Common Advocacy Plan for Expanding Contraceptive Choice in India

Publication date: 2013

COMMON ADVOCACY PLAN FOR EXPANDING CONTRACEPTIVE CHOICE IN INDIA February 2013 This document was prepared by Tanya Liberhan, Nirupa Rangaiah, Heer Chokshi, Himani Sethi, and Priya Emmart of the Health Policy Project based on the proceedings of the Spitfire Strategic Planning Workshop organised on December 4–5, 2012, along with ARC and civil society partners. HEALTH POL ICY P R O J E C T Photo credit (cover): Health Policy Project, India ISBN: 978-1-59560-013-4 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (CEDPA is now a part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Suggested citation: Liberhan, T., N. Rangaiah, H. Chokshi, H. Sethi, and P. Emmart. 2013. Common Advocacy Plan for Expanding Contraceptive Choice in India. Gurgaon: Futures Group, Health Policy Project. Common Advocacy Plan for Expanding Contraceptive Choice in India February 2013 The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. i CONTENTS Acknowledgements . ii   Abbreviations . iii   Background . 1   Rationale for Expanding Contraceptive Choice . 1   ARC National Task Force on Expanding Contraceptive Choices . 1   Section 1 . 3   Setting The Stage: Using Spitfire SMART CHART Communications to Develop a Common Advocacy Plan . 3 Civil Society Partners Develop a Common Advocacy Plan to Expand Contraceptive Choices in India . 4 Section 2 . 6   Common Advocacy Plan: “Contraceptive choices expanded with increased spacing methods and increased access to current methods of spacing” . 6 Unpacking “Choice”—Agreed Definition for Common Advocacy Plan . 7 Common Advocacy Plan . 8 Goal. 8   Objectives . 8   Increasing Methods of Spacing for Expanded Choice . 8   Increasing access to current methods . 14   Next Steps . 25   Appendix 1: List of Participants . 26   Appendix 2: Agenda for Two-day Strategic Workshop . 27   ii ACKNOWLEDGEMENTS This report is a compilation of the common advocacy plan developed by the Advocating for Reproductive Choices (ARC) National Task Force on Expanding Contraceptive Choices. The plan is based on the application of Spitfire SMART CHART Communications Tools1 during a two-day residential strategic planning workshop. ARC organised the workshop with support from the Health Policy Project (HPP), which is funded by the United States Agency for International Development (USAID). ARC thanks HPP for assisting with the strategic planning workshop and compile the common advocacy plan. In addition, we would also like to thank the Advance Family Planning Project (AFP) for providing technical support and facilitating the workshop. We are grateful to Dr Suneeta Mittal, Chairperson of the ARC National Task Force on Expanding Contraceptive Choices; Dr PK Shah, President of the Federation of Obstetric and Gynaecological Societies of India (FOGSI); Dr RK Srivastava of the Policy Unit, National Institute of Health and Family Welfare (NIHFW); and Dr Bitra George of FHI 360 for providing valuable input during the workshop. We also thank Dr Suneeta Sharma, Managing Director, Futures Group India, and Dr Meera Misra, Country Coordinator at the International Fund for Agricultural Development (IFAD), for reviewing the plans and providing valuable suggestions and technical inputs. Several individuals contributed to the drafting and review of this report, including Tanya Liberhan, Himani Sethi, Nirupa Rangaiah, Heer Chokshi, and Priya Emmart of the HPP; and Dr Manisha Bhise of the ARC and the Family Planning Association of India (FPAI). Finally, we thank Futures Group; FHI 360; FPAI; Marie Stopes India (MSI); Population Health Services India (PHSI); Population Foundation of India (PFI); Policy Unit, NIHFW; Citizens’ Alliance; and Jansankhya Sthirata Kosh (JSK) for participating in the workshop and providing input and time in the development of the common advocacy plan. We are confident that ARC will be able to synergise and amplify the strengths of all its members and advocate as a collective to expand contraceptive choice. 1The Communications Leadership Institute developed the Spitfire SMART CHART Communications Tools, which are used by various institutions to make family planning advocacy more strategic and locally owned. ABBREVIATIONS AFP Advance Family Planning Project ARC Advocating Reproductive Choices DCGI Drug Controller General of India DMPA depot medroxyprogesterone acetate EAG empowered action group FOGSI Federation of Obstetric and Gynaecological Societies of India FP family planning FPAI Family Planning Association of India GOI Government of India HPP Health Policy Project IFAD International Fund for Agricultural Development IMA Indian Medical Association IUCD intrauterine contraceptive device JSK Jansankhya Sthirtha Kosh MDG Millennium Development Goal MOHFW Ministry of Health and Family Welfare MSI Marie Stopes India NET-EN norethisterone enanthate NHSRC National Health Systems Resource Centre NIHFW National Institute of Health and Family Welfare NRHM National Rural Health Mission PFI Population Foundation of India PHSI Population Health Services India PIP programme implementation plan POP progestogen-only pill PPP public-private partnership PSI Population Services International RCH reproductive and child health SDM standard days’ method TFR total fertility rate USAID United States Agency for International Development iii 1 BACKGROUND India is undergoing a fundamental change in the way family planning (FP) services are being conceptualised and delivered. This change was most visibly represented at the London Family Planning Summit in July 2012, when the Government of India (GOI) committed to “a paradigm shift in our whole approach to FP with key emphasis now being laid on the provision and promotion of spacing methods.” There is increased funding for FP under the Twelfth Five Year Plan. A vibrant coalition of civil society organisations called Advocating Reproductive Choices (ARC) explicitly supports the government’s paradigm shift. The ARC National Task Force on Expanding Contraceptive Choices, with support from the Health Policy Project (HPP), came together to develop a common advocacy plan to make the government’s commitments a reality. Rationale for Expanding Contraceptive Choice The impact of expanding contraceptive choice on expanding contraceptive use and maternal health benefits is well established in the literature. For each additional contraceptive method made widely available in a country, the percentage of married women using contraception increases by an average of 3.3 percentage points, according to analysis of data from demographic and health surveys in 44 countries. In considering which methods to offer, programmes should keep in mind that there is no perfect mix of methods. In general, programmes should strive to offer as many contraceptive methods as they can reliably supply to meet the needs of individuals and couples. A reasonable mix includes methods that are short acting and long acting, client controlled and provider dependent, and natural and clinical. The contraceptives currently contained in the World Health Organization (WHO) Model List of Essential Medicines are oral contraceptives (combined and progestin-only), emergency contraceptive pills, progestin-only injectable contraceptives (norethisterone enanthate [NET-EN] and depot medroxyprogesterone acetate [DMPA]), copper intrauterine devices (IUDs), barrier methods (condoms and diaphragms), and Levonorgestrel implants. Under the National Rural Health Mission (NRHM), there is a basket of contraceptive options available for clients. The Ministry of Health and Family Welfare (MOHFW) is looking into improving the last-mile supply chain efficiencies but has a long way to go. The current basket of choices is still limited, and there are many contraceptive methods that have not found a place in the national FP programme. For example, injectable contraceptives have been in use by registered medical practitioners in India for decades—NET-EN since 1986 and DMPA since 1993. Today, several leading nongovernmental organisations (NGOs), professional bodies, and private medical practitioners provide injectable contraceptives—mostly DMPA—along with other available contraceptives. But, to date, injectable contraceptives are not part of the public health programme due to resistance from many health activists and women’s groups in India centred around concerns of adverse health consequences for women and inadequate public health infrastructure for counselling and follow-up. Postpartum FP is also part of the paradigm shift and is associated with the rapid expansion of institutional births made possible through NRHM’s investments in maternal health. At present the GOI emphasises the role of postpartum intrauterine contraceptive device (PPIUCD) services to expand choice beyond sterilisation. This will require a rapid scale-up of providers available to counsel and insert IUCDs, facility readiness, and strong support for referrals and monitoring by auxiliary health workers. Currently, postpartum FP does not explicitly include other spacing methods, which restricts choice for women who are interested in non-clinical or even non-hormonal methods. ARC National Task Force on Expanding Contraceptive Choices Initiated in 2005, ARC is a coalition of civil society organisations primarily working in the field of sexual and reproductive health (RH). ARC makes concerted and sustained advocacy efforts to enhance accessibility and expand contraceptive choices. Its advocacy initiatives primarily focus on addressing issues related to unmet need for contraception. ARC aims to expand contraceptive choices Common Advocacy Plan for Expanding Contraceptive Choice 2 for the Indian population by widely promoting and making available safe, effective, and high-quality contraceptives in the public and private health service delivery system at affordable costs. The coalition’s key objectives include repositioning FP at the national level in the context of maternal health outcomes and strengthening the coalition at both the national and state level. ARC has formed the National Task Force on Expanding Contraceptive Choices. The task force is chaired by Dr Suneeta Mittal and comprises representatives from Abt Associates, Futures Group, Population Services International (PSI), Janani, FHI 360, Family Planning Association of India (FPAI), Marie Stopes India (MSI), Parivar Seva Sansthan, and Population Health Services India (PHSI). The task force has identified its objective—to advocate inclusion of new and underutilised long-term reversible methods. The focus will be on progestin-only injectable contraceptives, combined injectable contraceptives, implants, and reversible inhibition of sperm under guidance, commonly known as non-surgical reversible vasectomy. The consortium met in September 2012 for a one-day stakeholder consultation, supported by FHI 360 and MSI through the United States Agency for International Development (USAID) on “Expanding Contraceptive Choice in India, with a focus on new and underutilised methods.” The Global FP Summit in London provided momentum for revitalising the FP programme and renewing commitments by GOI and the donor community (the Bill & Melinda Gates Foundation, USAID, and the U.K. Department for International Development [DFID]). In this context, the coalition met to share global evidence and experiences on new contraceptive methods; inform, consult, and influence partners/stakeholders by sharing scientific clinical updates and technical feasibility of new contraceptives through relevant experts; identify priority areas for advocacy and create an environment to deliver shared policy outcomes around contraceptive choices; and share in-country experiences and best practices on increasing uptake of underutilised contraceptive methods. One of the next steps and a key recommendation identified for the coalition was the need for a common advocacy strategy for expanding contraceptive choices. 3 SECTION 1 SETTING THE STAGE: USING SPITFIRE SMART CHART COMMUNICATIONS TO DEVELOP A COMMON ADVOCACY PLAN 4 CIVIL SOCIETY PARTNERS DEVELOP A COMMON ADVOCACY PLAN TO EXPAND CONTRACEPTIVE CHOICES IN INDIA ARC, with HPP support, brought together 20 consortium members and project partners to develop a common advocacy plan using Spitfire SMART CHART Communications Tools.2 A two-day residential strategic planning workshop was held from December 4–5, 2012, in Tarudhan Valley, Manesar. HPP drew on the technical competencies of the Advance Family Planning Project (AFP)3 to facilitate the workshop. Facilitators from HPP and AFP led the process by building focus, commitment, and consensus among consortium partners on a common advocacy issue. By the end of two days, the consortium members had identified key areas for policy advocacy that have the potential to become advocacy wins for ARC in the near term, identified the relevant key stakeholders, and developed action plans. Within the broader goal of expanding contraceptive choices, the key advocacy areas include increased spacing methods and increased access to current methods of spacing. Aligning themselves to the GOI’s commitment to focus on spacing and expanding access to current methods of spacing, the consortium identified the following areas of policy advocacy action for the next 12 months: • Increasing funding for spacing methods vis-à-vis permanent methods in accordance with the unmet need for spacing methods, as part of the health budget in the states; • Fostering intersectoral collaboration between the Federation of Obstetric and Gynaecological Societies of India (FOGSI) and the government to improve the quality of family planning services; • Promoting postpartum spacing contraception in the private sector in partnership with FOGSI; and • Advocating for inclusion of the progestogen-only pill (POP) in the national FP programme. The Spitfire SMART CHART Communications tool was designed specifically for nonprofits, civil society organisations, and foundations to strategically guide them through the steps of developing advocacy plans. During the workshop, the SMART CHART tools steered the discussions and planning process through key strategic decision areas to frame a smart strategy to reach the goal of expanding contraceptive choice. SMART CHART helped the group to develop their action plans by taking them through six major strategic decision sections: 1. Program Decisions (Broad Goal, Objective, Decision Maker) 2. Context (Internal and External Scans and Position) 3. Strategic Choices (Audience, Readiness, Core Concerns, Theme, Message, and Messenger) 2 The Advance Family Planning Project (AFP) adapted the Spitfire SMART CHART Communications Tools to make family planning advocacy more strategic and locally owned. The Communications Leadership Institute developed these tools. 3 The Advance Family Planning Project is supported by the Bill and Melinda Gates Institute for Population and Reproductive Health and the David and Lucile Packard Foundation. Futures Group is a partner and works in Africa through the project. In India, the Population Foundation of India is the project partner. Civil Society Partners Develop a Common Advocacy Plan to Expand Contraceptive Choices in India 5 4. Communications Activities (Tactics, Timeline, Assignments, and Budget) 5. Measurements of Success 6. Final Reality Check An in-depth exercise of scanning the external environment to gauge the opportunities and threats; assessing the internal strengths and weaknesses and subsequently framing the context; identifying target audiences; making strategic choices; zeroing in on advocacy activities; appropriate messaging, and messengers; and measuring success was undertaken. The exercise also focused on a reality check to assess the feasibility of the developed plan. The workshop was attended by senior experts and technical specialists, including Dr Suneeta Mittal, Chairperson of the ARC National Task Force on Expanding Contraceptive Choices; Dr PK Shah, President of FOGSI; Dr RK Srivastava, of the Policy Unit; Dr Bitra George, Country Director at FHI 360, and Dr Amit Shah, FP/RH Advisor for USAID, who provided guidance and support to the participants in developing attainable and realistic plans. The consortium members were motivated to contribute towards the implementation of the advocacy plans, offering their organisations’ technical expertise. With vast experience in the field of advocacy for FP and RH, Dr Suneeta Sharma, Managing Director at Futures Group India, and Meera Mishra, Country Coordinator for the International Fund for Agricultural Development (IFAD), reviewed and critiqued the advocacy plans during the last session. Consortium Members and HPP Partners at the Workshop Family Planning Association of India (FPAI) FHI 360 Federation of Obstetric and Gynecological Societies of India (FOGSI) Population Foundation of India (PFI) Marie Stopes India (MSI) Population Health Services India (PHSI) Futures Group Policy Unit, National Institute of Health and Family Welfare (NIHFW) Citizens’ Alliance for Reproductive Health and Rights Jansankhya Sthirata Kosh (JSK) 6 SECTION 2 COMMON ADVOCACY PLAN: “CONTRACEPTIVE CHOICES EXPANDED WITH INCREASED SPACING METHODS AND INCREASED ACCESS TO CURRENT METHODS OF SPACING” 7 UNPACKING “CHOICE”—AGREED DEFINITION FOR COMMON ADVOCACY PLAN “… the notion of a perfect, more or less universally acceptable contraceptive for women is unrealistic—women’s needs, concerns and (above all) their expectations and experiences of using contraception are very diverse.”4 CHOICE Within the above context, the group agreed that “Choice” goes beyond the availability of more products to include access, affordability, and clear information on the existing products. To ensure a choice of existing available methods, there is a need for trained providers at all levels; an adequate supply of commodities; the provision of information to clients on available methods, their access, and costs; and counselling on the side effects. In the Indian context, Choice is still not a reality for all women and it declines further with socioeconomic status and geographic location. There is a knowledge gap on spacing methods (pills and condoms): 87 per cent of women in urban areas know about the two methods compared with 59 per cent of rural women. This is further reflected in the uptake of spacing services, with only a marginal increase in the use of spacing methods—from 13.2 per cent in 1992–1993 to 18 per cent in 2005–6 (National Family Health Survey-3). Measured in terms of knowledge of products, of the seven methods available in the Indian basket, many couples are only aware of the three more terminal methods. Also, there is limited information on the side-effects, what to do in case of side-effects, and 4 WHO Reproductive Health and HIV Research Unit. 2006. Systematic Review of Contraceptive Medicines, “Does Choice Make a Difference?” Geneva: WHO. Common Advocacy Plan for Expanding Contraceptive Choice 8 other methods available in case the women wants to discontinue use. Thus, a majority of couples are not able to make an informed choice. The common advocacy plan developed during the workshop accentuates the importance of concerted action by the members and partners of ARC to address the need for improved and informed choice. By capitalising on the opportunities available and systematically addressing the challenges of this task, they can create a context for introducing new contraceptive methods into the public and private sectors. COMMON ADVOCACY PLAN Goal Contraceptive choices expanded with increased spacing methods and increased access to current methods of spacing Objectives A. Progestogen-only pill (POP) approved for introduction in the national FP programme in the next 12 months B. Advisory note issued to states by NRHM to increase funding for spacing methods, vis-à-vis the permanent method, in accordance with the unmet need for spacing methods within the 2013–2014 programme implementation cycle C. Ministry of Health and Family Welfare commitment to engage FOGSI to strengthen their Quality Assurance Mechanism to improve the quality of FP services in one district of one high-priority state, by September 2013 D. Private sector promotes postpartum spacing contraception Increasing Methods of Spacing for Expanded Choice Under the NRHM, there is a basket of contraceptive options available to clients. The MOHFW is looking into improving the last-mile supply-chain efficiencies but has a long way to go. The current basket of choices is limited, and there are many contraceptive methods that have not found a place in the FP programme. For example, injectables have been in use by registered medical practitioners in India for decades—NET-EN since 1986 and DMPA since 1993.5 Today, several leading nongovernmental organisations, professional bodies, and private medical practitioners are providing injectable contraceptives—mostly DMPA—along with other available contraceptives. Research work is underway in the country on various methods, such as spermicides, standard days’ method (SDM) or cycle beads, diaphragms, and vaginal rings, with special reference to hormonal contraceptives—a three-month injectable contraceptive, immuno-contraceptives, and anti-progestins.6 The National Task Force on Expanding Contraceptive Choices members are working on their own or in partnership with one another through different projects to advocate for the MOHFW’s acceptance or approval of certain methods for use in the private and public sectors. 5IFPS Technical Assistance Project (ITAP). 2009. Injectable Contraceptives in India: Past, Present and Future. Gurgaon, Haryana: Futures Group, ITAP. 6Sharma R.S., M. Rajalakshmi, and D.A. Jeyaraj. 2001. Current Status of Fertility Control Methods in India. New Delhi: Indian Academy of Sciences. Common Advocacy Plan 9 ARC will work with its partners to develop specific advocacy plans for each method. The matrix below elaborates the advocacy objective for each contraceptive method and specifies the partner responsible for leading that advocacy objective. Contraceptive method Advocacy objective ARC partner responsible Progestogen-only pill (POP) POP approved for introduction in the national FP programme in the next 12 months ARC Injectables in the private sector Use of injection Cyclofem in India approved for the private sector Market share and uptake of DMPA through the private sector increased FHI 360 and FPAI Injectables in the public sector Pre-program introduction of injection cyclofem in the public sector approved To build consensus for introduction of injection DMPA in the public sector amongst women’s groups and parliamentarians FHI 360 and FPAI Implants; SILCS7 diaphragms; Levonorgestrel Intrauterine System (LNG-IUS) Products in the pipeline for registration with the regulatory authorities (LNG-IUS, implants, and SILCS diaphragms) endorsed MSI for implants PATH8 for SILCS diaphragms FHI 360 for LNG-IUS Second, third, and fourth generation of combined contraceptives (COCs) oral Second, third, or fourth generation (lower dose) COCs introduced into the public sector in the next 12 months ARC/PHSI Standard days’ method (SDM)/long-acting method (LAM) SDM/LAM accepted as a modern contraceptive method in the long term ARC/Institute Health for Reproductive 7 Named for SILCS, Inc., a partner in the diaphragm’s development. 8 PATH is a member of the ARC Coalition and is presently holding trails of the SILCS diaphragms and LNG-IUS. Common Advocacy Plan for Expanding Contraceptive Choice 10 Objective A: POP approved for introduction in the national FP programme in the next 12 months Rationale and • POP is safe and suitable for nearly all women, including women who are breastfeeding and those who cannot use oestrogen assumptions • methods. The Drug Controller General of India (DCGI) has already given an approval for the use of POP in the private sector. The DCGI may require a recommendation from the Indian Council of Medical Research (ICMR) to approve introduction of this method into the public health sector. With the GOI focus on institutional deliveries and postpartum contraception, POP can be advocated as an additional option for postpartum contraception. Context Internal Scan Assets • ARC has a strong task force headed by Dr. Suneeta Mittal • ARC has access to technical expertise, data, and evidence • The ARC coalition has access to the Policy Unit, National Institute of Health and Family Welfare (NIHFW) headed by Dr RK Srivastava, ex-Director General Health Services, Ministry of Health and Family Welfare • Indian Association of Parliamentarians on Population and Development (IAPPD) is a core member of ARC • ARC can also access parliamentarians through the Citizens’ Alliance • ARC has committed donor support • As a product, POP has many positives along with having an emotional appeal Challenges • Processes in ARC are slow and need to be simplified • Work is not specifically divided among the coalition members • ARC has low visibility • ARC does not have adequate knowledge of the key decisionmakers (DCGI/Drug Technical Advisory Board [DTAB]) External Scan Assets • The time is right for advocacy with the budget session approaching • The FP 2020 Conference provided the requisite push for advocating an expansion in spacing methods • FOGSI and DTAB meetings are planned in February 2013, which can be used as platforms to build support for POP • The Twelfth Five Year Plan and National Rural Health Mission are now more inclined towards family planning • Manufacturers are willing to make a case for POP • The media can be tapped as a crucial audience for the advocacy activities Challenges • Perceived resistance to introducing new methods into the FP programme from the Additional Secretary and Mission Director of NRHM, MOHFW • Lack of public health system readiness to introduce a new method, especially with respect to counseling, supply chain and distribution, etc. Common Advocacy Plan 11 • Inadequate capacity of pharmaceutical companies for large-scale production, if POP is introduced into the public sector Positioning Framing the issue (POP is an additional and fertility rate [TFR] empowered action group effective postpartum [EAG] states) contraceptive method for women, especially in the high total Key decisionmaker Person/Position: DCGI Values: The DCGI is amenable to a systematic and logical approach. Thus, the benefits of POP and its cost effectiveness would prove effective. a thorough and logical analysis of data regarding Target audience • • • • • • • ICMR (building will) DTAB members (building will) Additional Secretary and Mission FP Division, MOHFW (building will) FOGSI (building will) Indian Medical Association (IMA) Media (sharing knowledge) Director (sharing of NRHM, MOHFW knowledge) (building will) Advocacy message Value: POP is a good option for most women, including those who are breastfeeding. It also provides an additional postpartum contraceptive option for women. Barrier: Costing could be a barrier in the initial stages. Data would need to be analysed to give a rationale for cost reduction through increased volumes. Though HLL Lifecare Limited will be approached initially, negotiations would be undertaken with other private pharmaceutical companies. Another barrier could be confusion among clients between the two different kinds of pills, which can be addressed by different branding. To begin with, the POPs could be offered by health providers at the primary health centres/community health centres/district hospitals to clients who come for institutional deliveries. Since POPs and oral contraceptive pills (OCPs) require similar consumption patterns, health workers would not require extensive training to counsel. Key ask: To introduce POP as one of the postpartum contraception methods in four EAG states of Uttar Pradesh, Rajasthan, Madhya Pradesh, and Bihar (states with high TFR requiring immediate and urgent action). Vision: Postpartum women will have an additional contraceptive option, thus contributing to a lowered infant mortality rate (IMR) and maternal mortality ratio (MMR). Messengers NIHFW Policy Unit—To provide analysis on the cost implications of POP; its potential users; increase in contraceptive prevalence rate and uptake of contraception with an additional postpartum contraception option; and the merits of an additional postpartum method in positively impacting the IMR and MMR in high TFR EAG states FOGSI, IMA, and Members of Parliament—To endorse the effectiveness of POP as a contraceptive method ARC—To advocate at all levels under the guidance of Dr Suneeta Mittal, Chairperson of the ARC task force Common Advocacy Plan for Expanding Contraceptive Choice 12 Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 1. FOGSI to issue technical statement on POP • ARC communication and coordination with FOGSI ARC and FOGSI December 15, 2012 Draft technical FOGSI statement from 2. Desk review on status of POP in the current India • • • Desk review FOGSI, Policy Unit, and ARC task force review of the desk review findings Final report on POP ARC Mid-January 2013 End of February 2013 End of March 2013 Desk review on POP document and brief 3. FOGSI Annual Conference FOGSI Mid-January 2013 Technical FOGSI Statement on POP by 4. Policy brief Policy Unit by the NIFHW • • ARC to send memorandum of understanding and scope of work to Policy Unit Preparation of policy brief on POP ARC NIHFW Policy Unit Mid-January End of March 2013 2013 Memorandum of understanding and scope of work for Policy Unit Policy brief on POP 5. Briefing on Spitfire ARC task force to the ARC First week of 2013 January Minutes of feedback the briefing and 6. IMA endorsement of POP • ARC communication and coordination with IMA ARC March end, 2013 Endorsement from IMA statement/letter 7. Obtaining ARC member commitment to act on the advocacy strategy • Emails to all members ARC First week of 2013 January Commitment from ARC members 8. ARC roundtable meeting ARC May 2013 Consensus statement of ARC 9. Meeting of with DCGI ARC delegation ARC June 2013 Minutes of the meeting with DCGI Common Advocacy Plan 13 Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 10. Meetings MOHFW with officials at the ARC Ongoing Minutes of the meetings 11. Endorsement of Parliament from members on POP ARC and Citizens’ Alliance August 2013 Product required: Brief for members of Parliament Product anticipated: Endorsement letter from members of Parliament 12. National consultation advocacy on POP for ARC August–September 2013 National Consultation Report 13. Media brief on POP ARC August–September 2013 Media brief on POP 14. Inclusion in the State Programme Implementation Plans (PIPs) (2014–2015) for selected EAG states ARC September–October 2013 Outcomes • Letter from DCGI recommending introduction of POP • Ministry letter approving the introduction of POP into the public health system • State PIPs (2014–15) with inclusion of POP in the state plan Common Advocacy Plan for Expanding Contraceptive Choice Increasing access to current methods Objective B: Advisory note issued by the NRHM to states the unmet need for spacing methods Increased funding/re-allocation for spacing methods at (Jharkhand, Rajasthan, and Bihar) to increase funding for spacing methods vis-à-vis permanent methods the state level and inclusion in 2013–2014 programme implementation in accordance plans (PIPs) with Rationale and Based on an analysis of some state PIPs, the suggested allocation of funds is highly focused on permanent methods (80 per cent) assumptions as compared to only 20 per cent for spacing methods. Aligning with the GOI commitment to focus on spacing and expanding access to current methods of spacing, there would be a requirement for increased financial allocation for spacing within FP. Key issues for FP include underutilisation of FP funds and reapportioning of FP funds to other health budgets when left underutilised. No dedicated Joint Secretary for FP (MOHFW) affecting reapportioning and monitoring of funds. Context Internal Scan Assets • Linkages with National Health System Resource Centre (NHSRC), implementation arm of the NRHM through the Policy Unit, NIHFW • Access to financial data from the MOHFW through Jansankhya Sthirata Kosh (JSK) (an HPP partner) • Capacity to analyse the data within the Policy Unit and HPP • Partnership with NHSRC (Dr T. Sundararaman, Executive Director) • Availability of technical staff from NHSRC, Policy Unit, and HPP • Leadership at the ARC coalition (Chairperson) • JSK, an autonomous government body, is an ally Challenges • No Joint Secretary for FP at the ministry • Requirement for extensive coordination with multiple agencies due to ARC being a coalition External Scan Assets • Commitment made by India at the London FP Summit to focus on current spacing methods • Dr SK Sikdar, Deputy Commissioner, FP, MOHFW, is proactive on the issue and an articulate supporter; he will be an ally to take the message to the Mission Director of NRHM, to advocate for the provision of additional funds and central guidance for spacing under FP • The HPP team, and Dr Alok Banerjee and Dr Kalpana Apte from ARC, can favourably influence the Deputy Commissioner, Family Planning, MOHFW • Increase in funding for FP under the Twelfth Five Year Plan 14 Common Advocacy Plan 15 Challenges • FP funds remain underutilised and the argument for increased financial allocation may not be a priority • FP funds may be reapportioned to health priorities where there is underutilisation Positioning Fortify and amplify (ministry committed to promote spacing for FP at the London FP Summit, 2012; additional funds committed for FP by the government) Key decisionmaker Person/Position: Additional Secretary and Mission Director of NRHM, MOHFW Values: As the Mission Director, she is committed to achieving the goals and objectives of NRHM and the MDGs. Target audience Deputy Commissioner, FP, MOHFW (building will) Executive Director, NHSRC (reinforcing action) Joint Secretary, Reproductive and Child Health and Policy, MOHFW (sharing knowledge) Advocacy message Value: Commitment to meet the Millennium Development Goals (MDGs) and achieve success for NRHM Barrier: The Mission Director, NRHM may not have necessary bureaucratic support to push for expansion in the budget for spacing methods, but if this is done, it will contribute to reducing maternal and infant deaths and will result in a reduction in costs. Key Ask: Advisory note for increasing financial allocation towards spacing methods Vision: Expanding contraceptive choice by increasing access to spacing methods Messengers Chairperson, ARC Task Force Senior Policy Advisor, Policy Unit, NIHFW Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 1. Policy Unit will seek collaboration and support from NHSRC for technical expertise to conduct the financial analyses on FP budget allocation and utilisation for four focus states • Policy Unit meeting set up with Executive Director, NHSRC, and JSK. Policy Unit, HPP, JSK December 4– 20, 2012 Minutes of the meeting 2. ARC will work out a schedule for all partners to detail next steps and timelines ARC December 2012 Schedule with timelines Common Advocacy Plan for Expanding Contraceptive Choice 16 Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 3. JSK to organise data from the ministry JSK December 2012 15, Data sets from the ministry 4. Data analyses completed by Policy Unit • Based on data received from JSK, Policy Unit will share the analysis with HPP Policy Unit December 2012 5. Draft Advisory Note developed by HPP (will include gaps, analyses, pilot idea, and advantages) • • HPP drafts the advisory note Note shared with ARC, to be circulated to all members Policy Unit and HPP (with data from different sources) January 2013 Draft Advisory members and provide timely Note (All ARC partners to feedback) 6. Finalisation of Advisory Note by HPP Policy Unit and HPP January 2013 Final Advisory Note 7. Getting buy-in from Chairperson, ARC National Task Force on Expanding Contraceptive Choice, to take the note forward ARC and HPP December 2012 8. Chairperson, ARC National Task Force on Expanding Contraceptive Choice, presents/delivers the Advisory Note to the Additional Secretary and Mission Director, NRHM, or the Minister of Health Chairperson, ARC January– February 2013 9. Guidance sent to states from MOHFW Government MOHFW order from Outputs • • • Policy Unit collaboration with NHSRC for data Advisory Note developed by HPP Financial analyses to support Advisory Note analyses Common Advocacy Plan 17 Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products • ARC Chairperson presents the Note to the Mission Director of NRHM Outcomes • Advisory Note issued and sent to the states by NRHM to increase funding for spacing methods vis-à-vis permanent methods. Objective C : Statement of Intent issued by Federation of Obstetric and Gynaecological Societies of India to volunteer the services of its members to strengthen district quality assurance efforts of Ministry of Health and Family Welfare Government commitment to engage FOGSI as part of its external quality assurance to improve quality of FP services in one district of one high- priority state by September 2013 Rationale and assumptions GOI considers FOGSI to be a neutral body of medical practitioners. With 219 member societies and more than 27,000 individual members spread across the country, FOGSI is one of the largest membership organisations for specialised professionals. FOGSI’s good standing with the Government of India’s Ministry of Health and Family Welfare is evident from the fact that GOI collaborates and partners with the Federation and that it is an invited representative on all policymaking bodies related to women's health. An example of FOGSI’s contribution towards quality of services is the formation of small coalitions called Doctors Opposing Sex Selected Termination of Pregnancy (DOSST) in every Obstetrics and Gynaecological Society of FOGSI. These committee members visit private practitioners to assess whether the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act guidelines are being followed. Practitioners performing sex selection tests are reported immediately, while others are counselled on correct practices and PCPNDT guidelines. FOGSI is also involved in advocacy and mobilisation around the issue through rallies; information, education, and communication campaigns; and other activities. Quality remains a key issue in both the public and private sectors. Within the public sector, the Monitoring and Evaluation Strategy of the MOHFW for NRHM and the Reproductive and Child Health (RCH) II Programme recognises the quality of RCH services as an important element. The technical strategies in NRHM/RCH II include setting up State and District Quality Assurance Groups/Committees, which assess the quality of services against set guidelines on a regular basis. A lot of work on this has been done; however, there is a need to further strengthen this activity. Some states have ensured regular quality assurance monitoring and improvement, some are unable to regularise it, and others have not performed assessments, despite setting up the Quality Assurance Committees. FOGSI would offer its support to the government for improving the quality of FP services. This can be done through the formation of an external quality assurance mechanism, with FOGSI members in select districts providing monitoring and training support for high-quality FP services. A pilot model implemented in one district of one state can demonstrate the Common Advocacy Plan for Expanding Contraceptive Choice 18 mechanism to the government. FOGSI has a pan-India membership with a strong presence in four states. FOGSI, the other ARC coalition partners, and HPP partners could identify issues related to quality assurance in FP service delivery in the public sector and advocate with the government for FOGSI’s involvement in strengthening district quality assurance efforts. Context Internal Scan Assets • FOGSI is a part of ARC • ARC has a task force on quality of care in FP and the Deputy Commissioner In-charge, FP, MOHFW, is a member; the task force has a mandate to partner with new organisations to improve the quality of services • FOGSI has proximity with the government • FOGSI has a comparative advantage, with a presence in four states across India (all fall in the high-focus states category) • FOGSI President Dr PK Shah is a dynamic leader who can take the objective forward • ARC, HPP, and the Policy Unit can work in partnership to push the objective forward Challenges • Coalition of multiple agencies requires coordination • FOGSI members are spread throughout the country, so identifying active members in the selected states and getting a commitment from them may be difficult • Government priorities may vary in terms of selection of districts for the pilot program External Scan Assets • 56th All India Congress of Obstetrics and Gynecology in January 2013 • MOHFW plan to develop an overall framework of quality assurance for NRHM Challenges • Government buy-in on the concept of an external monitoring mechanism is uncertain • Level of government participation at the conference is uncertain • Identifying proactive and dedicated members within FOGSI who would be willing to take on additional tasks might be difficult Positioning Key decisionmaker Person/Position: Dr. PK Shah, President of FOGSI Additional Secretary, Ministry of Health Values: Committed to meeting the MDGs and to the success of NRHM Common Advocacy Plan 19 Target audience Additional Secretary, Ministry of Health Advocacy message Value: Commitment to meet the MDGs and achieve success for NRHM Barrier: The government might be reluctant to expose the NRHM quality mechanisms to external evaluation, but because FOGSI is seen as a neutral body by the government, it will lend credibility to achieving the NRHM goals. Key Ask: • An external quality assurance mechanism for FP services • Private sector participation in quality assurance mechanisms Vision: Improved quality of services would lead to better maternal and child health outcomes Messengers President, FOGSI President-Elect, FOGSI Deputy Commissioner, FP, MOHFW Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 1. Letter from ARC to FOGSI • ARC develops a letter of intent ARC/HPP December 2012 Letter for partnership to partner with FOGSI on ARC external quality mechanisms • Letter sent from ARC to FOGSI 2. Identification of districts • Identify districts from JSK priority JSK, ARC, HPP December 2012 A list of the identified districts in tandem with the four districts states where FOGSI has a FOGSI comparative advantage • Identify active members across the selected districts and confirm agreement 3. Statement of intent developed HPP, ARC, FOGSI December 2012– Statement of intent along with the draft list of January 2013 districts 4. FOGSI presents the statement to • Present the statement at the FOGSI January 2013 Documentation from FOGSI Common Advocacy Plan for Expanding Contraceptive Choice 20 Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products support GOI for quality assurance across FP services at the 56th All India Congress of Obstetrics and Gynecology January 16, 2013 • • inaugural session with MOHFW representatives Present the statement at smaller meetings with MOHFW, GOI, during the conference Seek government buy-in (to include buy-in) government 5. Post-meeting analysis of quality of FP services across the selected districts, initiated at the committee level by FOGSI President • • Develop analyses of quality of FP services across selected districts Perform analysis of linkage between quality of FP services and maternal mortality FOGSI Report on analyses 6. Brief plan for to presenting MOHFW the draft • Compile the objective and the analysis of data and draft a plan for pilot HPP Brief 7. One-on-one meetings with Ministry of Health to present pilot plan • Follow-up for meetings and results (ARC QA Committee) ARC Meeting: FOGSI President ARC Chairperson Minutes of the meeting Outputs • • • • Draft letter of intent developed by FOGSI Letter of intent presented at the 56th All India Congress of Obstetrics and Gynecology in January 2013 Meeting between FOGSI and MOHFW Brief Additional Secretary, MOHFW (support with analysis of linkage between FP and maternal mortality for endorsement of pilot) Outcomes • Recognition from Government of India at the FOGSI conference • Partnership established between FOGSI and MOHFW • Pilot implemented in one district of one priority state Common Advocacy Plan 21 Objective D: Promotion of postpartum spacing contraception in the private sector FOGSI issues policy guidance for its membership on family planning, specifically promoting postpartum family planning FOGSI strongly recommends that medical practitioners should offer postpartum FP services, giving special attention to spacing needs for women. FOGSI has issued specific guidance on Progestogen Only Injectable and POP methods as safe, effective, and convenient for women in the postpartum period Rationale and In most states in India, where there is a decline in fertility rates, the pattern is a first child soon after marriage, followed assumptions within two to three years by a second child, and then the option of sterilisation—usually female sterilisation. To address this pattern, the government has placed renewed emphasis on birth spacing and the promotion of male sterilisation—with the introduction of a new IUD, better training, and non-surgical vasectomy as the main areas where significant advances 9have been made. The report of the Working Group on NRHM for the Twelfth Five Year Plan (2012–2017) states that spacing methods, including greater use of IUDs and oral contraceptive pills, should be actively promoted; sterilisation services will remain the primary strategy. Efforts will also be made to introduce injectable contraceptives. The Mission Director of NRHM has committed to renewing focus on current spacing methods of contraception, but the private sector remains skeptical about postpartum spacing methods. With the private sector entering the public domain in the form of public-private partnerships (PPPs), there is an entry point to promote postpartum FP. For example, private clinics and hospitals are implementing Janani Suraksha Yojana, a GOI scheme for institutional deliveries through the PPP mechanism. Based on evidence from the public sector, FOGSI can recommend postpartum contraceptive methods within the private sector. Information and evidence regarding expulsion rates, PPIUCD insertion techniques, and technique correction can be provided to inform the private sector. Integration of FP and RH can be pursued, with the private practitioners including the provision of postpartum FP services along with institutional deliveries through social marketing mechanisms. This will help the cost factor as well, if attached to institutional delivery; the cost of provision of postpartum FP becomes a hidden cost. FOGSI is considered to be a neutral body of medical practitioners by the government. With 219 member societies and more than 27,000 individual members spread across the country, FOGSI is one of the largest membership organisations for specialised professionals. FOGSI strongly recommends that medical practitioners offer postpartum FP services, giving special attention to spacing needs for women. FOGSI endorses the GOI guidelines in Standards for Female and Male Sterilisation Services and the IUCD Reference Manual for Medical Officers 9 Planning Commission. 2011. Report of the Working Group on NRHM for the Twelfth Five Year Plan (2012–2017). New Delhi: Planning Commission, Government of India. Common Advocacy Plan for Expanding Contraceptive Choice 22 (www.fogsi.org/index.php?option=com_content&view=article&id=85&Itemid=132). Context Internal Scan Assets • FOGSI is part of ARC • FOGSI is in good standing with the MOHFW and GOI and is an invited representative on all policymaking bodies related to women’s health; FOGSI is essentially an association of private practitioners across India, a primary entry point for promoting postpartum FP • FOGSI strongly recommends that medical practitioners should offer postpartum FP services, giving special attention to spacing needs for women • FOGSI can access evidence/data from the public health sector on the success of postpartum contraceptive methods • The President of FOGSI is a dynamic leader who can take the objective forward • ARC, HPP, and the Policy Unit can work in partnership to push the objective forward Challenges • FOGSI members are spread across the country, so identifying active members and getting a commitment from them may be difficult External Scan Assets • Private sector entering the public domain in the form of PPPs • Integration of RH and FP • Evidence is available from the public health system Challenges • Identifying proactive and dedicated members within FOGSI who will be willing to take on additional tasks • Getting buy-in from private practitioners about the advantages and success of postpartum contraception methods Positioning Fortify and amplify (data/evidence available from postpartum contraception in the private sector) the public health system/MOHFW for FOGSI to justify promotion of Key decisionmaker Person/Position: President, FOGSI; President-Elect, FOGSI Values: FOGSI exists to encourage and disseminate knowledge, education, and research in the field of obstetrics and gynaecology; to pilot and promote preventive and therapeutic services related to the practice of obstetrics and gynaecology for betterment of the health of women and children in particular and the well-being of the community in general; to advocate the cause of reproductive health and rights; and to support and protect the interests of Common Advocacy Plan 23 practitioners of obstetrics and gynaecology in India. Target audience Chairperson, Chairperson, Family Welfare Committee, ARC National Task Force on FOGSI (Dr Basab Mukherjee) Expanding Contraceptive Choices (Dr Suneeta Mittal) Message Value: Betterment of the health of women and children in particular and the to advocate the cause of reproductive health and rights. Key Ask: Policy guidance on family planning, specifically postpartum family planning, platform well-being of the community in general and issued by FOGSI and released on a public Messengers ARC Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 1. Letter from ARC to FOGSI • • ARC develops a letter of intent to suggest promotion of postpartum contraception as an area that requires attention Letter sent from ARC to FOGSI ARC January 2013 Formal letter from FOGSI seeking attention 2. Evidence from public health system for success of postpartum contraceptive methods prepared • Data sourced and compiled from states where postpartum FP methods have been successfully introduced ARC JHPIEGO-PPIUCD Technical paper 3. Information collected from social marketing organisations and international organisations implementing donor- funded projects • • Information collected from JHPIEGO, PSI, and other organisations on performance and success of postpartum FP Social marketing organisations contacted to discuss cost component MSI/Janani working on postpartum FP Briefs Common Advocacy Plan for Expanding Contraceptive Choice 24 Advocacy Activities and Products Activity Sub-activity Responsibility Timeline Products 4. Draft guidelines prepared for dissemination • ARC members, including HPP, prepare draft guidelines based on evidence compiled by the Policy Unit and from social marketing organisations ARC members working on postpartum FP/ Policy Unit Draft guidelines 5. Guidelines finalised in consultation with ARC Chairperson and FOGSI President ARC HPP Final guidelines 6. Guidelines presented FOGSI at a public forum/meeting or released online by President, FOGSI Chairperson, FOGSI Outputs • Formal letter from ARC to FOGSI • Draft guidelines for promotion of postpartum FP prepared by ARC and issued by FOGSI Outcomes • Guidelines for promotion of postpartum FP in the private sector released by FOGSI 25 NEXT STEPS The Common Advocacy Plan compiled by HPP will be finalised in consultation with the ARC task force based on priorities and timelines. The final plan will be presented at the next ARC task force meeting in January and shared with all consortium members. Meanwhile, each consortium member will initiate work on the areas of action and timelines identified for them during the two-day strategic workshop. Common Advocacy Plan for Expanding Contraceptive Choice 26 APPENDIX 1: LIST OF PARTICIPANTS Serial no. Name Organisation 1 Dr Suneeta Mittal Chairperson, ARC 2 Dr PK Shah President, FOGSI 3 Dr Rakesh Srivastava Policy Unit, NIHFW 4 Dr Bitra George FHI 360 5 Dr Amit Shah USAID 6 Dr Manisha Bhise FPAI 7 Avinash Choudhary ARC 8 Dr Shrabanti Sen FHI 360 9 Mr Vivek Malhotra PHSI 10 Pushpa Kumari JSK 11 Shivani Narayan Citizens’ Alliance for Reproductive Rights 12 Dr Tultul Hazra Das ARC 13 Paramita Kundu Population Fund of India (PFI) 14 Preeti Tiwari MSI 15 Bindiya Nimla FPAI 16 Dr Basab Mukherjee FOGSI 17 Ashish K Mishra HPP 18 Nirupa Rangaiah HPP 19 Tanya Liberhan HPP Facilitators 20 Priya Emmart AFP and HPP 21 Himani Sethi HPP 22 Heer Chokshi HPP 23 Sonal Sharma PFI 24 Jayati Sethi PFI Reviewers 25 Dr Suneeta Sharma Futures Group 26 Dr Meera Mishra IFAD 27 APPENDIX 2: AGENDA FOR TWO-DAY STRATEGIC WORKSHOP Strengthening Capacity for Evidence-Based Advocacy Using Spitfire SMART CHART Communication Tools to Develop a Common Advocacy Plan to Expand Contraceptive Choices Day 1: December 4, 2012 Time Session Presenters/Facilitators 9:00–9:30 am Registration 9:30–9:45 am Welcome Note and Address The need for an expanded basket of contraceptives in India and the efforts so far Dr Suneeta Mittal, Chairperson, ARC National Task Force on Expanding Contraceptive Choices 9:45–9:50 am Overview of the two-day strategic planning meeting Himani (HPP) Sethi, Health Policy Project 9:50–10:05 am Evidence for Policy Implementation Formulation and Dr RK Srivastava, Senior Policy Unit, NIHFW Policy Analyst, 10:05–10:20 am Products Implants in the Pipeline Preeti Tiwari, Marie Stopes India 10:20–10:35 am Summary: Key Findings from the National Consultation on Expanding Contraceptive Choices in India Dr Bitra 360 George, Country Director, FHI 10:35–10:55 am What does Choice mean? Framing choice as products, access, quality of services, and cost—making choice operational in the current context Priya Emmart, HPP 10:55–11:10 am Relevance and Need for common advocacy contraceptive choices for expanding Dr PK Shah, President, The Federation of Obstetric & Gynaecological Societies of India (FOGSI) 11:10–11:30 am Tea Break Using SMART CHART to develop Advocacy Asks 11:30–11:45 am SMART CHART Strategic Approach An overview of the process Sona Sharma, Advance Planning Project (AFP) Family 11:45 am– 1:00 pm Program Decisions: Defining the objective, and decisionmaker broad goal, Priya Emmart (AFP) (HPP) and Sona Sharma 1:00–2:00 pm Lunch Break 2:00–2:45 pm Program Decisions: Continued 2:45–3:00 pm Context: Internal and External Scan Jayati Sethi, AFP 3:00–4:30 pm Group Work Common Advocacy Plan for Expanding Contraceptive Choice 28 3:30–3:45 pm Tea Break (Working Tea) 4:30–5:30 pm Context: Position—Frame, Amplify or Reframe Followed by Group Work Fortify, and Sona Sharma, AFP 6:30–9:00 Reception Hosted by Advance Family Planning Project Day 2: December 5, 2012 9:00–11:30 pm Making Strategic Choices: Audience Readiness, Core Concerns, Theme, Message, and Messenger Priya Emmart, HPP 11:15–11:30 am Tea Break 11:30 am– 1:00 pm Advocacy Activities: Tactics, Assignments, and Budget Timeline, Sona Sharma, AFP 1:00–2:00 pm Lunch Break 2:00–3:00 pm Advocacy Activities: Continued 3:00–3:30 pm Measurements of Success: Day One and Day Two Using Results Cascades Priya AFP Emmart, HPP and Sona Sharma, 3:30–4:00 pm High Tea 4:00–5:00 pm Reality Check and Advocacy Asks Are the strategies realistic- and strategic? Will they obtain quick wins? Technical Discussion and Critical Review with Communication Experts Panel: Dr. Suneeta Sharma, Country Director, Futures Group Meera Mishra, Country Coordinator, International Fund for Agricultural Office Development (IFAD) India Country 5.00–5:30 pm Next Steps and Valedictory Himani Sethi, FPAI/ ARC HPP and Manisha Bhise, For more information, contact: Health Policy Project Futures Group One Thomas Circle NW, Suite 200 Washington, DC 20005 Tel: (202) 775-9680 Fax: (202) 775-9694 Email: policyinfo@futuresgroup.com www.healthpolicyproject.com Blank Page

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