Assessing Contraceptive Security in Nicaragua- SPARHCS
Publication date: 2006
[image: image1.emf] Documentation of the Use of SPARHCS: Nicaragua 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 February 2004, with input from Nicaragua’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 third of five rapid 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 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. The technical assistance will build capacity within Nicaragua and in the LAC region to address CS issues in the short, medium, and long term. This brief describes the Nicaragua CS context and SPARHCS assessment and the findings and recommendations, lessons learned, and activities and progress made since the SPARHCS application. CS Context in Nicaragua 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 Nicaragua to understand the context related to achieving contraceptive security (Taylor et al., 2004). Demographic indicators. The contraceptive prevalence rate (CPR) for all methods among married women of reproductive age (MWRA), ages 15–49, increased from 50 percent in 1992 to 69 percent in 2001. Increases in the CPR for MWRA in rural areas during the same time period were dramatic—from 32 percent to 62 percent. Among all MWRA, the CPR for modern methods increased from 45 percent in 1992 to 66 percent in 2001. In 2001, however, unmet need for family planning in Nicaragua measured 15 percent and higher among poor (25 percent) and rural (18 percent) women (Encuesta sobre Salud Familiar, 1992–1993; ENDESA, 2001). History of donor financing of contraceptives. Nicaragua’s Ministry of Health (MINSA) FP program has received contraceptives from donors for nearly 30 years and remains one of the few ministries of health in the LAC region still receiving its entire contraceptive supply from donors, including USAID and the United Nations Population Fund (UNFPA). USAID will continue to provide MINSA with contraceptive commodity donations for up to 10 more years, with gradual reductions in the amount each year. Until 2005, USAID also donated contraceptive commodities to the nongovernmental organization (NGO), PROFAMILIA, for its social marketing program. At the time of the SPARHCS assessment, there was a general lack of awareness among MINSA decisionmakers, NGOs, and other donors regarding USAID’s planned phaseout of contraceptive commodities. UNFPA has also donated contraceptive commodities to MINSA in the last decade, but in 2006, will gradually reduce these donations until 2008–2009 (Taylor et al., 2004; DELIVER, 2005). FP providers and methods. In 2001, Nicaragua’s MINSA was the main provider of family planning in the country, serving 64 percent of FP users (see Figure 1) with free contraceptive methods. The remaining FP users consulted NGOs (14 percent), pharmacies (12 percent), private hospitals and clinics (7 percent), and other sources (3 percent) for their contraceptives (ENDESA, 2001). [image: image2.emf]Nicaragua’s method mix is composed mainly of modern methods, and FP clients have a range of available methods to choose from. Among those using family planning in 2001, 36 percent used female sterilization, 21 percent used oral contraceptives (OCs), 21 percent used injectables, 9 percent used intrauterine devices (IUDs), 5 percent used condoms, 4 percent used traditional methods, and 4 percent used other methods (see Figure 2) (ENDESA, 2001). Economic and political environment. Nicaragua has a policy environment that is supportive of family planning. The Constitution guarantees the right to reproductive healthcare and universal access to basic health services. Within MINSA, the Minister of Health and the Director of Primary Care have consistently supported the national FP program. Now, MINSA is undergoing health sector reform, which will have significant effects on contraceptive security. Activities have included the adoption of an Integrated Healthcare Model and the Law of General Health and the integration of the supply system for essential drugs and contraceptives. Further decentralization of functions may require greater advocacy and awareness raising at the departmental level on the importance of family planning. According to Nicaragua’s 2001 National Survey on Measuring Lifestyle, 46 percent of the population is poor—of which 15 percent is extremely poor (EMNV, 2001). Internal migration has had a negative effect on the overall economy, as Nicaraguans are clustering in the western, urban parts of the country. These economic issues create challenges to contraceptive security, as they restrict the government’s capacity to invest resources in family planning. The SPARHCS Assessment in Nicaragua The SPARHCS assessment in Nicaragua, conducted from February 2–13, 2004, articulated the country’s national objectives, including identifying barriers to achieving greater contraceptive security in both the public and private sectors; raising awareness among decisionmakers about the need for coordinated action to overcome barriers impeding progress toward contraceptive security; and recommending interventions or strategies that would assist in reaching donor independence while, at the same time, protecting gains made in reproductive health within the last decade. Key players. The SPARHCS team included five individuals from DELIVER and POLICY and two individuals from PROFAMILIA and Management Sciences for Health (MSH)/Management and Leadership. The SPARHCS team relied on the input of representatives from MINSA at the central and departmental levels, the Ministry of Finance, the Secretariat of the Presidency, six local NGOs, and USAID/Nicaragua. The CS committee in Nicaragua, formed after the 2003 LAC Regional CS Conference in Managua, played a valuable role in planning and preparing for the SPARHCS assessment, including identifying interviewees and arranging meetings for the SPARHCS team. At the end of the assessment, the CS committee assisted the team in reviewing SPARHCS assessment findings and refining national CS recommendations. Information gathering. The SPARHCS team gathered information through a document review, interpersonal interviews, site visits to four regions, and debriefings with USAID and CS committee members. Contraceptive commodity and cost projections through the year 2015 were prepared using Spectrum software, with inputs drawn from available national data. Findings from a contraceptive logistics analysis of service delivery points conducted by DELIVER were integrated into the assessment (Beteta et al., 2003). Findings and dissemination of results. After completing the SPARHCS assessment, the team presented the preliminary findings to the CS committee. Because time limitations did not allow for jointly formulating country-level recommendations, the SPARHCS team formulated recommendations and the CS committee provided comments and suggestions for refining the recommendations at a later time. The SPARHCS team developed an in-depth assessment report in Spanish and a summary report, titled “Contraceptive Security in Nicaragua: 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 evidence of progress made toward contraceptive security but also revealed challenges in the areas of financing, market segmentation, procurement, logistics, and policy and political commitment that Nicaragua must address to achieve contraceptive security (Taylor et al., 2004). Financing. MINSA has not yet begun purchasing contraceptives. To meet the contraceptive requirements of its current market share, MINSA must begin purchasing contraceptives and increase its budget amount for contraceptives each year. By 2015, MINSA’s annual budget requirement would need to reach more than US$1.3 million if purchasing contraceptives at low prices and up to US$4.2 million if purchasing at intermediate prices. Given Nicaragua’s economic challenges and restrictions levied by the International Monetary Fund and World Bank on growth of the government’s recurrent cost budget, there is concern that MINSA will have difficulty assuming financial responsibility for contraceptives soon enough to avoid funding gaps. Market segmentation. MINSA’s market segmentation could be improved to make better use of its limited resources. Only one-third of MINSA’s FP clientele are poor, while the remaining two-thirds are from middle and upper economic groups, which could feasibly pay for some or all of incurred FP costs. MINSA also assumes the burden of providing services to Social Security affiliates, of which 43 percent who use family planning obtain their contraceptives from MINSA. As donated contraceptives are phased out, overdependence on MINSA will make the contraceptive market vulnerable both to changes in government administrations and to fluctuations in the national economy. The private sector could expand to serve the needs of those who are able to pay from the upper economic groups, and the Social Security Institute (INSS) could enhance its efforts to reach its affiliates with FP products and services. Procurement. Even though MINSA has not begun contraceptive procurement, it has the appropriate established systems and procurement experience. Each year, MINSA works with UNFPA and USAID to estimate contraceptive needs and prepares both short- and long-term procurement plans based on consumption and stock levels. Existing national procurement regulations may make it difficult for MINSA to procure contraceptives at the international level, which would be the most cost-effective procurement option. Purchasing contraceptives from Nicaraguan distributors is much more expensive than purchasing them from UNFPA or the International Planned Parenthood Federation. If national-level procurement is required, MINSA will need additional financial resources to procure the desired amounts of contraceptives. Logistics and information systems. In the late 1990s, inappropriate use of data and inadequate donor coordination resulted in frequent stockouts of some products and overstock of others in MINSA’s contraceptive supply. In 2000, to correct these inefficiencies, MINSA created a new contraceptive logistics policy and logistics information and administration system. In 2003, MINSA began the integration of the existing contraceptive logistics and essential drugs systems to create one system for storage and distribution. While the process is going well, the complications of integrating supply systems should not be underestimated. A next step will be to design a single system for monitoring, evaluating, and supervising contraceptive and essential drugs use. Policy, political commitment, and leadership. Nicaragua’s policy framework and political environment are supportive of family planning. The Constitution guarantees individuals’ rights to reproductive healthcare services and access to health services. The National Development Plan aims to reduce unmet need for family planning. The principal priority of the National Health Strategy is the reduction of maternal mortality, under which access to family planning is the first pillar. The National Sexual and Reproductive Health Program ensures the delivery of high-quality reproductive healthcare. Existing policy barriers could impede progress toward contraceptive security by restricting access to contraceptive methods for those who may want them. While the INSS service package will begin to include family planning, only INSS enrollees and not their beneficiaries will be covered with FP services. Also, women seeking permanent contraceptives in the public sector need a husband’s signature. Notably, spousal permission is not a feature of the Law of General Health, enacted in 2004, or the National Sexual and Reproductive Health Program. Finally, most, but not all, of the contraceptives currently provided by MINSA appear on the essential drugs list. Main Recommendations for Achieving Contraceptive Security The Nicaragua SPARHCS assessment helped to identify many potential interventions for increasing contraceptive security. These were grouped into five priority strategies: Allocate the national budget and increase funding for contraceptives to cover the imminent funding gap as USAID and UNFPA phase out contraceptive donations. Assist MINSA in procuring contraceptives at low prices through international procurement. Target MINSA’s limited resources for FP provision to vulnerable populations and encourage greater involvement of the private sector in FP provision for those clients who are willing and able to pay. Ensure sustainability and maintain effectiveness of MINSA’s contraceptive logistics system as it is integrated with the essential drugs management system. Strengthen the CS committee as an important body for influencing policy. Lessons Learned Using SPARHCS in Nicaragua Important lessons emerged from Nicaragua’s SPARHCS assessment that can be used to inform SPARHCS assessments in other countries. Because some members of the Nicaragua team went on to become 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. 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 Nicaragua. Draw on the SPARHCS framework as a guide. In Nicaragua, 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., NGOs, MINSA), depending on which would have the necessary information. The Nicaragua SPARHCS team 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, health facility data, 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. Involve national CS committees in all stages of the assessment process. In the five LAC countries, CS committees have provided valuable assistance to SPARHCS teams in preparing for assessments, revising and fine tuning findings and recommendations, and planning how to use them to move CS activities forward in-country. Activities and Progress in Nicaragua since the SPARHCS Application SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions. The SPARHCS assessment found evidence of progress made toward contraceptive security in Nicaragua, such as a political framework in support of family planning, strong leadership from MINSA, a high CPR for modern methods, an active NGO sector, and a good contraceptive logistics system. Selected activities and progress include the following: With eight other countries, Nicaragua participated in the CS LAC Regional Forum held in October 2004 in Lima, Peru. The CS committee created strategies to ensure that MINSA guarantees financing for the procurement of contraceptives and that INSS follows through with providing family planning to its insured population; to improve the inter-institutional coordination between the different sectors and encourage political commitment for market segmentation; to identify procurement mechanisms that take advantage of economies of scale; and to ensure the sustainability and efficacy of the contraceptive information system within the process of integrating information systems. DELIVER and POLICY conducted an in-depth procurement options analysis for Nicaragua, 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 completed an in-depth market segmentation analysis, using Nicaragua’s 2001 Demographic and Health Survey, the most current survey data available. Analysis of logistics indicators reveals that coordination of logistics functions in the public sector continues to improve even in the face of increased demand for contraceptives. In 2004, 94 percent of public sector FP providers maintained the range and quantity of products required to serve the contraceptive needs of clients, up from 84 percent of providers in 2003 and 38 percent in 2002. MINSA is assessing, with technical assistance from DELIVER, whether to integrate its nine separate product management systems into a single system, which would be less costly to manage, or maintain the nine systems because each is organized around the specific product needs. Since the SPARHCS application, efforts have been made to increasingly involve other sectors in FP provision. Discussions have begun on how the INSS can become more involved in providing family planning to the many MINSA clients employed in the formal sector and eligible for Social Security Health Insurance. The Law of General Health, in place since 2004, now describes public contribution to the cost of healthcare and medicines as civic responsibility, potentially allowing MINSA an opening to recover more costs. This proposed change may also result in an increased opportunity for the private sector, because those willing to pay for family planning may shift from MINSA to the private sector to purchase their contraceptive methods. As part of the LAC CS Initiative, Nicaragua will continue to take part in activities through 2006 to advance progress toward contraceptive security. DELIVER and POLICY will provide technical assistance to increase momentum. Main activities include capacity building on the use of data for projections and CS advocacy and CS strategic planning. These activities will ensure that Nicaragua can continue advancing toward contraceptive security after 2006. References Beteta, W., F.M. Cardoza, C. Arauz, and C. Basurto. 2003. Tercera Evaluación Anual Cuantitativa de Indicadores Logísticos. Arlington, VA: John Snow, Inc., DELIVER. DELIVER. 2005. “Sustaining Family Planning Successes in Nicaragua.” Arlington, VA: John Show, Inc. Instituto Nacional de Estadísticas y Censos (INEC). 2001. Encuesta Nacional de Hogares sobre Medición del Nivel de Vida 2001 (EMNV, 2001) [National Household Survey on Measuring Lifestyle]. Managua, Nicaragua: Instituto Nacional de Estadísticas y Censos. Instituto Nacional de Estadísticas y Censos (INEC) and Ministerio de Salud, República de Nicaragua (MINSA). 2002. Encuesta Nicaragüense de Demografía y Salud 2001 (ENDESA, 2001). Columbia, MD: ORC Macro. Instituto Nacional de Estadísticas y Censos (INEC) and Ministerio de Salud, República de Nicaragua (MINSA). 1999. Encuesta Nicaragüense de Demografía y Salud 1998 (ENDESA, 1998). Columbia, MD: ORC Macro. Population Reference Bureau (PRB). 2005. 2005 World Population Data Sheet. Washington, DC: PRB. PROFAMILIA, Centers for Disease Control and Prevention (CDC), and the Department of Health and Human Services. 1993. Encuesta Sobre Salud Familiar, 1992–1993 [National Family Health Survey, 1992–1993]. Managua, Nicaragua: CDC and the Department of Health and Human Services. Taylor, P.A., C. Arauz, G. Subiria, C. Cisek, J.A. Medrano, D. Fuentes, D. Sarley, L. Patykewich, and A. Karim. 2004. Nicaragua: Contraceptive Security Assessment, February 2–13, 2004. Arlington, VA: John Snow, Inc., DELIVER, and Washington, DC: Futures Group, 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 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 addressed in light of the phase out of contraceptive supply donations. The initiative, being implemented by the POLICY and DELIVER Projects, is now in its third year of activities. � Nicaragua’s population is 5.8 million, with 59 percent living in urban areas (concentrated in the western part of the country) (PRB, 2005). The number of women of reproductive age will increase to almost 2 million by 2015. � Includes both women married legally and by common law. � The CS committee includes representatives from the women’s health division, Programa de Atención Integral a la Mujer (AIM), of the Ministry of Health; the Social Security Institute (INSS); local NGOs, including PROFAMILIA and NicaSalud; and MSH/Management and Leadership; JSI/DELIVER; UNFPA/Nicaragua; and USAID/Nicaragua. � 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.rhsupplies.org/fileadmin/user_upload/toolkit/Drafts/www.policyproject.com"��www.policyproject.com�; �HYPERLINK "http://www.rhsupplies.org/fileadmin/user_upload/toolkit/Drafts/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 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 8
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