Assessing Contraceptive Security in Honduras- SPARHCS
Publication date: 2006
[image: image1.emf] Documentation of the Use of SPARHCS: Honduras 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. From April–May 2004, with input from Honduras’s CS committee, a team from John Snow, Inc. (JSI)/DELIVER and Futures Group/POLICY conducted a SPARHCS assessment as part of the Latin America and the Caribbean (LAC) Regional CS Feasibility Study. It was the last of five SPARHCS assessments 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 POLICY and DELIVER projects are working with USAID on assistance strategies for countries at regional, subregional, and national levels, under the LAC Regional CS Initiative. The technical assistance will build capacity within Honduras and in the LAC region to address CS issues in the short, medium, and long term. This brief describes the Honduras CS context and SPARHCS assessment and the findings and recommendations, lessons learned, and activities and progress made since the SPARHCS application. CS Context in Honduras 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 Honduras to understand the context related to achieving contraceptive security (Quesada et al., 2004). Demographic indicators. Honduras has seen a steady increase in the use of FP modern methods among married women ages 15-44 over the past decade—from 47 percent in 1991 to 50 percent in 1996 to 62 percent in 2001. During this time period, the increase was particularly notable in rural areas, where rates climbed from 36 percent to 54 percent, compared with the increase from 61 percent to 70 percent in urban areas. These increases are attributed to government investment in FP and reproductive healthcare. However, despite the progress made and the government’s investment, unmet need for family planning is still high among extremely poor (23 percent) and poor (11 percent) women. Furthermore, population growth over the next decade will significantly increase the total number of users and increase the demand for modern FP methods and services (ENESF, 1991/1992; ENESF, 1996; ENESF, 2001). History of donor financing of contraceptives. The Secretariat of Health (SS) of Honduras has received consistent contraceptive donations from USAID since 1995 and intermittent contraceptive donations from the United Nations Population Fund (UNFPA) since 1999. USAID plans to continue such support for two to three more years. The Honduran Social Security Institute (IHSS) has received only periodic contraceptive donations from USAID and UNFPA. The nongovernmental organization (NGO) and International Planned Parenthood Federation (IPPF) affiliate, Honduran Association for Family Planning (Ashonplafa), receives contraceptive donations from USAID and IPPF, which will continue for an undefined period (Quesada et al., 2004). FP providers and methods. The SS is the main FP provider in Honduras, serving 40 percent of FP users (see Figure 1). Ashonplafa serves 29 percent of FP users. The commercial sector serves 22 percent of FP users, with 12 percent using pharmacies and 10 percent using private providers. Finally, IHSS covers almost 5 percent of FP clients (ENESF, 2001). [image: image2.emf]Honduras has a diverse method mix (see Figure 2). Of married women, ages 15-44, using family planning, 29 percent use female sterilization, 17 percent use oral contraceptives (OCs), 16 percent use intrauterine devices (IUDs), 16 percent use injectables, and 5 percent use condoms. In the last decade, injectables and IUDs have had the largest increase in use among all economic groups. Traditional methods are used by 17 percent of FP users—down from 25 percent in 1991 (ENESF, 1991/1992; ENESF, 2001). Economic and political environment. Honduras is one of the poorest countries in the LAC region. Nearly 65 percent of households are classified as living in poverty. Efforts to address high levels of poverty made progress throughout the 1990s, but in 1998, Hurricane Mitch reversed that progress. While poverty levels have since declined, they are still at pre-Mitch levels. Over the last decade, public spending in health has increased; currently, health spending as a percent of gross domestic product is 6 percent. Political and public support is strong for the reduction of maternal and child mortality and for the use of family planning as a strategy to achieve this goal. However, the legal framework and institutional support for the provision of FP services is weak. Although under the national health policy, the SS is to provide family planning and five other services for free to those who want them, some SS facilities do charge a fee, thereby restricting access to those without the ability to pay. The SPARHCS Assessment in Honduras Honduras’s CS assessment was conducted from April 26–May 7, 2004, and included national objectives, such as identifying existing challenges in the government and NGO sectors affecting contraceptive security; raising awareness among decisionmakers about the need for coordinated action to overcome these challenges; and suggesting strategies for increasing independence from donated commodities while, at the same time, preserving gains made in reproductive health within the last decade. Key players. The assessment team included four individuals from DELIVER and POLICY. To complete the assessment, the SPARHCS team relied on the input of in-country partners from the USAID mission, UNFPA, various divisions of the SS, IHSS, and the NGO community. The CS committee in Honduras, formed after the 2003 LAC Regional CS Conference in Managua, Nicaragua, played a valuable role in planning and preparing for the SPARHCS assessment by identifying key players and arranging meetings for the team. Upon completion of the SPARHCS assessment, the CS committee, along with additional key players, 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, site visits to six health regions, and debriefings with USAID and CS committee members. Contraceptive commodities and cost projections through the year 2015 were prepared using Spectrum software, with inputs drawn from available national data. A market segmentation analysis conducted by DELIVER was integrated into the assessment. The team conducted in-depth interviews with 44 key informants drawn from a wide array of national governmental agencies and NGOs, international health and development agencies, and private sector organizations involved in health and family planning in Honduras. The team also carried out site visits in six health regions to review logistics data. Findings and dissemination of results. On the final day of the SPARHCS assessment, the team presented preliminary findings to the CS committee, which provided additional information and revisions. The SPARCHS team developed an in-depth assessment report in Spanish and a summary report, titled “Contraceptive Security in Honduras: Evaluation of Strengths and Weaknesses,” in both English and Spanish. 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 important issues in the areas of financing, market segmentation, procurement, logistics, and policy and political commitment that Honduras must face to achieve contraceptive security (Quesada et al., 2004). Financing. Until 2000, over 90 percent of contraceptives provided by the three most prominent sources of family planning in Honduras (SS, Ashonplafa, and IHSS) came from international donors (USAID, UNFPA, and IPPF). Since 1999, the SS has purchased contraceptives and, over time, has increased the quantities and types of methods. In 2003, the SS purchased approximately US$200,000 in contraceptives. The SS would need to increase its financial investment to meet its contraceptive requirements. For example, assuming low prices, the SS would need to increase its contraceptive purchases by 11 percent each year starting in 2004; thus, the SS’s annual financial requirements for contraceptives would need to increase from about US$400,000 in 2001 to US$800,000 in 2015 (procuring internationally based on UNFPA costs). If procured at intermediate prices, financial requirements for the SS would be significantly greater, increasing from US$700,000 in 2001 to US$1.7 million per year by 2015. Since 2001, Ashonplafa has purchased contraceptives. IHSS, on the other hand, has not begun purchasing contraceptives. Market segmentation. The current market structure in Honduras, with its reliance on the SS as the predominant provider, is not sustainable for the long term. The practice of providing free FP products and services attracts even wealthier users who could potentially pay for them. Accordingly, since 1991, the private sector’s market share has declined. Along with diverting wealthier users to private sector sources, it is important to develop a deliberate strategy to reach out to the poorest groups to ensure their FP needs are being met. IHSS does not have an established program that provides family planning; as a result, beneficiaries consult SS and private sector sources for their FP needs. Procurement. In 2003, the SS procured contraceptives through a special agreement with the United Nations Development Program in an effort to provide transparency to government processes. In Honduras, contraceptives are on the essential drugs list, making it possible to purchase contraceptives as a part of the budget amount assigned for procurement of medicines. It is important that the list is updated to include all contraceptive products that the SS will eventually procure and supply. Logistics and information systems. The methodology used for contraceptive programming and distribution could be revised to enhance accurate forecasting based on consumption data and efficient distribution of contraceptive supplies. Furthermore, the management of logistics and information systems could be improved to ensure, for example, that normative procedures for information channels and delivery of medicines are enforced and monitored closely. Policy, political commitment, and leadership. Enhanced political leadership and popular support, particularly a government commitment to funding family planning and making it a priority, are needed to continue Honduras’s progress toward contraceptive security. Fortunately, there is time to generate interest and support for contraceptive security, as phaseout of donor contraceptive commodity support is not scheduled for approximately three years. Main Recommendations for Achieving Contraceptive Security The SPARHCS assessment conducted in Honduras highlighted many potential interventions for increasing contraceptive security. These were grouped into five priority strategies: Work toward ensuring adequate funding for contraceptives as donor phaseout approaches, including allocating a line item in the national budget and increasing funding for contraceptives. Segment the contraceptive market by targeting government-subsidized contraceptives to those who need them most and encouraging the growth and involvement of the private sector in providing contraceptives to those who can pay. Formulate a phaseout strategy for NGOs that are still dependent on donor-supplied commodities. Design a plan to strengthen the government’s logistics supply system. Advocate for future health sector and government reforms that preserve past FP achievements and foster a more enabling environment for contraceptive security. Lessons Learned Using SPARHCS in Honduras Important lessons emerged from Honduras’s SPARHCS assessment that can be used to inform SPARHCS assessments in other countries. Because Honduras’s assessment was the last of five to occur in the LAC region, some of these lessons were first learned in earlier assessments and resulted in a more efficient assessment process in Honduras. 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 10 (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 Honduras. Draw on the SPARHCS framework as a guide. In Honduras, the SPARHCS team used the framework as a general guide for conducting the assessment rather than a stringent set of instructions. For example, the SPARHCS team found it necessary to fine tune interview questions for country relevance and to organize interview questions by institution (e.g., SS, Ashonplafa, commercial sector), depending on which would have the necessary information. The Honduras SPARHCS 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 stand-alone tool; it requires an array of sources and types of information for its proper use. The SPARHCS team relied on notes from interviews, various cost calculations, Spectrum, and a market segmentation 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. Activities and Progress since the SPARHCS Application SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions in Honduras. Selected activities and progress include the following: With eight other countries, Honduras participated in the CS LAC Regional Forum held in October 2004 in Lima, Peru. The CS committee created strategies to advocate for contraceptive security to be considered a priority among high-level government officials and civil society groups; create and sustain a specific budget allotment for contraceptives through a legal framework; and draft a national plan for the gradual and progressive purchase of contraceptives from 2005–2008. The SS is now operating under a donor phaseout plan for gradually assuming responsibility of the purchase of contraceptive commodities each year, culminating in 2009, when it is estimated that its annual investment for contraceptives will be US$1.7 million. For 2006, the SS has already reserved approximately US$1 million in the national budget for the purchase of contraceptives (Ochoa, 2005). To improve logistics and information systems affecting contraceptive supplies, the SS is currently adapting its system of statistical information and developing an inventory control program (Ochoa, 2005). The USAID mission in Honduras is now drafting a new strategic plan for Ashonplafa, a major provider of FP products and services, to improve efforts in reaching Honduras’s poorest populations. A next step will be to view these efforts within the greater context of sustainability and contraceptive security. DELIVER and POLICY conducted an in-depth procurement options analysis for Honduras, 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. As part of the LAC CS Initiative, Honduras will continue to take part in activities through 2006 to advance progress toward achieving contraceptive security. DELIVER and POLICY will provide technical assistance to increase momentum. The main activities include capacity building for CS advocacy and CS strategic planning. These activities will ensure that Honduras can continue advancing toward contraceptive security after 2006. References Quesada, N., P. Mostajo, C. Salamanca, C. Cisek, L. Patykewich, and A. Karim. 2004. Honduras: Contraceptive Security Assessment, April 26–May 7, 2004. Arlington, VA: John Snow, Inc., DELIVER, and Washington, DC: Futures Group, POLICY Project. Minsterio de Salud Pública. 1992. Honduras: Encuesta Nacional de Epidemiología y Salud Familiar 1991/1992 (ENESF, 1991/1992). Tegucigalpa, Honduras: Minsterio de Salud Pública. Ochoa, J. 2005. Personal communication. Tegucigalpa, Honduras: John Show, Inc./Honduras. Secretaria de Salud and Asociación Hondureña de Planificación Familiar (Ashonplafa). 1997. Honduras: Encuesta Nacional de Epidemiología y Salud Familiar 1996 (ENESF, 1996). Atlanta, GA: Centers for Disease Control and Prevention (CDC). Secretaria de Salud and Asociación Hondureña de Planificación Familiar (Ashonplafa). 2002. Honduras: Encuesta Nacional de Epidemiología y Salud Familiar 2001 (ENESF, 2001). Atlanta, GA: CDC. 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 use 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 assessments’ 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. � USAID’s Bureau for Latin America and the Caribbean (LAC) launched a regional initiative, following the Regional CS Feasibility Study, to determine how contraceptive security in the LAC region could be more effectively in light of the phase out of contraceptive donations. The initiative, being implemented by the POLICY and DELIVER Projects, is now in its third year of activities. � This section reviews the CS context at the time of the SPARHCS assessment. � Honduras has a population of 6.6 million people, with 54 percent living in urban areas. Women of reproductive age represent nearly one quarter of the total population (1.6 million). � Includes both women who are married legally and by common law. � The CS committee includes individuals from the SS, Ashonplafa (IPPF affiliate), UNFPA, and USAID. � Spectrum is 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. � www.policyproject.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 the lowest prices quoted by commercial distributors or to the 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. PAGE 7
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