional de Estadística e Informática, and Macro International. 1998. Bolivia Encuesta de Demografía y Salud (ENDESA, 1998). Columbia, MD: Macro International/DHS + Program. Instituto Nacional de Estadística (INE). 2001. Censo Nacional de Población y Vivienda. La Paz, Bolivia: INE. Saenz P. 2005. Personal communication. November 2005. La Paz, Bolivia: John Snow, Inc. Taylor P.A., N. Quesada, P. Saenz, K. Garcia, C. Salamanca, P. Mostajo, and V. Dayaratna. 2003. Bolivia: Contraceptive Security Assessment, December 1–12, 2003. Arlington, VA: John Snow, Inc./DELIVER and Washington, DC: Futures Group/POLICY. The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS), developed by the DELIVER, POLICY, and Commercial Market Strategies (CMS) projects (in collaboration with the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), and other donors and technical agencies), serves as an assessment, planning, and implementation tool to help countries address contraceptive security (CS) issues and to determine areas for strengthening and intervention. SPARHCS examines six key areas that factor into a country’s CS situation: client utilization and demand, context, commitment, capital, capacity, and coordination. Moreover, it is a universal assessment tool that can be tailored to specific timelines, country contexts, or program objectives. �The briefs in this series outline the experience of using SPARHCS in assessing contraceptive security in Peru, Bolivia, Honduras, Nicaragua, and Paraguay. The SPARHCS assessment findings have been used to stimulate dialogue on strategies to advance toward achieving contraceptive security in Latin America and the Caribbean. � USAID’s Bureau for Latin America and the Caribbean (LAC/RSD-PHN) conducted a Regional CS Feasibility Study to guide future policy and programmatic decisions at the regional and country levels. USAID’s DELIVER and POLICY projects implemented the study by creating CS assessments in Bolivia, Honduras, Nicaragua, Paraguay, and Peru using SPARHCS. 2 USAID’s LAC Bureau launched a regional initiative, following the Regional CS Feasibility Study, to determine how contraceptive security in the region could be more effectively addressed in light of the phaseout of contraceptive donations. The initiative, being implemented by the POLICY and DELIVER projects, is now in its third year of activities. � Bolivia’s population size is nearly 9 million inhabitants—63 percent of whom reside in urban areas. Since more than a third of the population (38%) is less than 15 years old; even with reduced fertility rates, Bolivia’s population of reproductive age will continue to grow in the next decade, as will the demand for contraceptives. � At the time of the SPARHCS assessment, 1998 survey data were the most current available. � Includes both women who are married legally and by common law. � The CS committee in Bolivia comprises individuals from two divisions of the Ministry of Health and Sports (Health Services and Medicines); from the NGOs, PROSALUD (social marketing) and Center for Research, Education, and Services (CIES); and from UNFPA, USAID, and JSI/DELIVER-Bolivia. � SPECTRUM is a suite of policy models, designed by the POLICY Project, used to project the need for reproductive healthcare and the consequences of not addressing reproductive health needs. � � HYPERLINK "http://www.policyproject.com" ��http://www.policyproject.com�; � HYPERLINK "http://www.deliver.jsi.com" ��www.deliver.jsi.com�. � Low prices are those that governments and organizations pay for contraceptives using UNFPA’s reimbursable procurement mechanism. These prices include shipping and a 5 percent charge for UNFPA’s management costs. � Intermediate prices are comparable to prices paid by NGOs with social marketing programs or by governments in other LAC countries when purchasing large quantities of contraceptives directly from pharmaceutical companies or are the lowest prices quoted by commercial distributors. PAGE 1
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