Continuous Financing Helps Advance Contraceptive Security in Burkina Faso

Publication date: 2010

Policy Brief Continuous Financing Helps Advance Contraceptive Security in Burkina Faso A family planning booth at a health fair in Burkina Faso. © C C P, C ou rt es y of P ho to sh ar e Burkina Faso uses multiple sources of financing—in tandem—to fill gaps and smooth peaks in funding, enabling the MOH to continuously supply contraceptives to their people. JULY 2010 This publication was produced for review by the U.S. Agency for International Development. It was prepared by the USAID | DELIVER PROJECT, Task Order 1. Contraceptive security is achieved when individuals can choose, obtain, and use quality contraceptives whenever they need them. Approximately 57 percent of the population in Burkina Faso, one of the poorest countries in the world, lives below the international poverty line of U.S.$1.00 a day (United Nations Development Programme 2009). The Human Poverty Index——which measures life expectancy, access to education, standard of living, and other well- being indicators——ranks Burkina Faso 131 of the 135 countries (World Bank. 2010). Additionally, because of the poverty and limited access to health services, the maternal mortality rate is one of the highest in the world (700 per 100,000 live births), the contraceptive prevalence rate remains low (9.8 percent for modern methods), and unmet need for family planning is high (28.8 percent) (National Institute of Statistics et al. 2004). In spite of these challenges, Burkina Faso’’s people and government have increasingly dedicated their own resources and hard work to attain their health and development goals. For example, in 2007, the country expended 6 percent of its gross domestic product (GDP) and 13 percent of all government expenditures on health. Only 10 out of 48 countries on the African continent——Botswana, Mozambique, Sao Tome and Principe, Chad, Gabon, Zambia, Madagascar, Liberia, Tanzania, and Rwanda——prioritize government spending on health at similar or greater levels. Beyond overall health spending, Burkina Faso also stands out among its neighbors and the world for their strong support of contraceptive security. More than 50 countries have developed contraceptive security strategies, yet fewer have moved beyond the planning phase. Burkina Faso can count itself among the exceptional group of countries that have translated their contraceptive security strategies into real action. For example, Burkina Faso implemented an innovative public sector financing scheme for contraceptives. Even more interesting, the country has implemented these contraceptive security strategies with limited technical assistance; they have truly been country-driven solutions. Strategic Planning Paves the Way for Contraceptive Security The Government of Burkina Faso (GOBF) has demonstrated a deep commitment to combating poverty and to tackling its millennium development challenge by prioritizing access to reproductive health, family planning, and contraceptives. For example, since the early 2000’’s, the country’’s multisectorial reproductive health commodity security (RHCS) committee, led by the Ministry of Health (MOH), has worked tirelessly to expand access to RH commodities and to gradually institutionalize the committee’’s functions into all the member organization’’s regular processes and workplans. One of the committee’’s key accomplishments was to develop a comprehensive RHCS strategy (2006––2015) that outlines these important goals: x transition from receiving donated contraceptive products to procuring these products x ensure continuous financing for family planning products x improve the quality of family planning services for clients x improve logistics management for contraceptives x develop effective actions to promote contraceptive method use x guarantee intersectorial and intrasectorial coordination for RHCS. Innovative Financing Helps Secure Continuous Supply of Contraceptives Since adopting the RHCS strategy, the MOH has mobilized government funds to cover their contraceptive needs. Even more important, the MOH staff have learned to use multiple funding sources to complement one another. In this way, the government not Burkina Faso has used only provides yearly innovative strategies to forward-fund contraceptive funding, but also procurement, quickly ensures more reliable mobilize resources when continuous financing facing a shortage, and make for contraceptives flexible financing available throughout the year, between regularly whenever it is scheduled budget cycles. needed——a major financing challenge for most countries. While donor support is an important source of contraceptives in the country (see figure 1), this support fluctuates from year to year (Reproductive Health Interchange 2010). As a result, the country sometimes faces delays in delivering urgently needed commodities. In response, the MOH has implemented a creative resource diversification strategy that provides a more continuous supply of commodities without depending on one donor or funding source. The following steps describe this strategy. Figure 1: U.S.$ Value of Major Donor Shipments of Contraceptives to Public Sector (thousands) $2,000 $1,800 $1,600 $1,400 World $1,200 $220 $451 $554 $473 $26 $1,932 $7 $60 $231 $678 $714 $1,587 $409 Bank $1,000 USAID $800 $600 UNFPA $400 $200 $0 2004 2005 2006 2007 2008 2009 Source: Reproductive Health Interchange (RHInterchange) Increasing Government Financing First, to support its goal of transitioning to self- sufficiency, the GOBF successfully allocated and expended large sums of public-sector funding to purchase contraceptives (see figure 2). In recent years, the GOBF spent—— x U.S.$850,000 in 2007 x U.S.$980,000 in 2008 x an impressive U.S.$1,001,000 in 2009. 2 Figure 2: Public Sector Financing for Contraceptives (U.S.$ millions) $1,050 $1,000 $950 $900 $850 $800 $750 2007 2008 2009 $980 $1,001 $850 Source: MOH and CAMEG financial and warehouse reports, April 2010 The most recent government contribution represents almost 36 percent of the forecasted need for 2009 (USAID | DELIVER PROJECT, Task Order 1 2001––2010.). In other words, the GOBF is financing a significant share of the total estimated need for contraceptives in-country, despite its limited GDP. Filling Funding Gaps between Budget Cycles Even more impressive than its budget line, however, is the way the GOBF uses multiple public-sector funding sources in tandem—— internally generated funds, basket funds, World Bank poverty reduction support credits, and cost recovery fees——to both finance contraceptives upfront and to quickly respond to challenges related to the release of funds or delays in shipments. For instance, recently, when the basket funds were depleted, the GOBF took funds from its cost recovery system to ensure that resources for contraceptive procurement were available (see box 1 for a brief description of the cost recovery system). In 2009, the MOH used funds collected by the cost recovery system to order oral contraceptives mid-year. The MOH quickly mobilized funds from this account to alleviate the widespread shortages due to delays in donor shipments, even though these funds were not originally designated for this purpose. The MOH identified a more flexible source of funding to respond to an emergency need for a contraceptive without waiting for the next disbursement of MOH budget financing, or the next donation, as would have been the case with the basket funds, World Bank credits, or donor supplies. Forward-Funding Contraceptive Procurement Finally, the MOH has partnered with the Central Procurement Agency for Generic Essential Medicines and Consumables (CAMEG) to forward-fund contraceptive procurement. Because CAMEG is a private, non-profit organization, subcontracted by the MOH; it has its own resources and it can determine how and when to use these funds. As a result, in recent years, CAMEG has loaned resources to the MOH before the quarterly budget disbursements were made. To set up this agreement, CAMEG signs a formal memorandum of understanding with the Box 1. How does the cost recovery system work in Burkina Faso? The partnership between the MOH and CAMEG—a private, non-profit organization—has been instrumental to managing the cost recovery system. For example, CAMEG helps administer the MOH cost recovery savings account on behalf of the government: x Health facilities charge a fee for contraceptives. ʊ Part of this fee is retained at the facility level to help cover health facility management costs. ʊ The other part is used by facilities to purchase their resupply of contraceptives from districts. x The districts, in turn, use the revenue collected from the health facilities to order their contraceptives from CAMEG. x CAMEG manages an account for each district to track the amount of contraceptives districts have ordered and to collect payment for these commodities. x CAMEG aggregates these payments into a total cost recovery account on behalf of the MOH. x CAMEG can only use these funds with approval from the Family Health Directorate and the MOH Finance Department, which manages the use and disbursement of funds from this account. x The MOH and CAMEG use this account for contraceptive procurement and to cover other supply chain management costs. 3 MOH, whereby the MOH agrees to repay CAMEG for the loan in an agreed-upon length of time. By forward-funding the MOH, CAMEG supports the MOH program and technical staff in their efforts to avoid procurement delays caused by waiting on the traditional budget disbursement process. After the MOH receives the regularly scheduled funds, the MOH pays CAMEG. Because CAMEG’’s own mission is to strengthen the in-country supply chain for essential medicines, it has willingly supported the MOH in executing this creative financing strategy. Wrapping It Up By using multiple funding sources to complement one another, the MOH staff have effectively overcome several serious financing obstacles. MOH leaders have used innovative strategies and a strategic partnership with a private, non-profit subcontractor (CAMEG) to—— x forward-fund contraceptive procurement x quickly mobilize resources when facing a shortage x make flexible financing available between regularly scheduled budget cycles. By using multiple consecutive sources of financing, strong government leaders have filled gaps and smoothed peaks in funding——from donors and the public sector——both at the beginning and throughout the year. By working hard to ensure a continuous flow of financing, the MOH and CAMEG managers provide a more continuous supply of the right commodities at the right time to those who need them. Challenges and Next Steps Despite these remarkable successes, many challenges remain for Burkina Faso if they are to maintain the gains in ensuring contraceptive security. For example, current MOH staff will need to work toward documenting their experiences in managing these financing strategies. By doing this, if they leave their positions, future staff will know how to replicate these practices and will understand why prioritizing financing for contraceptives is so important. Furthermore, the country will also need to continue to make progress toward implementing the various other goals included in the RHCS strategy. Overall, in spite of many challenges, Burkina Faso has made rapid progress in mobilizing financing for contraceptives; they have also made remarkable strides in strengthening contraceptive security, which should help satisfy the high unmet need in the years to come! References National Institute of Statistics (INSD) and ORC Macro. 2004. Burkina Faso’’s Demographic and Health Survey-2003. Calverton, Md.: INSD and ORC Macro International, Inc. Reproductive Health Interchange. 2010. Database provided by the Reproductive Health Supplies Coalition. Available at rhi/ (accessed February 15, 2010) United Nations Development Programme. 2009. Human Development Report. Available at fact_sheets/cty_fs_BFA.html (accessed February 1, 2010) USAID | DELIVER PROJECT, Task Order 1. 2001––2010. Various Burkina Faso internal technical assistance reports. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 1. World Bank. 2010. World Development Indicators. Available at subscriptions/WDI/WDI.html (accessed February 1, 2010) 4 About the Policy Brief Series Over the last 10 years, reproductive health commodity security (RHCS) advocates have helped strengthen global, regional, and in-country initiatives to improve access to essential health commodities, including contraceptives. To help promote and share promising practices in CS, the USAID | DELIVER PROJECT has initiated a series of policy briefs that showcase examples of CS success at global, regional, and national levels. For more information or to learn about other successes, please visit our website at The USAID | DELIVER PROJECT, Task Order 1, funded by the U.S. Agency for International Development, improves essential health commodity supply chains by strengthening logistics management information systems, streamlining distribution systems, identifying financial resources for procurement and supply chain operations, and enhancing forecasting and procurement planning. The project also encourages policymakers and donors to support logistics as a critical factor in the overall success of their health care mandates. The authors’ views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. USAID | DELIVER PROJECT John Snow, Inc. 1616 Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: Internet:

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