Assessing Contraceptive Security in Jordan- SPARHCS
Publication date: 2006
[image: image1.emf] Documentation of the Use of SPARHCS: Jordan 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. Jordan began CS efforts in June 2002 at the request of the government of Jordan (GOJ) and USAID to address the eventual phaseout of contraceptive commodity donations. During this time, POLICY conducted key informant interviews to obtain baseline data about the CS environment and identify perceived CS issues. POLICY, Commercial Market Strategies (CMS), and DELIVER introduced the SPARHCS framework and diagnostic guide in 2003, with the objective of synthesizing existing research and data on family planning (FP), identifying information gaps and conducting studies to fill the gaps, and moving CS activities forward. The overall goal of Jordan’s SPARHCS assessment and follow-up activities is to establish a funded, long-term strategic plan for achieving contraceptive security. A team from POLICY and Jordan’s Ministry of Health (MOH) conducted a situation analysis using SPARHCS in early 2004. This brief describes the SPARHCS application in Jordan, including the CS context; the process of applying SPARHCS as the basis for a CS situation analysis and as a tool for planning and implementation; and an overview of the findings, recommendations, lessons learned, activities, and progress made since the SPARHCS application. CS Context in Jordan POLICY and the MOH reviewed the demographic indicators, the history of donor financing of contraceptives, the FP market, and the economic and political environment in Jordan to understand the context related to achieving contraceptive security (MOH and POLICY, 2004). Demographic indicators. During the 1980s, Jordan experienced one of the highest population growth rates in the world, increasing by an average of 4.3 percent annually. From 1997–2002, the total fertility rate (TFR) declined from to 4.4 to 3.7 births per woman. Despite these recent fertility declines, Jordan’s TFR is well above the rates found in other Islamic countries such as Egypt, Indonesia, Iran, Malaysia, Morocco, Tunisia, and Turkey. The contraceptive prevalence rate (CPR) among married women of reproductive age (MWRA), ages 15-49, has increased slightly from 50 percent in 1997 to 53 percent in 2002. Disparities exist across economic groups in the use of modern methods—30 percent among Jordan’s poorest MWRA compared with 48 percent among Jordan’s wealthiest MWRA. Unmet need for family planning was 11 percent in 2002, declining from 14 percent in 1997 (JPFHS, 1997; JPFHS, 2002; Sharma and Almasarweh, 2004). History of donor financing of contraceptives. Since 1997, USAID has provided all the contraceptive commodity needs of the government and nongovernmental organizations (NGOs) in Jordan. However, the phaseout of USAID funding for contraceptive commodities will occur by 2008. The GOJ is working with USAID on a phaseout plan to gradually assume full responsibility for financing and procuring contraceptive commodities. FP providers and methods. The government, NGO, and commercial sectors actively participate in FP provision in Jordan (see Figure 1). In 2002, of those MWRA using family planning, reported sources of contraceptive methods included public facilities (34%), such as government hospitals, health centers, maternal child health clinics, the Royal Medical Services (RMS), Jordan University Hospital, and mobile clinics; the NGO Jordanian Association of Family Planning and Protection (JAFPP) (20%); commercial sector sources (38%), such as private hospitals, private doctors, and pharmacies; and other sources (8%), composed mainly of the United Nations Relief Works Agency (UNRWA) (Sharma and Almasarweh, 2004). [image: image2.emf]In 2002, among MWRA using a FP method, modern methods used included intrauterine devices (IUDs) (43%), oral contraceptives (OCs) (13%), condoms (6%), female sterilization (5%), lactational amenorrhea (LAM) (5%), and other methods (2%) (see Figure 2). Twenty-six percent of FP users chose traditional methods (JPFHS, 2002). Economic and political factors. In September 2000, the policy environment for family planning and reproductive health (RH) was significantly enhanced with His Majesty King Abdullah’s call for the revitalization of Jordan’s National Population Strategy and for the creation of a Reproductive Health Action Plan (RHAP) under the direction of the National Population Council (NPC). With the GOJ’s formal approval of RHAP’s first stage of development (2003–2007) and the 2002 reorganization of the NPC as the Higher Population Council (HPC), the stage was set for the introduction of contraceptive security as a principal element of the RHAP and for Jordan’s approach to coordinating all national population and RH programs under one agency. Jordan is classified as a lower middle-income country. Only 7 percent of Jordanians live on less than US$2 per day (PRB, 2005). Although Jordan is moving toward privatization and a free market economy, the GOJ still controls community and social services, including health services. The budget for the MOH is approximately 6 percent of the total government budget. The SPARHCS Application in Jordan Jordan began CS efforts in June 2002 at the request of the GOJ and USAID to address the eventual phaseout of contraceptive commodity donations. POLICY provided technical assistance in arranging key informant interviews—with representatives from pharmaceutical organizations, UNWRA, RMS, and medical and pharmaceutical consortia—and held meetings with stakeholders to raise the issue of contraceptive security and identify Jordan’s CS challenges. More efforts followed in November 2002, when the GOJ organized a large stakeholders’ meeting, with representation from the MOH; the ministries of planning, finance, and education; the JAFPP; and international organizations to diagnose the status of the country’s FP services and contraceptives and identify information sources and gaps in information needed to evaluate these issues. During this meeting, POLICY, CMS, and DELIVER introduced the SPARHCS framework. The objective of applying the SPARHCS framework as the basis for a situation analysis and planning was to support Jordan in further advancing its CS agenda, specifically in achieving a consensus around contraceptive security and a funded action plan for ensuring an adequate supply and choice of high-quality contraceptives that will meet client needs. Information gathering and compilation for the situation analysis lasted approximately 14 months and resulted in a briefing booklet. Key players. POLICY assisted with the situation analysis and compiled the information for the assessment into a briefing booklet. Two local consultants compiled information on FP accounts and procurement, respectively, to include in the booklet. Jordan’s CS Working Group (CSWG), initiated in 2003 by the GOJ, helped review the situation analysis, provide additional information, and formulate national CS recommendations. Information gathering. SPARHCS provided a framework to assemble the key findings that had been generated over the last five years by multiple organizations. In addition, SPARHCS highlighted gaps in information and data. Several studies were conducted to fill these gaps, including a policy analysis of barriers related to contraceptive security, an updated FP market segmentation analysis, and an evaluation of existing procurement and logistics systems for medicines/contraceptives (POLICY, 2004b; Sharma and Almasarweh, 2004; Touqan, 2004). In addition, POLICY and DELIVER prepared contraceptive commodity and cost projections through 2015, using Jordan’s own reporting system, with inputs drawn from national data and consumption data from DELIVER. From March 19–21, 2004, POLICY/Jordan and the MOH jointly held a “CS Issues Workshop” in Aqaba for a group of 44 multisectoral stakeholders. The objectives were to present the key findings from the SPARHCS assessment and identify and set priorities for CS issues in Jordan. The multisectoral group helped to validate, expand, and fine-tune findings, as well as identify the main CS issues in Jordan. The list of 18 CS issues was pared down to a shorter list of seven priority CS issues to be the focus of Jordan’s CS Strategic Plan. Findings and dissemination of results. The SPARHCS assessment culminated in the preparation of a “Contraceptive Security Briefing Booklet” that synthesized all available CS information (MOH and POLICY, 2004). The booklet was distributed to the workshop participants and is available from POLICY. In addition, POLICY prepared a workshop report that included a summary of the topics and the priority CS issues identified by participants (POLICY Project, 2004a). Overview of SPARHCS Findings SPARHCS revealed important issues in the areas of service delivery and use; market segmentation; financing; forecasting, procurement, and logistics; policy; and leadership and coordination that Jordan must face to achieve contraceptive security. Select findings from the CS briefing booklet are included below (MOH and POLICY, 2004). Service delivery and use. Technically, FP methods and services are accessible and affordable to most Jordanians, given the range of facilities and prices for services and methods. The public sector provides free FP services and methods to all those who want them. The JAFPP charges a nominal fee for FP services and provides free contraceptives. Commercial sector prices vary across types of providers. Other issues, however, affect people’s ability to access the kind of FP services they want and, thus, restrict access to family planning. A 1997 study of RH services in Jordan revealed that 75 percent of women visiting JAFPP clinics preferred to receive healthcare from female providers (Salah and Al-Qutob, 1997). The study revealed that there were not enough female physicians providing family planning to meet this demand. Physicians often lacked proper training and accurate information about methods. Furthermore, although family planning is known to be a cost-effective preventative intervention, health insurance companies, most self-insured firms, and the Social Security Corporation did not include FP services in the benefits packages they provided to their clientele (TOUQAN Management Consultants, 2000). The absence of operational policies at public facilities has inadvertently allowed for providers’ own policies and biases in FP counseling and provision of contraceptive methods (EngenderHealth/Jordan, 2002). Studies on policy and legal barriers to improved RH services revealed that physicians and other healthcare personnel face institutional barriers that limit the delivery of FP services. The MOH and the medical syndicate interpret a provision in the Public Health Law to mean that only licensed doctors of medicine may insert an IUD. Given the popularity of the IUD in Jordan, this provision could restrict access to preferred contraceptive methods (POLICY, 2004b; MRO, 2000). Market segmentation. In 2002, at least 31 percent and as much as 53 percent of government FP clientele could afford to pay commercial sector prices, while only about 47 percent were from the two poorest economic groups—those who rely on government subsidies to access family planning. These findings reveal an untapped potential for commercial products and services among wealthy users of subsidized products and the need for better targeting of resources to secure access to family planning by the poor. Resource targeting is particularly important in Jordan, as the public sector continues to rely on donor support for commodities. Since 1997, however, Jordan has improved public sector resource targeting efforts, resulting in a larger proportion of poor women benefiting from subsidized public sector services and methods; only 38 percent in 1997 of the poorest women obtained contraceptives from the public sector compared with 52 percent in 2002 (Sharma and Almasarweh, 2004). Finance. The GOJ finances its FP program expenses with a combination of donor, government, and household contributions. According to the recent National FP Accounts study, the GOJ spent an estimated US$36 million on family planning in 2002, which was 6 percent of the total health expenditures. The GOJ funded 47 percent of FP program expenditures, covering salaries, equipment, and buildings for FP services. Donors finance the majority of contraceptive commodity requirements of the FP program, as well as planning and training activities and facility upgrades, covering 26 percent of total FP program expenditures. Household contributions provided the remaining 27 percent of FP program expenses. When looking at how funds are distributed within the FP program, 82 percent is used for service delivery; 10 percent on training; 6 percent on information, education, and communication (IEC)/behavior change communication (BCC) activities; and 2 percent on research (POLICY, 2004c). Forecasting, procurement, and logistics. At the time of the SPARHCS assessment in 2004, the GOJ had not begun procuring contraceptives. When Jordan assumes full responsibility for procurement in 2008, it will continue to use the MOH’s well-functioning Jordanian Contraceptive Logistics System that manages the contraceptive supply chain in-country, distributes contraceptives to public and NGO sector recipients, maintains the logistics information system, and forecasts commodity requirements for each recipient for the coming year. Contraceptive needs are forecasted three years in advance and are based on consumption, adjustment and losses, and stock on hand. Ongoing site visits and physical inventories check the accuracy of reported data. Overall, the forecasting system is reliable and fully capable of determining commodity needs without donor assistance. The staff is well trained in contraceptive forecasting. Contraceptive distribution is based on monthly consumption reports received from service delivery points, and contraceptive stockouts rarely occur. Policy. Jordan received an FP policy environment score of 60 (out of 100) in 1997 and 65 in 2000; the highest scores were for policy formulation and political support, while the lowest scores were related to organizational structure (Almasarweh et al., 2000). However, when examining the implementation of the 1994 Cairo Program of Action during the 1990s, Jordan’s challenges were related to national policy and political support and included difficulties in identifying priority RH interventions to provide program guidance, initiating FP/RH program expansion, and mobilizing financial resources and a more effective use of existing resources (Hardee et al., 1999). More recently, with the 2002 ratification of the National Population Strategy and the RHAP 2003–2007—which promotes a multisectoral, participatory response to improved quality and access to FP/RH services and incorporates CS activities—Jordan is moving in a positive direction. In 2001, duties, tariffs, and sales tax on imported contraceptives were abolished by the government, making the commercial sector an affordable source for many potential FP clients and fostering a favorable policy environment for private sector expansion. Leadership and coordination. Contraceptive security in a resource-constrained setting requires a multisectoral, collaborative approach, based on joint action planning. In Jordan, improved coordination activities among donors and the public, NGO, and commercial sectors would enhance service delivery channels and facilitate the effective use of all available resources. Although the commercial sector is an active player in the provision of family planning, it is not considered a partner in service delivery by the government; the lack of active participation by the commercial sector in policy dialogue hampers program implementation. Although all sectors were represented in the national taskforce charged with developing the RHAP, they were not actively engaged in the preparation of the document. Priority Issues for Achieving Contraceptive Security Through an informed decisionmaking process and a vote, key stakeholders identified seven priority CS issues at the CS Issues Workshop in March 2004. Issues related to the areas of financing, procurement, FP use and demand creation, service delivery, policy and advocacy, logistics, and coordination and are ranked below, with the top priority issue listed first: Determine mechanisms for funding—for the next five years—all components of the FP program, including contraceptives, IEC/BCC activities, and research. Achieve effective contraceptive procurement for all sectors. Reduce unmet need and method discontinuation and improve access to family planning. Ensure sustained delivery of high-quality FP services and contraceptives. Raise awareness of contraceptive security among parliamentarians, religious leaders, young adults, males, teachers, and policymakers. Maintain and sustain an effective logistics system. Improve and maintain coordination among all partners (public sector, private sector, and donors). Lessons Learned Using SPARHCS in Jordan Valuable lessons have emerged from Jordan’s SPARHCS process, including the importance of conducting the assessment and creating a strategic plan to inform CS planning efforts in other countries. SPARHCS can frame and provide momentum to previous CS activities. In both Egypt and Jordan, SPARHCS did not initiate CS efforts, rather it provided structure and direction for how to move forward with CS agendas, namely in CS strategic planning. Teams used the SPARHCS framework as the basis for a situation analysis, synthesizing available information and data collected by multiple organizations but also determining gaps in information that needed to be filled by conducting new studies or consulting the appropriate stakeholders. Beginning the SPARHCS process prior to donor phaseout allows time for CS planning and mobilizing stakeholders. Having learned from other countries’ experiences with phaseout, Jordan has benefited from starting the CS planning process early, prior to imminent donor phaseout. As a result, Jordan has adequate time to carefully plan and formulate a CS strategy under local leadership, which will result in sustainable access to contraceptives. Multisectoral involvement in a national CS committee is valuable. Jordan’s CSWG is made up of a diverse set of stakeholders representing the public and private sectors and has provided critical momentum in moving Jordan’s CS agenda forward. One of the CSWG’s earliest activities was creating a consensus on the scope of work and next steps for devising the five-year strategic plan for achieving contraceptive security. In particular, early and consistent involvement of the Ministry of Finance was an important factor in Jordan’s ability to make progress on its plan and ensure its funding. Activities and Progress since the SPARHCS Application Since the assessment, Jordan has continued moving toward contraceptive security using the SPARHCS framework by conducting a strategic planning workshop, preparing a CS strategy, and setting the stage for advocating for approval of the strategy. Selected activities and progress include: In July 2004, His Majesty King Abdullah II re-enforced his government’s commitment to a proactive population program by stating, “…[D]espite what has been achieved in the past years in terms of economic growth averages, citizens did not feel such an increase in their standards of living. The reason for this could perhaps be the result of an alarming increase in the population growth rate, which obliterates any positive effect of average economic growth. A national campaign is needed to enhance family planning, regulate the increase in the population, in a manner that doesn’t contradict with our religious beliefs.” In November 2004, the GOJ undertook the challenge to assume full responsibility for contraceptive procurement beginning in 2008 by working with USAID to create a phaseout plan. The GOJ will start with the procurement of injectables in 2005 for delivery starting in 2006 and add a new method each year (condoms, IUDs, and OCs). POLICY and DELIVER conducted a CS Strategic Planning Workshop in Aqaba, from March 25–27, 2005. Forty-seven participants, representing the commercial sector, NGOs, government organizations, and the CSWG, drafted the Contraceptive Security Strategic Plan 2005–2008 for Jordan. It included a plan for donor phaseout and was designed to fit into the RHAP. Also in early 2005, POLICY, in collaboration with DELIVER, HPC, and MOHP, conducted meetings with CSWG members to identify the strengths and limitations of the current logistics system in managing the range of contraceptive commodities required to support the various programs in operation throughout Jordan. The goal of the meetings were to lay a foundation to ensure the long-term availability of products by highlighting the policy, financing, and management issues that affect commodity procurement, distribution, and use. POLICY assisted the HPC in facilitating CS activities during April–June 2005, which included meetings for CSWG, the CS Strategy Steering Committee (coordinated by the HPC), and the CS strategy component subcommittee to incorporate the strategy under RHAP and to complete the draft CS strategy document in English and Arabic. A follow-up meeting was held from June 23–25 in Aqaba to revise the five CS strategy components for 2005–2008, which include information systems development, financial sustainability, advocacy/behavior change, policy development, and coordination. Forty-two participants took part in the meeting, refining each component’s objectives, activities, and key players and coming to consensus on the next steps required to finalize the strategy before the end of 2005. In July 2005, after negotiations with two suppliers, the GOJ successfully conducted its first contraceptive procurement with Organon—of injectables at competitive prices. Such a success is promising for the procurement of other contraceptive commodities that are in higher demand, such as IUDs. In August 2005, POLICY participated in HPC’s meetings to discuss the final draft of the CS strategy and determine its corresponding financial requirements. At these meetings, the Ministry of Finance reiterated its plan to provide the needed funds. In November 2005, the HPC, with POLICY’s assistance, facilitated a CS Symposium, during which key stakeholders reviewed and reached consensus on the Jordan CS strategy that, being integrated into the RHAP, specifies the activities the GOJ will undertake during 2005–2008 in moving toward contraceptive security by 2020. Capacity building activities in advocacy, use of data, and strategic planning have also occurred to further build Jordan’s progress toward contraceptive security. Jordan’s commitment to achieving contraceptive security is clear in its early initiation of dialogue and fostering of multisectoral participation around CS issues. With the implementation of its strategic plan, Jordan will be on track to achieving contraceptive security in the near future. References: Almasarweh I., H. Amr, and J. Stover. 2000. The Policy Environment Score: Measuring the Degree to Which the Policy Environment in Jordan Supports Effective Policies and Programs for Reproductive Health. Amman, Jordan: Jordan National Population Commission and the POLICY Project. Department of Statistics (Jordan) and ORC Macro. 1998. Jordan Population and Family Health Survey (JPFHS) 1997. Calverton, MD: Department of Statistics and ORC Macro. Department of Statistics (Jordan) and ORC Macro. 2003. Jordan Population and Family Health Survey (JPFHS) 2002. Calverton, MD: Department of Statistics and ORC Macro. EngenderHealth/Jordan. 2002. Jordanian Providers’ Knowledge, Attitudes, and Practices Regarding Female Sterilization and Long-acting Hormonal Methods. Amman, Jordan: Engender Health/Jordan. Hardee, K, K. Agarwal, N. Luke, E. Wilson, M. Pendzich, M. Farrell, and H. Cross. 1999. “Reproductive Health Policies and Programs in Eight Countries: Progress since Cairo.” International Family Planning Perspectives 25: S2-S9. Market Research Organization (MRO). 2000. Analysis of Policy and Legal Barriers to Improved Reproductive Health Services in Jordan. Amman, Jordan: POLICY Project. Salah, M. and R. Al-Qutob. 1997. Integration of Reproductive Health Services within the JAFPP Clinics. Amman, Jordan: The Family Health Group. Ministry of Health and POLICY. 2004. Jordan: Contraceptive Security Briefing Booklet. Amman, Jordan: Futures Group/POLICY Project. POLICY Project. 2004a. CS Issues Workshop Report. Aqaba, March 19–21, 2004. Washington, DC: Futures Group/POLICY Project. POLICY Project. 2004b. Barriers to Improved Reproductive Health Programs and Required Policy Reform in Jordan. Washington, DC: Futures Group/POLICY Project. POLICY Project. 2004c. Jordan Family Planning Accounts. Draft. Population Reference Bureau (PRB). 2005 World Population Data Sheet. Washington, DC: PRB. Sharma S. and I. Almasarweh. 2004. Family Planning Market Segmentation in Jordan: An Analysis of the Family Planning Market in Jordan to Develop an Effective and Evidence-based Strategic Plan for Attaining Contraceptive Security. Washington, DC: Futures Group/POLICY Project. Touqan, K.J. 2004. Existing and Potential Procurement Mechanisms in the MOH, RMS, UNRWA, JUH, and JAFPP. Amman, Jordan: POLICY Project. TOUQAN Management Consultants. 2000. Cost-Benefit Analysis Study of Family Planning in the Context of Health Insurance in Jordan. Amman, Jordan: POLICY Project. 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 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 following brief outlines the experience of using the SPARHCS tool in assessing contraceptive security in Jordan. Overall, SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions. � This section reviews the CS context at the time of the SPARHCS application. All progress since 2004 is reported in the section titled “Activities and Progress since the SPARHCS Application.” � Jordan has approximately 5.8 million inhabitants—79 percent of whom reside in urban areas. Women of reproductive age make up approximately 26 percent (1.5 million) of the population (PRB, 2005). � Jordan’s CSWG comprises a multisectoral group of stakeholders from, among other agencies, the Ministry of Health; the Ministry of Labor; the Ministry of Religious Affairs; the Ministry of Education; the Ministry of Finance; the Higher Youth Council; the Royal Medical Services; the United Nations Relief Works Agency; the Private Sector’s Hospital Association; and the Jordan Association for Family Planning and Protection, an agency representing NGO FP healthcare providers. � Created by USAID’s DELIVER Project. PAGE 8
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